On diclofenac tablets? What should you do?

As of today, you can no longer buy diclofenac tablets (for pain and inflammation) over the counter from a pharmacy. The Medicines and Healthcare Products Regulatory Agency (MHRA) has made this decision based on the fact that diclofenac carries a 'small' risk of serious cardiac side effects, especially if taken in high doses or for the long-term treatment of chronic pain. Pharmacists are being told to take any diclofenac tablets off their shelves and return any stock.

What is diclofenac?
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID), in the same class of medicines as ibuprofen. It combats pain and inflammation and has commonly been used for arthritis symptoms.

Why is the availability of diclofenac tablets changing?
In 2013, the MHRA warned that diclofenac tablets shouldn't be taken by people with an underlying heart condition or a history of a heart attack or stroke. This evidence has now been looked at by the Commission on Human Medicines, which concluded that the side effects can't be ruled out, even when the medicine is taken for a short time or at a lower dose. Therefore, diclofenac tablets are being reclassified as a prescription-only medicine (POM).

What about diclofenac gels?
Diclofenac topical gel is still available to buy over the counter as Voltarol Pain-eze, Voltarol Emulgel and Voltarol 12-hour Emulgel. You rub these gently into your skin for local pain relief. The gels are suitable for rheumatic or muscular pain, sprains, strains and bruises (e.g. due to sports injuries). To buy certain Voltarol gel products over the counter, you need to have a discussion with the pharmacist first, as these are pharmacy-only (P) medicines.

What should you do?
Firstly don't panic!

If you have been prescribed diclofenac by your GP, continue taking your medicines as instructed, as your GP will have already assessed your medical history and individual risks. If you are concerned, speak to your GP at your next visit.

If you have bought diclofenac tablets over the counter, stop taking them and speak to your pharmacist about suitable alternatives. If you want to continue taking diclofenac tablets, you will need to make an appointment with your GP, who can assess the risks and will prescribe diclofenac if it's appropriate for you.

What else is available from your pharmacy?
There are many pain relief options available over the counter.
These include:

• Ibuprofen and/or paracetamol tablets or capsules: you can buy these painkillers separately or take them together in one product (Nuromol).
• Topical analgesic gels, containing either diclofenac or ibuprofen in various strengths.
• Hot and cold treatments (in the form of patches, rubs and sprays).
• Non-drug treatments (e.g. those using acupressure, electromagnetic pulse therapy, TENS etc.)

Before buying any pain relief products, always check with the pharmacist that these are suitable for you - disclose whether you have any underlying medical conditions or take any other medicines. Even non-drug treatments aren't suitable for everyone.

Before using a product, read the instructions carefully, checking how to use it safely and the correct dosage. If your pain is severe or persistent, you should always get it checked out by your GP.

Vaginal dryness - break the taboo

Most women don't like to talk about vaginal dryness. Let's face it, it's not a sexy topic. It's highly embarrassing and doesn't usually feature in daily conversations. Many women therefore suffer in silence.

Yet there's no reason for the subject to be such a big taboo. Vaginal dryness is a common problem in the UK. And, because it has a major impact on sex and relationships, needs to be discussed more openly.

According to Dr Diana Mansour, consultant in community gynaecology and reproductive healthcare, vaginal dryness is not just a menopause-related problem. "Pregnancy, hormonal treatments and even stress or tiredness may also lead to dryness in the intimate vaginal area," she says. "As you age, hormonal changes can cause vaginal dryness, which can be uncomfortable, leaving you more vulnerable to irritation or causing pain and discomfort during sex. If your dryness is persistent, contact your doctor or other healthcare professional for advice or more information."

Various moisturisers for vaginal dryness are available over the counter from pharmacies. These include Replens MD, Balance Activ Menopause, Sylk Natural Intimate Moisturiser and new Canesintima Intimate Moisturiser from Bayer Healthcare, which makes Canesten. Your GP can also prescribe some of these products on prescription.

Dr Mansour stresses the importance of using an intimate moisturiser specifically for vaginal areas. "Using an intimate moisturiser may help keep the external vaginal area hydrated and lubricated, therefore easing the discomfort and further irritation," she says. "These products should be free from parabens, soap and preservatives, as well as dermatologically tested, making them suitable for the vagina's delicate environment."

If you want to discuss intimate health issues with your pharmacist, ask if you can go into their private consultation room.

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Take up the Stoptober Challenge

On Wednesday 1st October, take up the challenge to give up smoking for 28 days with the Department of Health's Stoptober Challenge. Over 150,000 people are expected to kick their smoking habit during the month of October this year.

Research shows that stopping smoking for just 28 days can extend your life by up to one week if you remain smoke-free. And those who stop smoking for 28 days are five times more likely to stay smoke-free for good.

The only way to find out if the Stoptober Challenge works for you is to give it a go. Click here to register and get started.

Quitting smoking is the best thing you can do for your health, your family and your finances. But while most smokers know the risks, they still struggle to give up in the long-term. Nicotine cravings are one of the biggest obstacles to quitting for good.

You can seek the help of your local pharmacist for one-to-one support and advice on smoking cessation medicines to combat cravings.  All licensed smoking cessation products can help you stop smoking. In fact, using nicotine replacement therapy (NRT) can double your chances of quitting, but it's important that you choose the right products for you (gum, patches, lozenges, inhalators, nasal or mouth sprays or oral strips and micro tabs). Some types of NRT are designed to help you cut down on smoking, rather than stop all in one go. You will need to speak to the pharmacist about the right strength for you and, if you are a heavy smoker, about combination therapy (where you use two types of NRT together e.g. patches and gum).

GP surgeries in crisis

According to the Royal College of GPs (RCGP), waiting times to see a GP are now a national crisis. The latest predictions from the RCGP show that on 60 million occasions over the next year, patients will have to wait a week or longer to see their GP or practice nurse.

In the latest poll commissioned by the RCGP, two-thirds of those surveyed said that they worry that GP workloads are a threat to the standard of care that GPs can provide to their patients. Only 23% think that there are enough GPs to deal with Britain's changing and growing population, particularly with more and more people now living longer, often with multiple or complex health problems.

The RCGP and the National Association for Patient Participation have launched the campaign Put patients first: Back general practice in a bid to increase the share of the NHS budget for general practice to 11% by 2017. It's hoped that the extra investment will expand the GP workforce, especially in deprived or under-doctored areas.

Meanwhile, the Department of Health and Public Health England recently launched a new winter health campaign, called Treat Yourself Better with Pharmacist Advice, to encourage people to seek advice from their pharmacist before going directly to their GP. It is hoped that this will help to free up GP appointments for people who really need them. Research carried out to support the Treat Yourself Better campaign found that only one in five adults make use of their local pharmacist for winter ailments. Yet people wait on average less than five minutes to speak to a local pharmacist about winter ailments, compared with a 3.5 day wait to get a GP appointment, with one in five people waiting at least seven days.

The Treat Yourself Better campaign found that many people also underestimate the normal duration of colds and flu, visiting their GP too early in the infection. Ninety percent expect a cough to last on average only eight days, when in fact it can last for up to three weeks. And 80% expect flu symptoms to last only 10 days, when two weeks in the normal duration.

For more details about the Treat Yourself Better campaign, click here. Find out how you can treat colds and flu yourself, check your symptoms and watch out for warning signs that indicate you may need to see your GP.

Help to ease winter health pressures

A report this week by the All-Party Parliamentary Group of Primary Care and Public Health highlights the role of community pharmacies in managing winter ailments. The report focuses on the increasing pressure put on hospital A&E departments and GP practices during the winter months, and why it's important that people know the differences between 'urgent' and 'non-urgent' minor health issues. 

The report suggests that we - the public - should be going to our pharmacist before our GP when we are suffering from a cold or flu, unless we think it's a medical emergency. This is because weather-related health conditions, such as respiratory problems, are more common during the winter, increasing the pressure on A&E departments.  The cold and flu season also results in more people seeking medical advice from their GP, whether it's simply for reassurance or antibiotics, which leads to more pressure on the healthcare system as a whole.

Every year, winter health campaigns focus on the inappropriate prescribing of antibiotics and the importance of 'self care'. This year's Self Care Week, which is run by the Self Care Forum, takes place from 17th to 23rd November 2014, with the theme 'Self Care for Life - Be Healthy this Winter'.

But many people find it difficult to assess when their symptoms are 'urgent' or 'non-urgent'. And I include myself in this. 

• When should we worry about an annoying cough that keeps us awake or a persistent sore throat that just won't disappear? 
• Is it normal to be so congested that your face hurts or you get a seasick feeling every time you move? 
• Should we be coughing up green or brown phlegm?
• How long should our cough or cold last before we need to see our GP? 

Knowing more about our symptoms - and dealing with them without the need for antibiotics - doesn't just help us as individuals, but also helps to reduce the national (or rather international) crisis of bacterial resistance. Earlier today, the Prime Minister David Cameron warned about the growing threat of antibiotic resistance: there is a continual rise in drug-resistant bacterial strains, no new classes of antibiotics have been developed for more than 25 years and there is still an overuse of antibiotics globally. 

So what should we be doing? 

• Firstly, remember that antibiotics won't help a cold or flu as they kill bacteria, not viruses. So we don't need to ask for them at the first sign of a sneeze or sniffle.
• Secondly, if we are prescribed them, this should be because our GP thinks we already have a bacterial infection or that we are at an increased risk of one. 
• Thirdly, if we do take antibiotics, it's vital that we finish the full course, take the antibiotics at regular intervals during the day (as prescribed) and don't skip any doses. 

Ultimately, we need to try self-help measures for our cold, cough or sore throat first, rather than simply seeing our GP for antibiotics - and this is where pharmacy advice comes in. Pharmacies aren't just there to sell us cough and cold remedies (although these can often help to relieve our symptoms).  Pharmacists and pharmacy staff are trained to advise us about self-help measures too and tell us when we really do need to see our GP. 

The Proprietary Association of Great Britain (PAGB) has a great website called Treat Yourself Better, where you can find out how to treat coughs, colds and sore throats, rather than resorting to antibiotics.

Are you using your medicines properly?

A new report by the Royal Pharmaceutical Society (RPS), published last week, highlights the fact that pharmacists need to improve patients' use of medicines. Apparently, between 30 and 50 percent of patients taking medicines for chronic conditions don't take them as directed, leading to ill-health and extra costs for the NHS.

Ensuring the best use of medicines, reducing the risks of side effects and making sure people are taking medicines properly and safely are core activities of all pharmacy services. A report in May 2013, also by the RPS, revealed that 'only 16 percent of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need.'

But we can't put all the responsibility onto pharmacists. It's also up to us as patients to make sure we are taking prescribed medicines correctly (where possible). And while the reports focus on prescription medicines, this also apply to anything we buy over the pharmacy counter.

So how can you make sure you are using your medicines properly?

1. Speak out
The National Pharmacy Association's Ask your Pharmacist campaign stresses that you should always let your pharmacist know if you are:

• allergic to anything
• taking prescribed medicines from another pharmacist or hospital pharmacy
• taking over-the-counter (OTC) medicines or vitamin, mineral or herbal supplements
• pregnant or breastfeeding
• buying or collecting the medicines for someone else.

2. Always ask questions

Sometimes the instructions on the medicine label or in the supplied leaflet aren't clear (or in layperson's terms). So when picking up a prescription medicine or buying any OTC product for the first time, always ask:

• What is this medicine for? [Make sure you know which medicines are helping which symptoms or medical conditions,]
• How long does it take to work and will I notice the effects? [You may not notice blood pressure medicines doing anything, yet they will still be working in the background.]
• Why do I need to take or use it? [It's important to understand why you need to take a medicine and what will happen if you don't.]
• When should I take or use it? [How many times a day, morning or night etc.]
• How do I take or use it? [Make sure you know, for example, how to put eye drops in.]
• How long should I take it for? [Do you need to finish a specific course or do you need to keep getting new prescriptions each month?]
• What do I do if I forget a dose? [Do I take the next one, take it as soon as I remember etc?]
• Does it have any side effects? [What are the side effects? What do you do if you think you are experiencing any?]
• Are there any possible risks I should be aware of? [Some medicines can affect your liver, for example, so your doctor may advise that you have regular liver function tests.]
• Could it interact with any other medicines I am taking? [This includes over-the-counter medicines and vitamin, mineral and herbal supplements.]
• Will it still work if I have a stomach upset? [If you use oral contraceptives, for example, you will need to use condoms if you have a stomach bug as the contraceptive won't be as effective.]
• Can I take it with/without food or drink? [Some medicines, for example, interact with grapefruit juice.] 
• Do I need to store it any particular way? [e.g. in the fridge].

3. Find ways to remind yourself

If you don't always remember to take your medicines, what can you do to jog your memory?

• Get into a routine and stick with it.
• Fill up a dossette box with medicines for a week. So you will be able to tell if you forget a dose. 
• Link taking medicines with specific activities (e.g. the evening news, the morning paper TV programmes). 
• Set multiple alarms or reminders on your mobile phone. 
• Keep a diary or planner and tick off a dose once you have taken it.
• Ask your friends or family to remind you.

3. Access pharmacy services

If you are prescribed a new medicine for the first time for asthma, chronic obstructive pulmonary disease, type-2 diabetes or high blood pressure, ask your pharmacist about The New Medicines Services (NMS), which is free across England. If you are eligible, the pharmacist will answer many of the questions above to help you get the most out of your medicines and stay well.

If you are taking two or more prescribed medicines for a chronic conditions, you can have a free NHS Medicines Use Review (MUR). This service is available throughout England and Wales ('Managing your Medicines' is offered in Ireland and a 'Chronic Medication Service' is available in Scotland). During this personal consultation, your pharmacist can discuss the medicines you are prescribed, whether you are experiencing any problems or side effects and whether there could be a more effective way of taking them.

How is your asthma inhaler technique?

Today's big health story (so far) is a new report - Why asthma still kills - published by the Royal College of Physicians (RCP) to coincide with World Asthma Day. According to the report, nearly three-quarters of asthma deaths could have been avoided with better care and better access to medical help. The RCP report recommends that everyone with asthma has their inhaler technique assessed formally once a year and whenever the pharmacist dispenses a new device.

So what should you be doing to make sure you are using your inhalers properly?

1. Check your technique
I suffer from mild asthma - my symptoms usually only strike at the peak of the hayfever season or when I have a respiratory infection such as a cold. I don't need new inhalers very often, because I don't use them very often, but I don't recall any pharmacist checking my inhaler technique when dispensing my prescriptions since I was first diagnosed over 30 years ago. I think the fact that I don't use inhalers on a regular basis could possibly make me more likely to forget the correct technique.

Even if your pharmacist doesn't mention it to you, make sure you ask them to check that you are using your inhaler properly. There's nothing like a one-to-one practical demonstration. However, for general guidance, you can also visit Asthma UK's Using your inhalers page.

2. Get the right products
If you are having problems using your inhaler (because of arthritis in your hands, for example), speak to your GP, who may be able to switch you to a different type of inhaler or suggest products that can help, such as the Haleraid or Turboaid - you can't get these on prescription, but your pharmacist should be able to order them in for you. Spacers, which are available on prescription, make aerosol inhalers more effective by trapping the medicine inside so you don't have to worry about pressing the inhaler and breathing in at the same time.

Use inhalers appropriately
Also speak to the pharmacist about when you use your inhalers. The RCP report found that asthma patients are relying too heavily on their reliever inhalers (usually blue) and not enough on their preventer inhalers (usually brown, red or orange). Nearly half of those who died from an asthma attack had not had an asthma review with their GP or nurse in the previous year.

3. Write an asthma action plan
According to the RCP report, better education is needed for doctors, nurses, patients and carers to make them more aware of the risks of asthma, to spot the warning signs of poor asthma control and to know what to do during an attack. All patients should be provided with a personal asthma action plan (PAAP), to help them identify if their asthma is worsening and tell them how and when to seek help. Asthma UK has a useful Asthma Action Plan that you can download from the charity's Personal action plan page and take to your GP or asthma nurse to discuss and fill in.

4. Have a Medicines Use Review
You can also ask your local pharmacist if they offer a Medicines Use Review (MUR) - this is a free NHS service in a private consultation room. You can discuss all your medicines with the pharmacist, to check they are all necessary, you are using them properly and to solve any problems you may have.

Licensed herbal medicines

As of the 1st of May 2014, all herbal medicines sold in pharmacies must have a traditional herbal registration (THR) or product licence (PL). So what does this mean for pharmacy customers?

According to Dr Linda Anderson from the Medicines and Healthcare products Regulatory Agency (MHRA), the THR scheme gives people access to traditional herbal medicines that are safe, of good quality and sold with information on how to use the product correctly.

What are THR products for?
You can use a THR product for minor self-limiting ailments like colds or hayfever. Beware of any unlicensed product claiming to cure, treat or prevent any illness.

The THR scheme doesn't mean the herbal remedy has been tested and proven to actually work. It just means the product is made to good-quality standards with appropriate labelling and a product information leaflet. It also means the herb has been used in traditional remedies for more than 30 years.


What to look for on the label:

• Look for the THR number on the packaging of herbal products.
• Most registered herbal products will have the THR logo (see right) too.
• Licensed medicines have a nine-digit PL (product licence) number on their labels, just like conventional medicines.

Herbal medicine safety
Natural doesn't always mean safe. Some unlicensed herbal medicines can cause side effects or may interact with other medicines. It's always important to tell your GP or pharmacist whether you are taking any herbal remedies or dietary supplements. St John's Wort, for example, which can be taken for mild depression, may interact with a whole host of medicines including the contraceptive pill, hormone replacement therapy (HRT), thyroid hormones and some anti-depressants.

Always read the product information leaflet carefully before taking any herbal remedy. If you experience any possible side effects, stop taking the product and speak to the pharmacist.

If you have an adverse reaction to any medicine, including herbal remedies, your pharmacist (or GP) can report this to the MHRA under a system called the Yellow Card Scheme. Alternatively, you can report it yourself directly at the MHRA Yellow Card Scheme website.


Consulting a medical herbalist
If you wish to consult a herbalist to get tailor-made advice, make sure you choose a reputable practitioner. You can find a herbalist in your local area through the website of The National Institute of Medical Herbalists (NIMH). 

Paying for prescriptions

Yesterday I picked up a prescription from my local pharmacy. NHS prescription charges have risen again, now £8.05 per item. While I don't need regular prescriptions, it made me spare a thought for those people who do.

Prescriptions raise valuable resources for the NHS. But for people with long-term conditions who take several medicines every month, the cost can be prohibitively expensive. At present, England is the only part of the UK where patients pay for their prescriptions, unless they are exempt (see below). In Wales, Northern Island and Scotland, prescribed medicines are free for everyone.

The Prescription Charges Coalition (PCC) is campaigning for free NHS prescriptions for everyone of working age who has a long-term condition. The PCC, which has more than 30 member charities and organisations (including the Royal Pharmaceutical Society), has found that many people are having to choose between food, clothing, bills or prescriptions. Some patients are rationing their prescriptions, or stopping them completely, because they simply can't afford them. Yet prescription medicines are vital in preventing serious health problems associated with long-term conditions and ultimately in reducing extra costs to the NHS and society as a whole.

In a survey by the PCC on prescription charges and employment in March 2014, over a third of people reported that the cost of their medication had prevented them from taking it as prescribed, with significant numbers saying this had affected their ability to work.

So are you entitled to free NHS prescriptions?
Some people can get free NHS prescriptions because of their age, income or medical condition. Visit  NHS Choices to find out if you are one of them.

Only certain medical conditions are covered. According to a report by the PCC in March 2013, this list is limited and not in keeping with the times. While people with insulin-controlled diabetes or an underactive thyroid are entitled to free prescriptions, those with asthma, high blood pressure, arthritis etc. still have to pay. The PCC's report (Paying the Price - Prescription Charges and People with Long-term Conditions) states:

'While some people are exempt from prescription charges on the basis of age, income and medical condition, the criteria for exemptions were set in 1968 and have remained largely unchanged since then. 45 years on, these criteria are now outdated, arbitrary and inequitable. Schemes to provide extra support with health costs, in particular the Prescription Prepayment Certificate and NHS Low Income Scheme are poorly publicised and difficult to access.'

The PCC is calling for people in England to email their MP, asking them to call for an end to prescription charges for those with long-term conditions. Visit the PCC's Take Action page to learn more.

So how can you minimise the cost?
The Prescription Prepayment Certificate (PPC) is intended to help people with long-term conditions, as long as they live in England. It is basically a season ticket for prescription medicines, for a period of either three months (£29.10) or 12 months (£104), covering all prescriptions during that period.

The PPC allows anyone to obtain all the prescriptions they need for £2 a week. However, it's only worth it if you require four or more prescription items over three months or 13 or more items over one year, and probably isn't worth it at all if your medical condition is unpredictable or fluctuating.

You can pay by 10 monthly direct debit instalments. Visit https://www.gov.uk/get-a-ppc to buy a PPC online, phone 0300 330 1341 or fill in the form FP95 (available from your pharmacy or GP surgery). Some pharmacies also sell PPCs direct.

Is your hayfever under control?

It is Allergy Awareness Week in the UK, timed to coincide with the start of the hayfever season.

Hayfever is often thought of as a minor inconvenience - causing a slight stuffy nose, itchy eyes, an occasional sneezing fit ... But for many of the 18 million hayfever sufferers in Britain, it can cause significant distress. I know that when my hayfever flares up, I feel tired, heady and lose my concentration easily. Poorly controlled hayfever can lead to an asthma flare up and is a common trigger of sinusitis and ear infections at this time of year. So it's essential to make sure you are using the right medicines and products to ease your hayfever symptoms.

According to Allergy UK, millions of people don't find that their hayfever medicines effectively control their symptoms - and this is usually down to user error. New research by the charity reveals that while one in three hayfever sufferers use a corticosteroid nasal spray, only 14% are using it correctly. This means that for 86% of nasal spray users, the product won't work for them.

During Allergy Awareness Week, Allergy UK is urging hayfever sufferers to speak to their local pharmacist about their symptoms and how to use the nasal sprays properly. The key is to tip your head forward while looking down, insert the nozzle and spray towards the outside of your nose. Your pharmacist should be able to give you a demonstration if you are having problems with your technique.

If you use antihistamines for your hayfever, check that you are using the right one. According to Allergy UK research, 12% of hayfever sufferers are using sedating antihistamines (e.g. chlorphenamine), which can make you feel drowsy. You would be far better off sticking to one-a-day antihistamine products (e.g. those containing cetirizine, loratidine or acrivastine), as these won't affect driving, work or your social life.

With any over-the-counter medicines, always ask the pharmacist before you buy, to make sure the products are suitable for you and won't interact with anything else you are taking.