Public News

A regular visitor to your pharmacy asks to talk to you about a rash on his face. It has been present for many years, but he wants to try and improve his appearance as his granddaughter is due to be Christened, and the family have hired a professional photographer for the event.

QUESTIONS

1. This condition only occurs on the face of adults and is never seen in childen. True or false?

2. Moderate strength steroids are the treatment of choice in this condition. True or false?

3. The condition tends to be associated with outdoor life, sun and exposure cold weather. True or false?

4. The condition is usually easily reversible once the cause has been found. True or false?

5. When occurring is a very localised area, this rash may be a sign of underlying malignancy. True or false?

DISCUSSION

1. False. Although this condition is most common on the face, it can occur anywhere on the body and at any age.

2. False. This condition is called telangiectasia, which can be caused by strong topical steroids.

3. True. It is more common in those who work outside, such as farmers.

4. False. The condition is not usually reversible, and usually requires physical therapy such as cautery or laser treatment.

5. True. Nodular basal cell carcinomas offer develop telangiectasia on the surface.

The British public has coughed up a total of £265 million for cold and flu remedies in the last year, but only £76m was spent in pharmacies – an 8 per cent fall from the previous year (Kantar Worldpanel value sales, 52 weeks to August 8, 2010).

Last autumn saw a flurry of excitement in the cold and flu remedy market, as it was predicted a winter swine flu epidemic would boost already-buoyant sales after a slight uplift in cold and flu remedy sales during the summer of 2009.

But when the anticipated increase in swine flu cases failed to materialise, the summer sales spike meant that consumers had already stocked up their medicine cabinets and did not need to buy extra supplies during the winter.

Despite the swine flu scare, 2009-10 actually saw a lower than average incidence of colds and flu. Combined with the growth of cheaper own label products and a heightened level of promotional activity, this resulted in less money being spent on cold and flu remedies.

The unseasonable sales uplift during last year’s summer was followed by a three-year low in sales, with multi-symptoms products bearing the brunt of this downturn (Nielsen value sales 21 weeks to January 23, 2010).

The market returned to value and unit growth during the first half of 2010, although the pharmacy channel still lagged behind in some sectors, including multi-symptom and cough products. Pharmacy sales were stronger in the decongestant sector (Nielsen, 26 weeks to July 10, 2010).

Decongestant sales up

Jane Westgarth, senior retail analyst at Mintel, says: “The market for decongestants has been stimulated by the growing trend for consumers to use this medication to relieve the symptoms of hayfever and allergies.

“This in turn has helped to spread more of the sales throughout the year, with less of an emphasis on winter seasonal sales.”

Mintel research shows that Boots was the single largest retailer of cough, cold and flu remedies in 2009 with an estimated 22 per cent share, closely followed by Tesco with 20 per cent; other grocery multiples accounted for 26 per cent while other pharmacies/drugstores had a 23 per cent slice of the market.

“Pharmacies are losing their dominance of the winter remedy sector to grocery multiples, which offer greater convenience as well as lower-priced, own-label alternatives,” says a new Mintel report on cold, flu, cough and throat remedies.

But although pharmacy is losing out to grocery in GSL sales, GSK Consumer Healthcare says that pharmacy-strength products and P-line pack sizes can continue to drive sales through the pharmacy channel, especially where professional advice is called for.

Independent and high street pharmacies retain the lion’s share of P-line business, being responsible for 81 per cent of P-line sales compared to just 19 per cent going through in-store pharmacies within grocery multiples (Nielsen value share, year ending July 10, 2010).

Highlight P-meds

Lynne Henshaw, Numark’s director of marketing, advises pharmacies to highlight the message that P medicines are available at the counter.

She says: “Direct your customers to ask for advice – this is, after all, your USP from the grocers.”

She also points out: “It is vital that you don’t forget about children’s medicines. Parents are more likely to purchase for their children than they are for themselves. So it’s essential to display winter remedies for children in a visual position.”

And she adds: “Don’t forget many of your customers suffering with a cough or cold may already be feeling poorly, so make the selection process as simple as possible.”

GSK research shows that those with heavier colds and more personal stress find supermarket shopping particularly unpleasant (in terms of noise, etc) in contrast to shopping at a pharmacy, which was viewed as a more positive experience. When a cold is unfamiliar or a new symptom is experienced, pharmacist advice is also more likely to be sought.

Mintel reports that cold and flu remedies are widely accepted by consumers, with 57 per cent always keeping a supply at home. Half of adults would treat a slight temperature without consulting their doctor, while fewer than three in 10 do nothing and wait for these symptoms to clear up on their own.

When it comes to the methods people choose to alleviate cold and flu symptoms, tablets are the most popular format, with 41 per cent of consumers saying they use them. This is followed by powdered drinks, which are preferred by 29 per cent of people, and capsules, which are used by 24 per cent of consumers.

New ways to treat

Reckitt Benckiser (RB), which is the overall winter remedies market leader with the Lemsip brand, says shoppers are always looking for new and more effective ways of treating their cold or flu symptoms. With its launch of Lemsip Max Lemon Flavour Tablets (see p25), RB is offering consumers the flexibility to choose the product as a tablet or as a hot drink. The company is backing the launch this autumn/winter with a £7m campaign that includes TV and radio advertising.

GSK is also planning to invest £6m in a winter multi-media campaign for Beechams Ultra All in One, which is the strongest all-in-one range from the brand. With this level of investment, the top two winter remedy giants are hopeful their promotional activity will help drive cold and flu product sales in the coming months.

An RB spokesperson comments: “2010-11 looks set to return to stronger growth, perhaps closer to those seen in the 2008-09 season, which would mean growth levels of up to 6 per cent.”

5 tips for boosting winter remedies sales

1. “Ensure beacon brands that are TV-advertised are given adequate space in the pharmacy at the expense of slower-selling products.”
Ed Round, marketing manager,Thornton & Ross

2. “Dummy packs of P-med cough and cold medicines let the customer know that there are other products behind the pharmacy counter. This also gets them access to advice from the pharmacy team.”
Angela Chalmers, pharmacist, Boots

3. “Stocking the market leader in a sub-category will help signpost the customer to the right section. Use brands to clearly define shelf section by symptoms.”
Rob Jackson, UK pharmacy shopper-based design manager, P&G PharmacyCare

4. “Off-shelf displays in the key months of November, December and January are essential to encourage impulse sales, avoid out-of-stocks, tempt non-treaters and drive premium products.”
Spokesperson, GSK

5. “Utilise a gondola end to highlight winter medicines, not gifts!”
Lynne Henshaw, director of marketing, Numark

Best-selling brands: winter remedies

Total market
1.    Lemsip
2.    Beechams
3.    Benylin
4.    Boots own label
5.    Strepsils
6.    Sudafed
7.    Covonia
8.    Vicks
9.    Tesco own label
10.   Olbas

Pharmacy
1.    Boots own label
2.    Benylin
3.    Lemsip
4.    Covonia
5.    Sudafed
6.    Vicks
7.    Strepsils
8.    Olbas
9.    Night Nurse
10.    Beechams
Source: Kantar Worldpanel value sales, 52 weeks to August 8, 2010

For a full breakdown of product subcategories, click here

How the subcategories compare

Total market              
Cold treatments    £75m    28.3%    -6%
Cough liquids    £68.9m    26%    +3%
Cough/throat lozenges    £60.1m    22.7%    +5%
Decongestants    £60.9m    23%    -4%
Pharmacy              
Cold treatments    £17.2m 22.5%  -15%
Cough liquids    £24.7m    32.4%    -3%
Cough/throat lozenges    £14.4m    18.8%    -2%
Decongestants    £20m    26.2%    -13%

Source: Kantar Worldpanel value sales 52 weeks to August 8, 2010

Brands V own label products

Total market
Brands         83.8% -2%
Own label    16.2% -3%

Pharmacy
Brands         79% -10%
Own label    21% -4%

What are the risk factors?
There is a small genetic link, with around 25 per cent of patients having a history of bowel inflammation. Acute stress can play a major role in triggering relapses. Smoking has contradictory effects; smokers are more prone to Crohn’s than non-smokers, but are less prone to UC. Environmental factors such as diet and lifestyle may play a role.

How does IBD present?
Patients with IBD present with non-specific symptoms, such as severe diarrhoea, abdominal pain, cramping, fever, anorexia, nausea and vomiting. Symptoms tend to be of long duration and fail to respond to treatment. Patients with severe diarrhoea of more than 24 hours’ duration should be referred to a GP.

Other features include very frequent bowel movements with stools consisting of little more than blood, mucus and perhaps pus, malaise, and weight loss.

Inflammatory bowel disease (IBD) is a collective term covering two chronic diseases that mainly affect the GI tract. It affects one in 500 people in the UK and is characterised by progressive damage to the gut wall, usually in the large and/or small intestine, with resultant abdominal pain, diarrhoea and eventual deteriorating function.

Although IBD is mainly a disease of the bowel, there can also be serious inflammatory damage to other tissues, such as the eye and the joints.
IBD consists of Crohn’s disease and ulcerative colitis (UC), the former being the more serious. Crohn’s can affect any part of the gut, progresses faster than UC, is more likely to have serious complications and is more resistant to treatment. Patients with Crohn’s tend to have poorer outcomes.

By contrast, UC is generally less debilitating. It is restricted to the rectum and colon and fewer patients are seriously ill for long periods. It also affects an older group of patients than Crohn’s. See table 1, below, for a comparison of the clinical aspects of the two conditions.

Causes and risk factors
As with most autoimmune diseases, IBD has some genetic links, but these are not strong: about 25 per cent of patients have a family history of bowel inflammation, and the concordance rate for identical twins is about 35 per cent for CrohnÕs and 10 per cent for UC.

Certain HLA (histocompatibility) genes predict a predisposition to IBD, and there is overlap with other autoimmune conditions. For example, HLA-B27 is found in IBD and ankylosing spondylosis.

It is currently believed IBD is caused by a fault in immune recognition, which persuades the body to mount an inflammatory-immune response to gut tissues. This is commonly associated with or triggered by an intestinal microbe, such as the measles virus. However, the precise connection of microbes to the disease process is uncertain.

Other aetiological factors for IBD have been sought but no unequivocal influences have been found. Industrialised countries have the highest rates of IBD, which are increasing in these areas. Certain ethnic groups have different prevalence,  for example Crohn’s is more common among people of Jewish descent. Dietary and other lifestyle factors have also been implicated, with prevalence changing following migration to another area suggesting environmental factors.

Acute stress can play a major role in triggering relapses. Smoking has contradictory effects; smokers are more prone to Crohn’s than non-smokers, but are less prone to UC. Both genders are equally affected.
Crohn’s and UC can both start in early adulthood, although patients with Crohn’s tend to be younger. A further cohort of patients can suffer their first UC attack in middle age.

Pathology

In Crohn’s disease the entire thickness of the gut wall is affected, with inflammatory swelling significantly reducing the gut lumen. In severe cases this can lead to intestinal obstruction.

Inflammatory lesions can occur simultaneously in various parts of the gut, and appear anywhere from the mouth to the anus, although in 95 per cent of patients only the small and/or large intestine is affected. These discontinuous disease areas are referred to as skip lesions.

In UC usually only one, continuous, strip of gut is affected, most commonly either in the rectum or the distal (sigmoid) colon. Inflammation is restricted to the gut lining, so obstruction is not a problem. Indeed the opposite, toxic megacolon, is a potential complication.

Signs and symptoms

The classic features of an acute IBD attack or exacerbation may superficially resemble nonspecific abdominal upset, gastroenteritis or acute abdomen, with severe diarrhoea, abdominal pain, cramping, fever, anorexia, nausea and vomiting.
Key features to look for when a patient first presents with IBD include the duration and chronicity of the condition, and failure to respond to standard non-specific remedies. Patients who present with severe diarrhoea of more than 24 hours’ duration should be referred to a GP.

Other features include very frequent bowel movements (often more than 10 times daily) with stools consisting of little more than blood, mucus and perhaps pus; malaise; and weight loss. Crohn’s is usually more insidious in onset, and is associated with greater weight loss than UC.

Diagnosis

Blood tests in a patient with IBD will reveal typical signs of systemic inflammation, with a raised erythrocyte sedimentation rate (ESR) and plasma C-reactive protein.

There will also usually be anaemia, perhaps exacerbated by iron deficiency from malabsorption and anorexia. In Crohn’s, malabsorption may also cause hypoalbuminaemia and possibly hypovitaminosis (eg folate, B12).

In either disease, severe and prolonged acute attacks of diarrhoea may cause dehydration, with reduced blood pressure, tachycardia and possibly hypokalaemia. Other tests required include liver function tests and stool examination for pathogenic microbes and blood.

The definitive diagnosis of IBD relies on imaging. For colonic disease, a barium enema or colonoscopy/sigmoidoscopy is standard. If disease in the ileum is suspected, access is more difficult as colonoscopes cannot penetrate further back than the caecum. Similarly, duodenoscopes cannot penetrate very far along the ileum from the stomach.

Alternatively, a barium meal with follow-through can be used, where a radio-opaque test meal is followed radiologically for an extended period. Areas affected by Crohn’s will show up as a grossly narrowed lumen (called the ‘string sign’). It is also possible to inject radio-labelled leucocytes and scan the patient for hotspots, because inflammatory cells will concentrate at sites of inflammation.

CT and MRI scanning may also be used. Otherwise, laparotomy may be needed, using modern keyhole techniques to inspect the abdomen directly with an endoscope. Endoscopy also allows tissue samples to be taken for biopsy, which may help in identifying inflammatory cells or possible neoplasia.

An emerging technique is capsule endoscopy. In this a miniaturised video camera is fitted inside a capsule small enough to be swallowed. It transmits pictures of the interior of the gut wirelessly at intervals, until expelled in the faeces. This technique can be used when all other tests have failed to locate a lesion, but it is expensive as the instrument is not reusable.

The course of IBD

IBD is a chronic progressive disease characterised by relapses and remissions. In about 10 per cent of patients the disease remits permanently, while about 20 per cent of patients progress to severe disease, with almost continuous ill health and the eventual need for surgery.

However, most patients with UC experience long periods of relatively normal health, although they usually require maintenance therapy. Life expectancy is not significantly reduced, and the effect on work may be minimal.

Crohn’s tends to follow a more debilitating course, with a greater proportion of sufferers experiencing prolonged ill health, more frequent relapses and hospital admissions, and greater weight loss. Life expectancy is slightly reduced.

Up to three quarters of Crohn’s patients will need surgery. However, surgical excision of one or more problem areas (with rejoining of the gut) rarely solves the problem; the disease tends to subsequently flare up again elsewhere in the gut.

Because frequent operations have a cumulative risk and a progressively debilitating effect in themselves, surgery is delayed as long as possible. On the other hand, surgery for UC patients may be practically curative, although it may leave the patient with a stoma.

Complications

In UC, sudden gross swelling of the colon (toxic megacolon), often associated with infection, may occur. This may cause perforation of the intestinal wall and resultant peritonitis.

Crohn’s disease tends to cause more frequent intestinal perforation than UC, because although the GI wall is thickened in the condition it is insubstantial and has deep, ulcerated clefts. It therefore tends to cause fistulas through to other intestinal organs, such as the bladder, or even through to the surface of the abdominal wall. Perforation and abscesses are also quite common, and obstruction can occur.

These should be considered a medical emergency requiring surgery. Both Crohn’s and UC predispose patients to colon cancer after about 10 years, especially if the condition is poorly controlled. Therefore regular screening is necessary.

There are also possible extra-intestinal inflammatory complications that may affect patients with Crohn’s or UC. These include limb joint arthritis (up to 20 per cent of patients), spondylitis, iritis, hepatitis and dermatitis. These may either follow the course of the underlying disease, or follow an independent course (and may be the cause of first presentation).

From suncare to eczema, the skincare market is worth £2bn in the UK. Hannah Flynn looks at how pharmacists can boost their share of this diverse sector

The skincare market, including suncare, was estimated to be worth £2 billion in the UK in 2009, according to market analyst Key Note. This represents a year-on-year rise of 5 per cent, and skincare makes up over a quarter of total value sales of toiletries in the UK.

It is a diverse market, but there are several distinct areas in which pharmacists can focus their efforts to ensure customers are getting the most out of their products, and boost their own sales in the process.

Eczema and dermatitis

Pharmacy’s share (excluding Boots and Superdrug) in the eczema and dermatitis market decreased in 2009, according to data analyst Nielsen. It is currently worth £13.6 million, representing a decline of 8.5 per cent, year-on-year. The total market is worth £40.9m, and has experienced a slower decline of 2.5 per cent over the past year.

Despite this, the past year has seen launches in this subcategory of the skincare market. Thornton & Ross this month announced the launch of a Derma division, which will focus on the prescription emollient sector. According to data from analyst IMS, this sector is worth £120m and is experiencing 8 per cent year-on-year growth.

Janet McClean, marketing manager of the new Derma division at Thornton & Ross, says this sector is stable as it treats a chronic condition.

Ms McClean explains: “I think the market is going to grow as eczema affects one in five children and one in five adults. The population is increasing and things like allergens and other environmental triggers can affect it.”

Rates of eczema have increased over the past 10 years, adds Pasante Healthcare managing director Lawrence Boon, which distributes sensitive skincare product range Sebamed. He says there was a 42 per cent rise in the number of eczema cases diagnosed between 2001 and 2005, and also cites a 40 per cent rise in sales of the Sebamed range over the past year.

Mr Boon says: “Customer understanding of science has increased and they are asking for more from their products and want to know what     it contains besides vanilla essence.”

Acne and medicated skincare

The medicated skin care subcategory is worth £76m, according to market analyst SymphonyIRI Group, which represents an 10 per cent decline year-on-year. However, acne is a condition that was highlighted in the PAGB’s annual report as a minor ailment that could be treated with OTC medication. Though there is an overall downward trend in this area, the medicated skin treatment format – which represents almost a fifth of the subcategory – has grown by 9 per cent over the past year, according to IRI. Cleansers, which make up a further fifth of the subcategory, are also showing growth – of 4 per cent.

Anti-ageing and cosmetic skincare

Growth in the skincare market continues to be driven by premium-priced anti-ageing formulations, according to a Key Note report.

One notable event in the area this year was the repackaging of Astral, a heritage product that is currently the focus of a £500,000 campaign citing the benefits the product offers to ageing skin. This followed clinical research into the effects the cream has on skin on women over 50.

Camouflage products are also becoming increasingly popular. Lloydspharmacy offers a Dermablend service at its London Selfridges store (see case study, below) and Varama Covercream is currently going through approvals to be made available on prescription, according to Vanessa Jane Davies, the creator of the product. She says GPs generally direct patients to occupational therapists, who offer skin camouflage services in hospital, but thinks making the product available on prescription as well will help customers considerably.

Four tips to boost your skincare sales

1 “Take just one line which includes face and body products and sell it as a whole system so the products become a skincare system rather than individual products.”
Lawrence Boone, managing director, Pasante Healthcare

2 “People with chronic conditions react differently to different products and should be offered help to find what works for them. We offer 30g samples so patients can try our products first; pharmacists should suggest this to patients.”
Janet McClean, marketing manager, Derma division, Thornton & Ross

3 “Pharmacists need to ask patients about previous treatments to help identify where treatment went wrong and where it can be improved.”
Aini Alcock, lead clinical pharmacist, Sheffield Teaching Hospitals Foundation Trust

4  “Skincare is very experimental and pharmacists need to help keep their patient’s spirits up while they try to find the products that work for them.”
Ann Hart, pharmacist, Lloydspharmacy, Selfridges

Market changes 2009-10 Medicated skincare

Total market value
£76,127,600 – down 10.3%

Pharmacy**   
£3,738,737 – down 24.4%

Grocery*    
£71,407,080 – down 9.1%

Dry skin treatment

Total market value
£73,710,304 – up 1.9%

Pharmacy*   
£48,883,536 – down 0.8%

Grocery**    
£23,499,328 – up 8.7%

*includes Boots and Superdrug
**excludes Boots and Superdrug

Source: SymphonyIRI Group,
52 weeks to August 7, 2010

The medicated skincare market – how the formats compare

Wash 27 per cent (down 12 per cent)

Toner/2-in-1 1 per cent (down 39 per cent)

Moisturiser  4 per cent (down 16 per cent)

Soap  0 per cent (down 29 per cent)

Body products  0 per cent  (down 54 per cent)

Treatment 19 per cent (up 9 per cent)

Strips 4 per cent (down 28 per cent)

Wipes 9 per cent (down 29 per cent)

Pads 4 per cent (down 32 per cent)

Cleanser 18 per cent (up 4 per cent)

Other 14 per cent (down 17 per cent)

Source: SymphonyIRI Group, to June 12, 2010

Tips for your CPD entry on skincare

Reflect  Are my patients getting the most out of skincare products?

Plan Review my and my staff’s knowledge and sales protocols.

Act Read this article, revise common skin conditions such as eczema and acne, review available products and arrange training as necessary.

Evaluate Do my patients get better advice on managing skin conditions?

A middle aged man presents his prescription at the Update Pharmacy and asks to speak to the pharmacist. Pharmacist David Spencer comes to see him in the consultation area.

As he hands over his prescription, the man says: “My GP and the practice nurse say you run a stop smoking programme with a high success rate that can help me.”
David nods. “Can you tell me a bit about your situation? Have you tried giving up before?”

“Several times, I just can’t do it. But I have managed to cut down.”

“So, how many do you smoke?” asks David.

“On a good day, 10 cigarettes, on a bad one up to 20. But I was up to 40 a day at one time. I know it’s killing me – I’ve had a heart attack and had to have a by-pass operation, and I’ve also got diabetes. But the doctor says there’s still time to improve my health and my life expectancy – as long as I give up now, before it really is too late.”

David looks at the man’s prescription. It reads: Humalog insulin mdu; lisinopril 10mg tablets

i od; aspirin 75mg i om; simvastatin 40mg tablets i on.

“We’ll do our very best to help you,” David says, “and once you actually stop smoking I’ll give you some advice connected with your medicines.”

Questions

1. What advice will David give?

2. Aside from any on this prescription, which other medications may be affected by stopping smoking?

3. Which NRT presentation/s are most suitable for which type of smoker?

Answers

1. To monitor blood glucose levels carefully, as insulin absorption may be increased by stopping smoking. Insulin dose may need to be reduced.

2. Anti-psychotics: blood levels of several increased, effect with clozapine potentially most serious.

• Beta-blockers: effects can be enhanced, increasing blood pressure and heart rate.

• Theophylline/aminophylline: plasma levels may be increased; important as theophylline has a narrow therapeutic index and toxic effects may ensue.

• Warfarin: possible increase in INR. • Zolpidem: clearance reduced, possible increased sedation.

3. Low dependency (less than 10 cigarettes/day): lozenges, sublingual tablets or 2mg gum (Low dependency and high motivation to quit: encouragement and advice only). Moderate dependency (10-20 cigarettes/day), with low behavioural component* and normal or heavy build: patch**, starting with highest strength.

Moderate dependency, low behavioural component, slight build: patch, starting with middle strength (where available). Moderate dependency, high behavioural component: inhaler, sublingual tablets or 2mg gum (switching to 4mg if necessary); High dependency (more than 20 cigarettes/day): 4mg gum or lozenges or nasal spray. Very high dependency: nasal spray.

*Behavioural component: where part of the addiction is ritual behaviour associated with lighting, holding and inhaling a cigarette.

** 24-hour patch is better for smokers who crave a cigarette within 20 minutes of waking up.

16-hour patch should be used if sleep disturbances occur.

Multiple sclerosis (MS) is the most common cause of neurological disability among white populations in temperate regions.1 In Europe and North America the prevalence is one in 800 people, and the incidence two to 10 per 100,000.

It is most often diagnosed between the age of 20 and 40 years and is more likely to affect women than men. The life expectancy of people with MS is on average around 10 years less than that of the general population.2 However, it is rare for MS to be the direct cause of death.

The main symptoms of MS result from the damage in the brain and spinal cord. They include weakness, fatigue, numbness, tingling, depression, bladder, bowel and sexual dysfunction, visual problems, pain, cognitive deficits and ataxia (loss of muscle co-ordination). Other related symptoms include contractures, urinary tract infections, osteoporosis, muscle atrophy and skin breakdown.3

Problems with mobility can mean people with MS lose their jobs and suffer the consequent problems with status and their social life, and can become isolated and depressed.

The cause of MS is not known, although there is evidence it may be an autoimmune disorder triggered by environmental factors in individuals genetically predisposed to develop MS.1

There is also some debate about whether MS is a single condition or a cluster of disorders with distinct characteristics that clinicians do not yet have the tools to separate sufficiently clearly.

The three types of MS

There are three main types of MS, which are characterised by the course the condition takes, namely relapsing-remitting, primary progressive and secondary progressive:4

1. Relapsing-remitting MS The most common form of the disease, relapsing-remitting MS is characterised by attacks followed by periods of recovery and of no disease progression. These are believed to reflect a pathological process of inflammation that causes damage and then subsides, and is followed by healing that results in the formation of myelin plaques.

The lesions have been used as a surrogate marker for the disorder, but their relationship with the progression of disability associated with the disease is controversial.

The symptoms seen in MS are thought to be due to an immune response that damages the myelin sheath around the nerves; however, as well as targeting myelin (and the oligodendrocytes that make myelin), the acute inflammatory process can damage axons and their cells, the neurons. Axonal and neuronal loss can be seen on MRI as black holes, even at the earliest stages of the disease.5

Relapsing-remitting MS affects around 85 per cent of people with MS at the outset; on average, relapses varying from mild to severe last for about four to six weeks and occur slightly less than once a year.

2. Secondary progressive MS follows on from relapsing-remitting MS with gradually more or worsening symptoms. Clear evidence of sustained deterioration for at least six months that is independent of the effect of relapses confirms that the patient’s condition has evolved from relapsing-remitting to secondary progressive MS.

Typically, 65 per cent of people with relapsing-remitting MS will have developed secondary progressive MS after 15 years.3

3. Primary progressive MS exhibits a slow progression of disability from the start, with no relapses or remissions. Commonly, it is diagnosed later than relapsing-remitting MS, and affects men and women equally. Problems tend to occur in one main area and often relate to walking. This may be because the spinal cord is affected more than the brain, and so bowel, bladder and sexual function may be compromised. Primary progressive MS occurs in 10 to 15 per cent of people diagnosed with MS.

Two further classifications are benign and malignant MS:

* Benign MS is where MS symptoms do not become worse after 10 to 20 years and there is little or no disability. This is the case in around 10 to 30 per cent of people with MS. However, MS is rarely completely problem free, and a relapse can happen after years of inactive disease.

* Malignant MS is also know as Marburg’s disease or acute MS, and is a rare form that develops rapidly, leading to severe disability or death within a year.

Diagnosis

Diagnosing MS is difficult because there is no single specific diagnostic test. A thorough neurological history and examination together with MRI scan and cerebrospinal fluid testing are required, but are not enough on their own Ð a diagnosis can be made only if there is no other explanation for the patient’s symptoms.2

Nice says the diagnosis of MS should be made clinically by a specialist clinician, on the basis of evidence of CNS lesions separated in space and time, and a history and examination.4

Nonetheless, GPs should suspect MS in any young adult with symptoms including:
– double or blurred vision
– poor balance and coordination
– muscle weakness (often in legs)
– stiffness or spasticity in muscles
– altered sensation (numbness, tingling or a burning feeling)
– slurred speech
– fatigue inappropriate to activity
– bladder and bowel problems
– impotence
– forgetfulness and poor concentration.
After diagnosis, according to the Nice guidelines, an individual should be:
– offered at least one more appointment in the near future to see, wherever possible, the doctor who gave the original diagnosis
– put in touch with an MS nurse, or other professional with specialist knowledge of MS or other neurological conditions and counselling experience
– offered written information about local and national disease-specific support groups, including details of local rehabilitation services
– offered information about the disease, preferably in the form of an information pack, specific to the newly-diagnosed (the MS Society produces an information pack for recently diagnosed patients)
– offered the chance to take part in an educational programme on all aspects of MS within six months of diagnosis.
MS nurses generally provide a comprehensive service to people newly diagnosed with MS and work with the primary health care team on meeting Nice guideline requirements.

The first symptom in about 20 per cent of patients with MS is optic neuritis. Nice says “every individual presenting with an acute decline in visual acuity, with or without associated pain, should be seen by an ophthalmologist for diagnosis”.
The Nice guidelines also state that if the diagnosis of optic neuritis is confirmed and no other specific cause is identified, the ophthalmologist should discuss the potential diagnosis with the individual and refer them to a neurologist for additional assessment. The guidelines acknowledge the anxiety and potential problems with insurance that a possible diagnosis of MS might raise.4

To help patients maintain their quality of life, people with MS will need support from a multidisciplinary team of health professionals to manage a range of related symptoms including:

– fatigue
– bladder dysfunction
– bowel problems
– weakness and cardio-respiratory fitness
– spasticity and spasms
– contractures at joints
– ataxia and tremor
– visual problems
– pain
– sensory loss
– cognitive loss
– depression
– anxiety
– emotionalism
– swallowing difficulties
– speech difficulties
– sexual dysfunction
– pressure ulcers.

The MS Society guide3 emphasises that it is particularly important that primary care professionals are aware of the hidden symptoms of MS, which can include cognitive dysfunction, depression or other mood changes, sexual dysfunction, pain, fatigue, and bladder and bowel problems.

“Often, people with MS neglect to mention such symptoms, either because they are unaware of their relationship to MS or are too embarrassed to talk about them,” says the organisation.

“It is important to ask people with MS about any new or uncomfortable problems they may be experiencing at every opportunity, and to understand the complex pattern of disability that can arise from MS symptoms, and the impact of treatment. For example, anti-spasticity and antidepressant agents can exacerbate fatigue.”3

Steve Titmarsh MRPharmS is a former editor of the journal Progress in Neurology and Psychiatry

A new era in the struggle against multiple sclerosis

News that the US FDA’s peripheral and central nervous system advisors have recommended it should approve the new oral treatment for relapsing-remitting multiple sclerosis, fingolimod, must come as a real fillip to many patients with the disease.

Current disease modifying drugs for MS are administered by regular injection, but the new drug is both the first oral disease-modifying treatment for MS, and the first of a new drug class known as sphingosine-1 phosphate receptor modulators.6

In another move, the effective legalisation of components of cannabis as Sativex spray for the relief of spasticity associated with MS will come as good news to many and has long been advocated by some MS sufferers as providing effective relief from some symptoms of MS that impact significantly on quality of life.

For MS patients for whom the available drug treatments do not work or who have a form of MS for which current treatments are not licensed, these items of news may also provide hope that progress is being made in the fight against what is potentially a severely disabling condition that can even prove fatal for those with its most aggressive manifestation.

Clinically isolated syndrome

Clinically isolated syndrome (CIS) is an episode of symptoms suggestive of multiple sclerosis (MS) that results from demyelination Ð damage to the myelin sheath around the nerve cells Ð in one or more areas of the central nervous system, a hallmark of MS.

Confirmation that a person has a CIS is made by carrying out tests such as magnetic resonance imaging (MRI) and eliminating all other potential causes. Symptoms of CIS depend on where in the CNS damage occurs and can include: optic neuritis, muscle weakness, bladder and bowel problems.

More than eight out of 10 people who have clinically isolated syndrome are eventually diagnosed with MS.1

A new era in the struggle against multiple sclerosis

News that the US FDA’s peripheral and central nervous system advisors have recommended it should approve the new oral treatment for relapsing-remitting multiple sclerosis, fingolimod, must come as a real fillip to many patients with the disease.

Current disease modifying drugs for MS are administered by regular injection, but the new drug is both the first oral disease-modifying treatment for MS, and the first of a new drug class known as sphingosine-1 phosphate receptor modulators.6

In another move, the effective legalisation of components of cannabis as Sativex spray for the relief of spasticity associated with MS will come as good news to many and has long been advocated by some MS sufferers as providing effective relief from some symptoms of MS that impact significantly on quality of life.

For MS patients for whom the available drug treatments do not work or who have a form of MS for which current treatments are not licensed, these items of news may also provide hope that progress is being made in the fight against what is potentially a severely disabling condition that can even prove fatal for those with its most aggressive manifestation.

Reflect

Who is most likely to be affected by multiple sclerosis? What are the main types of MS and the differences between them? What does Nice recommend for newly diagnosed MS patients?

Plan

This article describes multiple sclerosis and includes information about its different types, symptoms and diagnosis. The Nice guidelines for newly diagnosed patients and the help health professionals can give is also discussed.

Act

Find out more about MS and how it interferes with nerve function from the Multiple Sclerosis Resource Centre (MSRC) website at http://tinyurl.com/msclerosis 1.

– Read more about the causes of MS on the MSRC website at http://tinyurl.com/msclerosis 2.
– Find out more about how MS is diagnosed from the Multiple Sclerosis International Federation website at http://tinyurl.com/msclerosis 3.
– Find out more detailed information about the symptoms of MS including optic neuritis, pain,
bladder and bowel problems, spasticity and cognitive problems from the MSRC website at http://tinyurl.com/msclerosis 5.

Evaluate

Are you confident in your knowledge of the types of multiple sclerosis, how the disease affects the nervous system and its main symptoms? Do you know how MS is diagnosed and about the help and advice health professionals can give?

It is Saturday afternoon, and the local GP surgery is closed. A very anxious teenager comes in, worried she has a tumour adjacent to her nail on her big toe. Her grandfather died several years ago after a similar looking lesion higher on his leg, which was diagnosed very late as a squamous cell carcinoma.

Questions

1. There is a high chance that this is a malignant skin lesion. True or false?

2. An urgent appointment is not required. However, treatment with antibiotics is required. True or false?

3. One treatment option is the use of silver nitrate, which can be directly applied to the granulomatous tissue. True or false?

4. Once applied, the silver nitrate will cause the skin to turn black. This is normal and will fade with time. True or false?

5. A chiropodist would be a better choice of therapist than a GP in the treatment of this condition. True or false?

DISCUSSION

1. False. Although squamous cell carcinomas can assume many different guises, this type of skin cancer would be very unlikely in a teenager. This is actually granulomatous tissue caused by an underlying in-growing toenail.

2. False. There is no sign of pus or redness in this case to suggest an infection.

3. True. Silver nitrate used for warts and verrucas can be applied directly, and after a few days will cause the tissue to reduce in size.

4. True. However, ideally only the granulomatous tissue should be touched with the silver nitrate and care is required on application.

5. True. Chiropodists can offer a wider range of treatment for in-growing toenails than GPs.

After a week’s camping holiday this child has developed multiple red spots, which were widespread over his whole body. The child has been scratching the spots, and hadn’t slept very well the night before.

The father requests treatment for insect bites which he assumes have come from the camping holiday. He says other members of the family weren’t affected. Close inspection reveals small blisters at the site of each spot, some of which has crusted over.

QUESTIONS

1. This is a typical presentation of insect bites, with large areas of the body affected at the same time. True or false?

2. As in this case, insect bite rashes usually develops a few days after the initial bites are received. This is the result of an allergic reaction to the bite. True or false?

3. Although other members of the family aren’t affected, this condition is contagious. True or false?

4. An elderly relative currently has shingles, and had been in contact with the child a week before. This is the likely source of the rash. True or false?

5. Urgent referral to a GP is recommended so that antiviral medication can be prescribed within the first 48 hours. True or false?

DISCUSSION

1. False. Insect bites usually occur in clusters where the insect has come into contact with the body.

2. False. This rash is typical of chicken pox, not insect bites, with widepread vesicles and crusting on older lesions.

3. True. Chicken pox is caused by a virus which is present in the vesicles. Generally immunity develops after the first infection and so recurrent infection is uncommon.

4. True. Although shingles can’t be caught, it is caused by the same virus which causes chicken pox. Shingles lesions will shed this virus which can cause chicken pox.

5. False. In an otherwise fit and healthy child antiviral medication isn’t recommended.

Following the publication of Nice guidelines on the pharmacological management of neuropathic pain, Gavin Atkin explains what you need to know

Nice guidance published in March outlines the recommended approach to managing patients suffering from neuropathic pain in primary care, and also hospital care where no specialist pain service is immediately available. A wide range of drugs is used to manage neuropathic pain, including antidepressants, anti-epileptics (anticonvulsants), opioids and topical treatments such as capsaicin and lidocaine. Many patients require treatment with more than one drug, but the correct choice of drugs and the order in which they should be used has been unclear, not least because guidelines in this area have been inconsistent.

1. Neuropathic pain arises from damaged or dysfunctional nerves, and can be due to a range of disorders affecting the peripheral and central nervous systems, including diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia.

2. People with neuropathic pain may experience altered pain sensation, areas of numbness or burning, and continuous or intermittent evoked or spontaneous pain. Neuropathic pain is an unpleasant sensory and emotional experience that can have a significant impact on a person’s quality of life.

3. Neuropathic pain remains difficult to treat because it is resistant to many medications and the effective treatments have adverse effects.

4. Patients should be referred to a specialist pain clinic or disease-specific specialist at any stage if their pain is severe or limits daily activities, or their underlying health deteriorates.

5. Patients’ concerns and expectations should be addressed when agreeing which treatments to use, and these are likely to include the benefits and possible adverse effects of pharmacological treatment, coping strategies for dealing with pain and the adverse effects of drugs, and non-pharmacological treatments including surgery and psychological therapies.

6. The selection of treatments should take comorbidities, safety issues and contraindications into account, as well as mental health problems. The titration process must be explained, and when withdrawing or switching treatment, doses should be tapered. Clinicians should consider overlapping treatments to maintain the pain control.

7. Patients should be reviewed shortly after a change in treatment to ensure it is suitable, and should be reviewed regularly.

8. In patients where the source of pain is not associated with diabetes, the first-line treatments are oral amitriptyline starting at 10mg/day gradually titrated upward to the maximum tolerated dose up to 75mg/day, or pregabalin starting at 150mg/day (or less in some patients) in two daily doses with upward titration to the patient’s maximum tolerated dose of no higher than 600mg/day. If satisfactory pain reduction is not achieved with first-line treatment at the maximum tolerated dose, the patient should be referred to a pain clinic or offered another drug in addition or as an alternative to their first-line treatment. The third-line options are oral tramadol and topical lidocaine.

9. In patients whose pain is due to diabetic neuropathy, oral duloxetine should be offered as a first-line treatment, starting at 60mg/day (less in some patients). Where duloxetine is contraindicated, amitryptyline should be offered.

10. If amitryptyline proves effective but the patient is unable to tolerate its adverse effects, oral imipramine or nortriptyline should be considered.

Reference: Neuropathic pain pharmacological management, http://guidance.nice.org.uk/CG96

Tips for your CPD entry on neuropathic pain management

Reflect Do I understand current guidance on the pharmacological management of neuropathic pain?

Plan Assess which aspects of neuropathic pain management you are least clear about

Act Read this article and the relevant sections of the Nice guidance (see reference above)

Evaluate Can I advise GPs and patients on drug treatment for neuropathic pain?