When a lack of proper medication reconciliation (MedRec) led to a sharp deterioration in her father’s health Dr Rita Shane (Vice President and Chief Pharmacy Officer at Cedars Sinai Medical Center, Los Angeles, California) promised herself that she would ‘fix’ the problem before she retired. Just 20 years later she succeeded – MedRec by pharmacy staff became a legal requirement in California.

In 1998 Dr Shane’s father underwent a craniotomy for a brain metastasis associated with lung cancer. He developed “intractable agitation” and was transferred to a geriatric-psychiatric unit where his condition became much worse. When Dr Shane asked about his medication it became apparent that the steroids that he had been prescribed after the craniotomy had been abruptly discontinued when he was transferred.  “I knew you can’t just ‘cold turkey’ discontinue a steroid in a patient. Ultimately, I had him transferred back to Cedars Sinai because he ended up febrile. He was getting a decubitus [ulcer] and I was concerned that he would die of sepsis in a gero-sych unit due to what I considered an iatrogenic issue”, she says.

Medication reconciliation is often viewed as a simple clerical task. In fact, making an accurate record of current medication is an important procedure because the list becomes the basis for future prescribing decisions. Dr Shane has spearheaded a decades-long campaign to transform this process, arguing that pharmacy staff – pharmacists and technicians – are the only professionals with the specific expertise required to ensure medication safety during transitions of care. This effort recently culminated in California law SB 1254 and subsequent regulatory changes that mandate pharmacy-led MedRec for high-risk patients at both admission and discharge.

The “poly problem” and iatrogenic risk

One important reason for specialised pharmacy intervention is what Dr. Shane calls the “poly problem”: poly-disease, poly-doctor, and poly-pharmacy. As patients over 65 tend to have multiple chronic conditions, they often receive prescriptions from multiple providers and pharmacies. This fragmentation can create a chaotic medication history. In many ambulatory settings, medication histories are entered into the electronic health record (EHR) by medical assistants who, while vital to practice support, may lack in-depth training in pharmacology. These entries then become the “source of truth” for hospital admissions. For example, “When we first implemented our electronic health record, we would see orders like “methotrexate daily” [instead of weekly] that the pharmacist would intercept – and that’s really just a lack of knowledge and skills on the part of people that are transcribing orders without the benefit of the clinical knowledge”, she notes. Dr. Shane compares a medication order to a complex sentence: it requires the correct drug, dose, dosage form, route, rate, and duration. The pharmacist serves as a guardian angel over this process, making sure that orders are complete and accurate in the context of the whole patient, she says.

The evidence: Why pharmacy ownership matters

The push for legislative change was based on rigorous research evidence. Dr. Shane and her team conducted a randomised controlled trial in the emergency department, comparing “usual care” (medication histories taken by busy physicians or nurses) with those taken by trained pharmacy staff. The results were stark: pharmacists and technicians were significantly more accurate, identifying up to eight errors per high-risk patient.

The business case for pharmacy-led MedRec

For healthcare administrators, the argument for pharmacy-led MedRec extends beyond clinical outcomes to financial sustainability. Adverse drug events (ADEs) are a primary driver of increased hospital costs and. Data indicates that an ADE can increase a patient’s length of stay (LOS) – and therefore hospital costs – by an average of 3.1 days. At the time of the evaluation, the cost of a single admission or readmission due to these errors was estimated at $12,000 to $14,000.

By leveraging pharmacy technicians to transcribe histories accurately into the EHR, hospitals can achieve significant savings while allowing nurses and physicians to practice at the highest level of their licenses. One organisation demonstrated savings of $830,000 by utilising technicians for this function. Furthermore, reducing the 40 minutes of nursing time typically spent per patient on medication histories provides a major relief to frontline clinical staff.

All of this information was brought together in an infographic that was used to educate the State Board of Pharmacy and the California legislature about the problem. “Timing is everything” says Dr Shane and it turned out that one of the California senators was a pharmacist and he enthusiastically supported Dr Shane’s initiative. After a number of hearings, the bill was signed into law in September 2018, just two years and four days after her father’s death. “It was an exciting journey and really an outstanding opportunity to educate legislators”, she recalls. Moreover, during her discussions with legislators, “Everyone seemed to have an example of a family member having a problem with an inaccurate medication list – and that brought it home”, she adds.

Following the passage of SB 1254 (the bill in question) in 2018, a larger study involving 11 California hospitals (ranging from university-based to community hospitals) further validated these findings. Over a six-week period, the study captured approximately 16,000 errors across 2,300 medication histories. Notably, 94% of medication lists contained at least one error, and 25% of those errors were classified as serious or life-threatening. These findings were verified by independent physician reviews, ensuring that the severity of the errors was not overstated. Reflecting on the findings, Dr Shane says, “We demonstrated that we prevented significant harm in the state of California for the hospitals that implemented this new law”.

Closing the loop: MedRec at discharge

While the 2018 legislation focused on admission, Dr. Shane realised that the “back end” of the hospital stay remained a point of extreme vulnerability. She uses the analogy of a totally wrecked car (the patient) that is painstakingly repaired in a body shop (the hospital), only to be driven off a cliff at discharge because the final medication list was inaccurate.

Studies showed that even with accurate admission medication lists, patients still experienced an average of two medication errors at discharge. Approximately 20% of hospital admissions are medication-related, and at least 40% of patients have an error on their discharge medication list, she says. These errors, such as the inadvertent omission of anticoagulants or antibiotics, are then perpetuated by community pharmacists who, lacking access to patient records, have no way of recognising the mistakes.

To address this, Dr. Shane successfully advocated for a regulatory change through the California State Board of Pharmacy’s “sunset review” process. As of January 1, 2026, the law was expanded to include medication reconciliation at discharge for high-risk patients.

A new paradigm: The “high-alert patient”

Perhaps the most transformative concept proposed by Dr. Shane is the shift from focusing solely on high-alert medications to identifying the “high-alert patient”. This designation would apply to the most vulnerable individuals – those with multiple diseases and complex regimens – who should be “tagged” for prioritised pharmacist attention across all providers.

Dr. Shane’s vision is to see these California-led successes become a national standard. Through collaboration with the National Association of Boards of Pharmacy (NABP) and the Joint Commission, she continues to advocate for model legislation that designates pharmacy staff as the clear “owners” of the medication list. For health professionals, the message is clear: ensuring an accurate medication list is not a secondary task; it is a foundational element of patient safety that requires the specialised clinical lens of the pharmacy profession.

Uveitis

Uveitis is an umbrella term for inflammation affecting the uvea, the middle layer of the eye. Patients can present with pain, photophobia, blurred vision and floaters. Uveitis can be caused by infections but can also be associated with auto-immune inflammatory diseases such as rheumatoid arthritis, Crohn’s disease or Behcet’s disease. If untreated, uveitis can impair vision permanently; “There is potential for vision loss from this inflammation and the damage that it causes. It can induce macular oedema, which is leaky fluid in the eye and if that fluid accumulates at the macula, which is responsible for your central vision, then it can impact your vision temporarily, but if left untreated can lead to permanent vision loss”, explains Ms Goacher.

Treatment of uveitis

The primary goal of treatment is the control of inflammation to prevent damage such as macular oedema. The clinical approach to uveitis is determined by the anatomical site of the inflammation. Anterior uveitis, affecting the front of the eye, is typically managed with topical steroid or anti-inflammatory drops. However, topical treatments cannot penetrate deeply enough for intermediate, posterior, or panuveitis, and systemic steroids are the standard first-line treatment. “If we can’t control patients on systemic steroids or …. if you can’t get patients off the steroids without them flaring back up with their uveitis you would then move on to secondary immunosuppressive medications. So, commonly we’d use mycophenolate or azathioprine”, says Ms Goacher. The biological, adalimumab is available as a third-line treatment, she adds.  Immunosuppressive treatment is steroid-sparing and can enable patients to transition off systemic steroids and avoid long-term side effects. Despite these options, an unmet need persists for patients who do not tolerate immunosuppressants, those who require maximal treatment but still experience flares, or those for whom systemic steroids are contraindicated.  Fluocinolone acetonide intravitreal implants (Iluvien ®), which provide local treatment, can be useful in these situations.

Fluocinolone intravitreal implants

The fluocinolone acetonide implant is a miniature device, measuring only 3.5 mm in length and 0.37 mm in diameter—roughly the size of a grain of rice. It is designed to be injected into the vitreous (the jelly-like part of the eye), where it slowly elutes the medication over a period of up to three years.

The implantation is performed as an outpatient procedure.  After the administration of numbing drops, the device is injected; the process typically takes 10 to 20 minutes, followed by a course of antibiotic drops. Once implanted, the patient cannot feel the device, and the polymer shell remains in the eye after the drug has been fully eluted.

Real-world clinical outcomes

Ms Goacher conducted an evaluation of 45 eyes (34 patients) treated with fluocinolone implants since 2019. The study group included patients with associated systemic inflammatory diseases, such as rheumatoid arthritis or Crohn’s disease. The findings highlighted several key clinical benefits:

• Visual acuity: 58% of patients experienced an improvement in visual acuity.
• Macular oedema resolution: At the six-month mark, 80% of patients with macular oedema saw the condition resolve.
• Systemic treatment reduction: 84% of patients taking systemic immunosuppressive medication were able to reduce their dosage, and three patients were able to stop systemic treatment entirely.
• Topical treatment reduction: There was a 20% reduction in the need for topical drops among the study group.

While the implant is designed to last three years, the audit found the average time to treatment failure (defined as the need for rescue therapy, such as increased drops or additional implants) was approximately 15 months. However, not all the patients had reached the three-year time point, notes Ms Goacher. Nevertheless, one-third of the patients in the study did reach the three-year mark without requiring further intervention, she says.

Managing complications

The use of local steroids in the eye is associated with known complications, primarily cataract development and increased intraocular pressure (IOP). In this audit,16% of patients developed cataracts post-insertion, with the average time to surgery being 12 months. Furthermore, 11% of patients experienced an IOP rise at the three-month mark. While three patients required surgery to manage this pressure, most cases were manageable with glaucoma drops.

From a clinical perspective, these complications are often viewed as a necessary trade-off; as Ms Goacher notes, cataract surgery is a routine, “bread and butter” procedure, whereas uncontrolled inflammation can lead to permanent, irreversible blindness.

Conclusion and future directions

The real-world data suggests that fluocinolone implants offer a robust option for stabilising uveitis and reducing the systemic medication burden on patients. Current efforts are focused on refining this data by looking at long-term outcomes for patients who have had the implant for two or more years to provide further insights into treatment efficacy.

Ophthalmology specialist pharmacist

The role of the specialist pharmacist in ophthalmology is expanding. Although initially Ms Goacher’s role was concerned with oversight of high-cost drugs, it has since grown considerably. The ophthalmology team at the Sussex Eye Hospital was welcoming and supportive and she soon found that ophthalmology offered many opportunities for pharmacy input. “It may not be that obvious on the outset but as soon as you scratch the surface there’s a lot to do in ophthalmology for pharmacy”, she says. For pharmacists looking to specialise in this important field, Ms Goacher highlights the support available through the UK Ophthalmic Pharmacy Group (UK OPG), which provides a network for advice and collaboration.

Defining the clinical burden

Insomnia is more than a few sleepless nights. Diagnosis requires three components: difficulty falling asleep, difficulty staying asleep, and significant next-day consequences. Chronic insomnia is defined by these symptoms occurring at least three times a week for more than three months.

The epidemiological data is sobering. Chronic insomnia affects 5% to 10% of the adult population and is strongly associated with chronic physical illnesses involving pain or respiratory distress, as well as psychiatric disorders such as major depression.

The consequences of sleeping less than five or six hours a night are significant:

• The risk of type 2 diabetes trebles
• The risk of hypertension increases fivefold
• The risk of vascular dementia and impaired cognitive functioning more than doubles.

Furthermore, even a small reduction in sleep (less than six hours compared to seven to nine) is associated with a 13% increase in mortality risk due to accidents, stroke, cardiovascular disease and cancer.

In mental health, insomnia acts as a “multiplier” of poor outcomes. A landmark study using big data found that in patients with major depression, those with comorbid insomnia had more GP appointments, higher medication consumption, more psychiatric admissions, and increased rates of attempted suicide.

The limitations of traditional pharmacotherapy

Both benzodiazepines and the “Z-drugs” (e.g. zopiclone) are used for the short-term management of insomnia. Both classes of drug promote the actions of the inhibitory neurotransmitter gamma amino butyric acid (GABA) in the central nervous system. In effect, they “dial up” the effects of GABA. Benzodiazepines are non-selective; they affect pathways relating to sleep and also those relating to anxiety and memory. “In addition to inducing sleep, they’re anxiolytic but they also have an amnesic effect which is quite common with benzodiazepines, particularly [for] short-term memory” explains Mr Donoghue. The Z-drugs lack the anxiolytic effects and generally have shorter half-lives than benzodiazepines, making them less likely to have next day hangover effects.

A NICE appraisal concluded that there was no compelling evidence of a clinically useful advantage with Z drugs and recommended that short-acting benzodiazepines should continue to be the treatments of choice. Mr Donoghue noted that the commonly-used (short-acting) temazepam has a half life of 10-20 hours, meaning that after a 20mg night-time dose,10 mgs could still be in the body the next morning. “And here’s one of the things that pharmacists must advise patients – not ‘be careful when you’re driving’, but simply ‘do not drive’. Do not operate dangerous machinery of any kind, because even the short acting benzodiazepines have significant hangover effects” says Mr Donoghue.

Antihistamines (e.g. diphenhydramine), antidepressants and antipsychotics are also sometimes used for insomnia. Although over-the-counter antihistamines are often recommended for insomnia but they are commonly associated with side effects such as ataxia, blurred vision, constipation and dizziness. “So, diphenhydramine and drugs like promethazine are not the benign drugs that we think they are, and they do need to be used cautiously, and patients should be warned about particularly the danger involved with driving after they’ve been taking them”, he says. Antidepressants and antipsychotics should be avoided as hypnotics, he adds.

Orexin and chronic insomnia

The discovery of orexin in the late 1990s changed the understanding of the sleep-wake cycle. Orexin is an excitatory neurotransmitter that acts as the brain’s “wake signal,” released in response to daylight to kickstart alertness.

Current thinking suggests that chronic insomnia is not necessarily a lack of “sleep pressure” but rather a disorder of orexin overactivity. Essentially, the wake signal is being released inappropriately during the night. This explains why simple sleep hygiene measures often fail in chronic cases; sleep hygiene measures cannot suppress the inappropriate release of orexin.

Daridorexant: A dual orexin receptor antagonist (DORA)

Daridorexant represents a new class of treatment approved by NICE for chronic insomnia in adults. Unlike traditional hypnotics that induce sleep by “closing down” the brain, Daridorexant is a DORA that blocks the wake signal from reaching excitatory pathways. It suppresses both the wake signal (Orexin 2 receptor) and the motivation/reward signal (Orexin 1 receptor), allowing sleep to occur naturally while maintaining normal background brain activity.

Clinical evidence and safety

Two large randomised controlled trials published in The Lancet Neurology highlight several key findings for clinicians¹:

• Efficacy: At the 50mg dose, patients gained approximately one hour of extra sleep per night after three months, falling asleep 30 minutes faster and waking up for 30 minutes less.
• Daytime alertness: Critically, daridorexant showed a significant improvement in daytime alertness, with no “hangover” effects observed.
• Long-term profile: In a 12-month extension study, there was no evidence of loss of effect over time and, remarkably, no withdrawal symptoms upon discontinuation.
• Tolerability: The side effect profile is “remarkably benign,” with only fatigue occurring more frequently than placebo (affecting only 1 in 25 patients).

Responding to symptoms of insomnia

NICE recommends daridorexant as a second-line treatment following cognitive behavioural therapy for insomnia (CBTI). However, if CBTI is unavailable or the patient refuses it, daridorexant can be considered first-line.²

When patients seek help for insomnia in primary care Mr Donoghue suggests five key questions should be asked:

1. What are the sleep problems (getting to/staying asleep)?
2. Are there external factors (noise, shift work)?
3. How long has it been going on (the 3-month threshold)?
4. How often does it occur (the 3-times-a-week threshold)?
5. How do you feel the next day?

Patients who meet the criteria for chronic insomnia should either be referred to their GP or a prescribing pharmacist, who may consider prescribing daridorexant.

Regarding the cost – a common barrier to prescribing – Mr Donoghue points out that at £42 per month, the treatment costs less than half a cup of coffee per day. Given the serious consequences of chronic insomnia for people’s emotional, mental and physical well-being, this makes it a highly cost-effective intervention.

About John Donoghue

John Donoghue is the Director of Medicines in Mental Health Ltd. His work involves:

• The provision of continuing education related to the treatment of severe mental illness. His key interest is schizophrenia, but he also covers major depression and bipolar disorder. He provides medical education to psychiatrists, pharmacists, mental health nurses, psychologists and social workers.
• Pharmaco-epidemiology research. He was an early adopter of big data and has been involved in landmark studies using big data to follow outcomes in major depression.
• Consultancy He provides consultancy services, mostly to the pharmaceutical industry but also occasionally to the National Health Service.

Mr Donoghue is also a published novelist. His debut novel, The Death’s Head Chess Club was published in 2015. His new novel, Not Alive, Not Dead, was published in 2025.

References

1. Mignot E, Mayleben D, Fietze I, Leger D, Zammit G, Bassetti CLA, Pain S, Kinter DS, Roth T; investigators. Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials. Lancet Neurol. 2022 Feb;21(2):125-139. doi: 10.1016/S1474-4422(21)00436-1.
2. NICE Technology appraisal guidance (TA 922) Daridorexant for treating long-term insomnia. October 2023

HRT Safety: Disentangling Breast Cancer Risk

One common query is whether hormone replacement therapy (HRT) increases the risk of developing breast cancer. The direct answer is often no, but the distinction between hormone types is crucial: the only type of HRT shown to be associated with a non-statistically significant increased risk is medroxyprogesterone acetate (a synthetic progestogen). Oestradiol, progesterone, and testosterone have not been shown to be associated with an increased risk of breast cancer.

The use of HRT in women with a history of breast cancer is challenging because comprehensive studies are lacking and historical data often included synthetic hormones such as tibolone. Moreover, many women have been told that they cannot have hormones because they’ve had breast cancer. However, “an oestrogen receptor positive breast cancer doesn’t mean it’s been caused by oestrogen and it doesn’t mean that oestrogen per se is all bad”, says Dr Newson. She often prescribes testosterone for women who have had oestrogen receptor positive breast cancer, and this can significantly improve symptoms and potentially improve prognosis.

Women who are BRCA-gene positive and have undergone prophylactic bilateral mastectomy or bilateral oophorectomy, can usually safely receive body-identical hormones. Studies, though small, suggest that women with the BRCA gene who have undergone oophorectomy and receive HRT may have a better prognosis, possibly due to the anti-inflammatory actions of hormones. “It’s really sad when I see women who have the BRCA gene [and] they’ve been told they can’t have hormones”, comments Dr Newson. Synthetic hormones should not be prescribed, she adds.

Genitourinary Syndrome of Menopause (GSM)

Genitourinary Syndrome of Menopause (GSM), formerly known as vulvovaginal atrophy (VVA), describes symptoms affecting the genital and urinary tracts. The term VVA is being phased out as “atrophy” means “withered and wasting away”, which may be seen as unduly negative.

GSM is very common, affecting 70–80% of menopausal women, but it is critical to recognise that it is not exclusive to menopausal women. It can also occur during perimenopause, in young women, those using oral contraceptives, or those breastfeeding, says Dr Newson. Beyond genital symptoms like dryness, soreness, and pain during intercourse, GSM includes significant urinary symptoms such as incontinence, urgency, and increased frequency. Most importantly, GSM is strongly linked to recurrent urinary tract infections (UTIs). Considering that urosepsis causes 30% of all sepsis cases, prevention is vital. Decades of data, dating back to the 1980s, show that the incidence of UTIs significantly reduces when women use vaginal hormones. Despite this powerful evidence, only a minority of women with GSM are prescribed these “transformational hormones,” which can also be safely used by women who have had breast cancer.

Neurokinin receptor antagonists (NK3RAs) for hot flushes

The neurokinin receptor antagonists elinzanetant and fezolinetant have been marketed to treat vasomotor symptoms (hot flushes). Originally developed as neuroleptics to help with psychosis, NK3RAs were found to reduce the frequency of hot flushes in women participating in trials. NK3RAs work by affecting the thermoregulatory zone in the hypothalamus and have been shown to reduce hot flushes compared to placebo.

However, significant caution is advised regarding their use. They have not been compared against the gold standard treatment (HRT) in clinical studies, which is unusual. Furthermore, because neurokinin receptors exist throughout the entire body, blocking them raises concerns about unknown long-term effects, explains Dr Newson.

Key concerns include:

1. Hormone inhibition:NK3RAs may inhibit natural hormone production, potentially reducing oestradiol, progesterone, and testosterone levels, especially in the brain, which is the site of the commonest menopausal symptoms.
2. Kisspeptin blockage:These drugs block kisspeptin, a protein known to inhibit metastatic spread. Given that NK3RAs are marketed heavily toward women with breast cancer, inhibiting this protective protein is a major concern regarding potential metastatic disease.
3. Safety Data:Long-term data is lacking. One small study has raised concerns about an increased incidence of epithelial cancers in women taking these drugs and fezolinetant received a black box warning from the FDA related to deranged liver function.

Addressing the age myth and guidelines

The notion that women can be “too old” for HRT is a misconception stemming from the findings of the Women’s Health Initiative (WHI) study. The WHI study reported an increased incidence of cardiovascular disease (CVD) in women over 60. However, the study used synthetic hormones (conjugated equine oestrogens) and high doses in women often already suffering from established CVD. “It was really giving the wrong type of hormone, the wrong dose to the wrong woman”, says Dr Newson.

It is illogical to assume that the body responds differently to oestradiol at age 59 versus age 61. Synthetic hormones are pro-inflammatory, which is detrimental, especially to older individuals or those with established CVD.

When starting HRT for older women who have “missed out”, Dr Newson advocates beginning with a low-dose transdermal oestradiol and progesterone, sometimes adding testosterone, and then allowing the patient to choose. While randomised controlled trials (RCTs) for natural hormones will never be available (because they would be considered unethical given the known benefits), personalised care and patient choice remain paramount, emphasises Dr Newson.

Finally, HCPs must critically assess guidelines. The latest NICE guidelines state that first-line treatment for the majority of women is hormones. However, the analysis failed to distinguish between synthetic and natural hormones due to a perceived lack of RCT data, meaning the guidelines conflate treatments with different risk profiles. Furthermore, a word search of the guidelines reveals a disproportionate focus on the word “risk” and the topic of “breast cancer” compared to “benefit” and “osteoporosis,” reflecting a potential bias. Effective menopause management requires applying the guidelines while prioritising the art of medicine and individualisation of care, says Dr Newson.

About Dr Louise Newson

Dr Louise Newson is a GP and menopause specialist.  She is the founder of Newson Health and Newson Education. She developed the Balance app (a menopause support app) and the Confidence in Menopause course for health care professionals.  She is the author of the best-seller, The Definitive Guide to the Perimenopause and Menopause and hosts a website that provides a wealth of articles, podcasts and other information.

Cognitive and psychological symptoms

Historically the menopause been defined by measurable symptoms like hot flushes and night sweats. However, data analysis from hundreds of thousands of symptoms logged in the Balance app reveals that the commonest and most severe symptoms affect the brain. These include brain fog, memory problems, fatigue, poor concentration, poor sleep, reduced libido, anxiety, and irritability. Hot flushes often rank significantly lower – around number 24.

This “all makes sense because actually the hormones we’re talking about, not just    oestradiol, but progesterone and testosterone – they are made in our brains as well” explains Dr Newson. Viewing the menopause merely as an ovarian or period condition overlooks the profound systemic impact of hormone deficiency.

Furthermore, this misunderstanding leads to frequent misdiagnosis. Many women experiencing perimenopause or menopause are inappropriately diagnosed with mental health conditions, such as depression and anxiety, or even schizoaffective disorders. Symptoms related to hormonal decline may also be incorrectly attributed to sero-negative arthropathy, chronic fatigue, fibromyalgia, or long COVID. The impact on quality of life can be severe with approximately 10% of women reporting giving up their jobs due to symptoms like memory issues, anxiety, and fatigue. When the appropriate hormones are administered, these misdiagnosed symptoms often “melt away”, says Dr Newson.

Hormone deficiency: A risk to long-term health

The consequences of post-menopausal hormone deficiency extend beyond immediate symptoms; they increase the risk of future diseases because these hormones function as important anti-inflammatory agents in the body. Post-menopausal hormone deficiency is associated with an increased risk of inflammatory diseases, including dementia, cardiovascular disease (CVD), osteoporosis, cancers, autoimmune diseases, Parkinson’s disease and multiple sclerosis.

For example, oestradiol plays a vital anti-inflammatory role in the cardiovascular system. It acts as a vasodilator, aids in blood pressure control (affecting the renin-angiotensin system), and reduces the incidence of arrhythmias, including atrial fibrillation, while also helping build heart muscle. Hormone deficiency leads to accelerated atherosclerosis, increased atheroma, and elevated blood pressure, significantly raising cardiovascular risk after menopause.

Furthermore, HRT is licensed as a preventative treatment for osteoporosis. “One in two – so 50% – of women who are menopausal [and] who don’t take hormones are estimated to develop osteoporosis in their lifetime and one in three will have an osteoporotic hip fracture” says Dr Newson. A hip fracture carries a mortality rate of around 20% within a year, a prognosis worse than most cancers or heart attacks, highlighting the critical need for preventative prescribing.

Precision in prescribing

When discussing treatment, precision is paramount. We must differentiate between progesterone and synthetic progestogens (used in older HRT and many contraceptives) and utilise body-identical oestradiol. The confusion and fear surrounding HRT stem largely from studies like the Women’s Health Initiative (WHI) study (2002), which used synthetic progestogens and conjugated equine oestrogens, components long known to affect the cardiovascular system negatively. These findings are not comparable to the effects of body-identical hormones, emphasises Dr Newson.

Despite NICE guidance recommending hormones as first-line treatment for menopausal and perimenopausal symptoms, prescribing rates remain low – around 14% in the UK and 4% in the US, significantly below the 30–40% rates seen prior to the WHI study. Simultaneously, about one in six women are inappropriately prescribed anti-depressants, which carry known risks like addiction, increased incidence of osteoporosis and dementia. In some cases, women may be given anti-psychotics or electroconvulsive therapy (ECT) for symptoms of treatment-resistant depression.

“But when you take a really clear history, ……. they’ll tell you that they’ve had really bad PMDD (pre-menstrual dysphoric disorder) for many years. They’ll tell you that they’ve had postnatal depression. They’ll tell you they felt really great mentally when they were pregnant, and they’ll tell you that they fell off a cliff at the age of 48.  ….. So, you don’t have to be a hormone specialist to understand that some of it’s related to hormones”, says Dr Newson. It is also important to note that anti-psychotics can induce a chemical menopause by suppressing hormone production, potentially exacerbating the underlying issue, she adds.

Moving forward, we should be precise in our language, focusing on oestradiol deficiency, progesterone deficiency, or testosterone deficiency rather than the broad term “menopause”, argues Dr Newson.  This would ensure that patients have a “label” that helps them to get the right treatment. The current criteria for prescribing testosterone are overly restrictive, often requiring women to demonstrate hypoactive sexual desire disorder (HSDD) for at least six months. This overlooks the broader benefits of testosterone in improving energy, concentration, mood and stamina, she says.

Upskilling and holistic training

To serve patients better, HCPs must receive comprehensive training that views the body as a whole, not just a gynaecological system. Training should prioritise practical, evidence-based knowledge and be delivered by clinicians who manage a high volume of patients, rather than specialists who see only a few cases each week.

It is vital to empower pharmacists and nurses, as has successfully been done in diabetes and contraception management, to ensure wider access to care. It is also important to educate patients “so that women can come a lot more prepared to their consultations”, says Dr Newson. The goal is to move beyond the current limited system and ensure that patients are central to treatment choices, receiving the appropriate, individualised hormone replacement required to improve symptoms and mitigate future disease risk.

About Dr Louise Newson

Dr Louise Newson is a GP and menopause specialist.  She is the founder of Newson Health and Newson Education. She developed the Balance app (a menopause support app) and the Confidence in Menopause course for health care professsionals.  She is the author of the best-seller, The Definitive Guide to the Perimenopause and Menopause and hosts a website that provides a wealth of articles, podcasts and other information.

Strategic goals and operational success

The Women’s Health Hub was designed three years ago to provide women with easier access to critical health services. It was initially focused on improving cervical smear management, reducing waiting times for long-acting contraception (coils and implants) and removing barriers to menopause care.

The menopause clinics operate around three core Key Performance Indicators (KPIs) designed to streamline care and enhance professional development:

1. Improving access: This tackled the 8:00 a.m. rush for appointments by offering additional capacity slots in the evenings and on Saturdays.
2. Reducing secondary care referrals: Part of the fundamental vision was to “move the specialist closer to the patient”, by providing menopause specialists in primary care rather than relying on traditional secondary care referrals.
3. Improving the primary care knowledge base: By training and utilising pharmacists across the 12 surgeries, the knowledge base within primary care has been raised. This, in turn, supports the achievement of the first two KPIs, notes Mr Singh.

The operational impact has been significant. The Northwest Leicester GP Federation has achieved a 24% reduction in secondary care referrals for menopause patients. This large reduction is attributed to the ability of the specialist primary care team to avoid inappropriate referrals and manage moderately complicated patient scenarios, reserving secondary care for more complex cases requiring physical intervention or specialised scans (e.g., fibroid removal or polyp removal).

The focus on hormone replacement therapy (HRT) access has resulted in a 21% increase in HRT prescribing compared to neighbouring federations. In addition, the service has also impacted mental health prescribing, managing to flatline a previous 6% annual increase in anti-depressant prescribing among its patient population.  This could reflect adherence to the NICE guidance that stipulates HRT as the first-line treatment for menopausal symptoms rather than anti-depressants, suggests Mr Singh.

Since its inception the service has grown considerably; the number of additional appointments has grown from 40 to 140 appointments per week, and as a result some 1800 patients have been seen over the past two years.

Digital health as a Unique Selling Point (USP)

Digital technology is integral to the hub’s forward-thinking approach, ensuring efficiency and high standards of governance, explains Mr Singh. Key digital innovations include:

• Remote appointments: Consultations, typically lasting 20 minutes, are usually conducted via telephone or video link, maximising patient throughput.
• Digital reminders and DNA reduction: A communication system called AccuRx is used to send digital appointment reminders two weeks and two days prior to the slot. This system also allows patients to rebook easily, minimising the costly Did Not Attend (DNA) rate.
• Patient priming videos: Before their consultation, patients receive a video link via text message. This video educates them about risks and benefits of HRT and menopause symptoms, in preparation for the appointment. The video also serves as a governance tool, confirming the patient has been informed of risks such as breast cancer and clots.
• Workflow efficiency: A system called Phonebar automatically dials the patient (integrating with the GP record) and records the call for governance purposes. An AI scribe (Heidi AI) transcribes the appointment notes directly into the patient’s record, reducing the administrative burden.
• Medication education: One of the problems the team discovered at an early stage was that patients were requesting appointments for irregular bleeding resulting from incorrect use of complex HRT regimens. To combat this problem, the team now sends personalised, AI-generated videos detailing how to use the prescribed medication.
• Feedback mechanism: Immediately following the service, a digital feedback form is sent via AccuRx. High levels of patient satisfaction have been found with 96% of patients being ‘extremely satisfied’ or ‘satisfied’ with the service.

Specialist care in primary care: testosterone

The hub has successfully brought specialist functions, previously confined to secondary care or private practice, into the primary care setting. This is exemplified by testosterone prescribing. In line with NICE guidance (NG23) and British Menopause Society recommendations, testosterone is only prescribed for hypoactive sexual desire disorder (HSDD) (low libido).

For dosing accuracy, the service prefers the Tostran pump over Testogel, arguing that expecting a woman to measure accurately an eighth of a sachet (of Testogel) is clinically unrealistic. The team maintains rigorous governance, performing baseline blood tests (free androgen index, total testosterone, sex hormone binding globulin (SHBG) and oestradiol) followed by checks at three months, six months, and annually.

A holistic, community-focused model

Community and patient engagement is an important part of the Women’s Health Hub offering. “Menopause care isn’t just about HRT”, says Mr Singh. With this mind, he also developed Patient Participation Groups (PPGs) – evening group consultations which offer education on symptoms, risks, and treatment options, often leading to immediate appointment bookings.

To combat loneliness and address physical health needs, the hub funds external initiatives like the “menopause active group” at the local leisure centre, which provides access to nutritionists and pelvic floor exercises. Social prescribers are also utilised to connect women struggling with isolation to ongoing local support groups, such as menopause cafes.

Conclusions and call to action

The Northwest Leicester Women’s Health Hub demonstrates that specialised, high-quality, and holistic menopause care can and should be delivered free at the point of service within the NHS. With a strong focus on clinical governance, patient feedback, and leveraging digital infrastructure, this model is now being prepared for national rollout through the NHS Clinical Entrepreneur Program, says Mr Singh.

For frontline health care staff, his message is clear: Be curious about menopause management and use the many free resources that are available e.g. from the British Menopause Society or the NHS menopause website. “It’ll help you treat your patients better. It’ll help you have better clinics. It’ll help you have better relationships with your staff and your family”, concludes Mr Singh.

About Anthony Singh

Anthony Singh is an Accredited BMS Menopause Specialist and Lead Clinical Pharmacist for NWL GP Federation. In 2024 he received the Excellence in Primary Care award at the Clinical Pharmacy Congress. In 2025 he was selected for The NHS Clinical Entrepreneur Programme where he is leading a nationwide initiative to improve menopause care. Recently, he and his team received a British Menopause Society award for the evaluation of the NWL project. He has also been nominated for HSJ awards in the primary care and innovation categories.

The landscape of cancer care has undergone considerable changes over the past three decades with significant implications for healthcare professionals. The incidence of cancer has shifted from one in four to one in two people receiving a diagnosis and a 2 to 3% increase in the cancer population is anticipated by 2040.  While advances in treatment offer more options, improved cure rates, and longer lives, this also places an increasing emotional and psychological burden on patients and an escalating demand on the National Health Service (NHS). Against this background, Maggie’s is “even more needed to work in partnership with our NHS colleagues”, reflects Dame Laura.

Maggie’s offers cancer support through centres located on hospital grounds but physically separate from the hospital premises.  The core aim of Maggie’s is to empower individuals to feel more in control, less alone, and instil a sense of hope, even when facing the immense challenges of a cancer diagnosis, says Dame Laura.

The unique model of Maggie’s originated from the personal experience of Maggie Keswick Jencks. Following a recurrence of breast cancer, she recognised a significant gap: while the NHS provided excellent medical care, it was not equipped to address the broader psychosocial needs of patients. Drawing inspiration from the American approach to active patient participation and leveraging her background as a landscape designer/architect with philanthropic experience, Maggie envisaged a dedicated space alongside the NHS for expert, additional support. Dame Laura, who was Maggie’s clinical nurse specialist at the time, witnessed firsthand this patient-driven push for a more holistic care approach.

A defining characteristic of Maggie’s centres is their deliberate and beautiful architectural design. Maggie Keswick Jencks believed that the typical hospital environment, with its strip lights and lack of natural views, often made patients feel worse. In contrast, Maggie’s buildings are crafted to make visitors feel valued, safe, relaxed, and hopeful, incorporating gardens and intriguing spaces that are both inspiring and beautiful. Dame Laura observed that these supportive environments encouraged patients to share openly worries and concerns they had kept private in traditional hospital settings, thereby helping health professionals be more effective in their work.

The support at Maggie’s is provided by professional experts, including senior clinical nurse specialists, clinical psychologists, and benefits advisors. These specialists assist patients in navigating complex practical issues such as communicating with employers or mortgage lenders, discussing their diagnosis with children, and making sense of overwhelming medical information – a critical function given that “you only retain 10% of what you’ve been told when you’re anxious”, says Dame Laura. The goal is to empower patients, helping them understand their situation and fostering the best possible relationship with their medical team, which is considered crucial for positive outcomes. While volunteers contribute to the warm welcome, the expertise of the staff is paramount, she adds.

Accessing Maggie’s support

Maggie’s is designed to be highly accessible, actively removing common barriers to support. Many individuals are referred by NHS colleagues, including clinical nurse specialists and doctors. Upon arrival, there is no traditional reception desk. Instead, visitors are warmly greeted by staff who lead them to the kettle for a cup of tea, allowing time to relax and feel comfortable before any conversation begins. A key element of this approach is immediate access to a Maggie’s cancer support specialist with no waiting times, and no appointment is needed for subsequent visits. The small, consistent teams ensure that returning visitors are recognised, and their ongoing story, including personal issues like childcare or pet care, is known, fostering a vital sense of trust and continuity of care.

Maggie’s actively champions collaboration with other cancer support organisations, acting as a “roof” to facilitate access to other specialised cancer charities. Their centres house literature from organisations such as Macmillan Cancer Support, Bladder Cancer UK, and Prostate Cancer UK, and they host support groups for charities like Black Cancer Care and Teenage Cancer Trust, providing a professional and appropriate space for these meetings.

Maggie’s is entirely funded by philanthropy and relies on a diverse range of fundraising activities, from substantial capital donations for building centres to community events like cake sales, pub quizzes, and extreme challenges such as ultra-marathons or abseiling. The organisation’s ambitious vision is to establish a centre at each of the 60 UK cancer centres, in addition to its growing internationalpresence. This expansion is driven by the understanding that as the cancer landscape continues to evolve, the need for Maggie’s unique, person-centred support becomes even more vital and necessary than ever before.

The mortality gap

Individuals with schizophrenia face a 15 to 20-year reduction in life expectancy, typically dying 13 years younger than the general population (mean age of death 66 vs. 79 years in the UK). This means that “for a person with schizophrenia, on average, they won’t live long enough to qualify for the state pension”, says Mr Donoghue.

A landmark systematic review by Christoph Corell that included 4.5 million individuals with schizophrenia, underscored the severity of the problem. It revealed that overall mortality rates are nearly three times higher (risk ratio 2.9), suicide rates are ten times higher (risk ratio 9.8), and natural cause mortality rates are twice as high (risk ratio 2.2) compared to age- and sex-matched controls in the general population.

This excess mortality is multifactorial. The illness itself can impair cognitive function, making it difficult for patients to understand and engage with care, manage appointments, or adhere to treatment. Lifestyle factors contribute significantly, with high rates of obesity (affecting two-thirds of patients), smoking (twice as high), alcohol misuse (three times higher), and drug misuse (seven times higher) compared to the general population. Moreover, the historic division between mental and physical healthcare often results in fragmented care, communication gaps, and inadequate monitoring of physical health. Comorbidities such as cardiovascular disease (the most common cause of death, with mortality rates 85% higher than in the general post-myocardial infarction population), diabetes (three times higher mortality), and cerebrovascular disease (60% higher mortality) are often poorly managed.

Antipsychotics: benefits and risks

While antipsychotics are the cornerstone of schizophrenia treatment, their cardio-metabolic side effects, including weight gain, obesity and type 2 diabetes, are a concern. It is important to recognise that the risks of these effects vary widely by individual drug, and a false dichotomy between first- and second-generation agents is misleading. For instance, “weight gain and BMI change with haloperidol (first-generation) is no different from placebo but the same is true of aripiprazole, cariprazine and lurasidone, all of which are second generation agents”, says Mr Donoghue.  In contrast, “olanzapine is associated with significant weight gain and increased risk for type 2 diabetes but so is chlorpromazine”, he continued. Individual drug profiles must guide clinical decisions.

Despite these considerations, the evidence for efficacy is unequivocal: regular antipsychotic use significantly reduces mortality risk.

Evidence for second-generation LAIs

The Corell review strongly supports the role of SGA LAIs as key mitigating factors for premature mortality. These agents offer profound benefits including an overall mortality reduction of 61% and a 57% reduction in suicide mortality. For first-episode (incident) patients, second-generation LAIs are associated with an 85% reduction in all-cause mortality. In contrast, first-generation oral antipsychotics are associated with a doubling of suicide mortality rates in first-episode patients. “For this reason alone, first generation antipsychotics should be contraindicated in first episodes of schizophrenia”, says Mr Donoghue.

The superior outcome with second-generation LAIs is attributed to enhanced long-term mental stability and significantly improved treatment adherence. Furthermore, psychosis is a neurotoxic process, causing irreversible brain volume loss with each episode; preventing relapse is therefore paramount. LAIs dramatically reduce relapse risk with a ‘number needed to treat’ (NNT) of 4 at one year). In addition, SGAs are more effective at preventing relapse and possess neuroprotective properties, unlike some first-generation drugs which may actually be neurotoxic.

Clozapine

For treatment-resistant schizophrenia, clozapine is indispensable. Despite its challenging side effect profile (including agranulocytosis, myocarditis, and crucially, constipation, which is the most common cause of clozapine-related death), it delivers a remarkable 60% reduction in overall mortality and an 80% reduction in suicide mortality in this difficult-to-treat population. Its effectiveness is linked to significant improvements in quality of life and extremely high adherence rates, even with its side effects. Healthcare professionals must understand that “for patients with treatment-resistant schizophrenia, clozapine literally is a matter of life or death”, emphasises Mr Donoghue, and they should counter any ill-informed negative press comment.

Revision of NICE guidance

The current NICE guideline (CG 178, 2014) for schizophrenia, recommends oral antipsychotics with no preference for first or second-generation. As such, it is outdated and no longer fit for purpose given the compelling new evidence, explains Mr Donoghue.

He suggests that an updated, evidence-based approach should involve:

• A presumption that first-line treatment for all patients will be a second-generation LAI, unless clinically contraindicated.
• Immediate consideration of clozapine if a patient fails two second-generation oral treatments, accelerating access to this vital therapy.
• Integrated, holistic physical health monitoring within mental health services, adequately resourced to manage the complex needs of this population, rather than relying solely on overwhelmed primary care.

Implementing these changes is not merely a clinical imperative but an economic one. The average cost of a single hospital admission for a psychotic relapse is £47,000. Investing in effective, long-term treatments like LAIs, which prevent relapses, leads to substantial overall cost savings for healthcare systems.

The evidence demands a paradigm shift in the management of schizophrenia. By prioritising second-generation LAIs, judiciously utilising clozapine, and ensuring comprehensive physical health monitoring within specialised mental health services, it should be possible to reduce significantly premature mortality and improve the lives of those affected by this complex illness.

A career in mental health pharmacy?

Mr Donoghue recommends a career in mental health for pharmacists. “I have thoroughly enjoyed working in mental health. I find the work interesting, challenging, involving and rewarding. Pharmacists are welcomed as members of an extensive multidisciplinary team – and that’s true in both acute and community settings. …. I wouldn’t work in any other specialty”, he says.

In rheumatology, treatment often begins with disease-modifying anti-rheumatic drugs (DMARDs)5. When patients do not respond adequately or their disease progresses, treatment is escalated to biologics or advanced therapies, explains Ms Flora. The introduction of biologics has “revolutionised” treatment for patients, she says. They have been described by patients as life-transforming, fast-acting, controlling disease, and getting patients into remission quickly.

The rapid development of biosimilars over the past five years has had a significant impact. Unlike simple generics such as paracetamol or aspirin, biologics and biosimilars are large, complex molecules that require complex manufacturing processes. They are not direct copies of the originator molecules and for this reason they are called “similar”. However, their clinical effects are the same as the originator drugs’. Indeed, biosimilars are clinically equivalent and now considered interchangeable with their originator biologic medicines, says Ms Flora. Biosimilars have widened access to treatment for patients; for example, NICE guidelines have allowed patients with moderate rheumatoid arthritis to access these medicines earlier than was previously possible. Furthermore, biosimilars cost less than the originators, enabling the NHS to provide more cost-effective services, she explains.

Optimising treatment is a key aspect of the specialist pharmacist role, particularly once patients are stable or in remission on a biological DMARD (bDMARD). Guidance suggests that, at this stage, the dosage of bDMARDs can be reduced either by lengthening the interval between doses or reducing the dose. For tablets, reducing the dosage is typically easier, while for prefilled injections (many biologics), the dosage is fixed. Therefore, in clinical practice, dose optimisation for injectable biologics often involves extending the dosing intervals. For example, a monthly injection could be extended to every second month.

Dose reduction or interval extension can be driven by both clinicians identifying stable patients and patients proactively seeking to take less medication. Patients may wish to reduce their medication burden and potential long-term risks. Feedback from patients indicates that they often feel empowered and listened to when involved in these decisions, and many are happy to inject less frequently, explains Ms Flora. While dose optimisation is encouraged in remission, stopping treatment abruptly is generally not recommended. Clinical evidence shows that simply stopping biologics is likely to cause a patient’s disease to flare. Slowly tapering the dose or extending the interval reduces this risk, helping to keep patients well.

Homecare

Homecare services ensure that medicines, including injections and even tablets, are delivered directly to the patient’s doorstep, eliminating the need for frequent hospital visits to collect medications. For new injectable treatments, a trained professional, often a nurse, visits the patient’s home to provide counselling, instructions on how to take the medicine, things to look out for, and training on administration. Homecare also frees up hospital resources for patients who require in-hospital care, says Ms Flora. Medicines delivered via homecare can sometimes be cheaper due to VAT regulations. Moreover, homecare also indirectly supports sustainability efforts by reducing patient travel to hospitals and potentially using less plastic over the long term if dose intervals are extended, she adds.

Rheumatology pharmacy

A rheumatology specialist pharmacist’s work is very varied. About 80% of the role is clinical or patient-focused, involving activities like overseeing biologic services to ensure safety and access, managing prior approval for funding from Integrated Care Boards (ICBs), and supporting patients from different areas. Ms Flora is also heavily involved in shared care, supporting access to medicines across the interface between hospitals and GPs. She also works closely with the multidisciplinary team (MDT), supporting nurses, allied health professionals, junior doctors, and consultants and participating in MDT meetings to review patients, discuss funding issues, and address barriers to treatment. In addition, the role includes supporting and training junior pharmacy colleagues and contributing to service improvement and audit.

For pharmacists considering a career in rheumatology or high-cost drugs, Ms Flora offers several tips: be inquisitive about complex cases, be visible, and form strong professional relationships within the MDT. Networking is highly valued, as “your network is your net worth”. To young pharmacists contemplating this path, the advice is simple: “just try it”, she says. The field is varied, with many different conditions and constant changes, making it a rewarding career choice.

The role of the rheumatology specialist pharmacist is integral to optimising the use of advanced therapies, improving patient outcomes, enhancing access to care, and contributing to the sustainable delivery of rheumatology services.

About Kalveer Flora

Kalveer Flora leads the rheumatology specialist pharmacy service at London Northwest University Healthcare Trust. She also serves as the lead pharmacist for the Clinical Reference Group (CRG) for NHS England.  She chairs Rheumatology Pharmacists UK which is a group of specialist pharmacists and pharmacy staff working within the space of rheumatology and biologics and she is co-chair of the Sustainability Special Interest Group (SIG) of the British Society of Rheumatology.  Kalveer Flora’s work embraces a variety of different aspects “but essentially it’s overseeing the rheumatology services to patients and that can be a wide range of inflammatory conditions”, she says.

ESCP Workshop

In October 2024 Hilary McKee and Kalveer Flora ran a workshop at the ESCP Symposium in Krakow, Poland, at which they described their work as independent prescribers and invited the audience to think about how they might tackle some of the common problems that arise in rheumatology clinics.

Currently, medicines are delivered to wards in original packs. Nurses then issue these medicines to individual patients, a process that is both time-consuming and prone to errors. Recognising these limitations, the hospital decided to implement a unit dose supply system to enhance efficiency and patient safety. The main goal of automation is to “liberate time for the nursing staff” allowing them to spend more time with patients and less time in the office or at the medicine cabinet, explains Mr Mustakallio.

Robotic packaging

The unit dose system at Oulu Hospital operates through a two-phase process integrated with the hospital’s patient information system. The workflow begins with electronic prescribing, from which patient medication information flows to the unit dose system.

The pharmacy unit dose packaging and storage operation comprises eight Sinteco robots housed in a dedicated,150 square metre, Class D cleanroom where the atmosphere (temperature, air quality and humidity) is carefully controlled. There are additional cleanroom areas for original packs and staff. It is much like a small factory, says Mr Mustakallio. Three Calypso robots repackage medications into individual unit dose pouches. These machines, cleverly named OS (oral solids) and Omnia (all forms), can handle a wide array of medication formats, including ampoules and transdermal patches, he says.

Interior of the Calypso OS robot showing cut blisters of tablets being over-wrapped into unit dose pouches

Blister packs are cut so that the tablets or capsules remain in the blisters, which are then over-wrapped into unit dose pouches.

Interior of the Calypso OS robot showing the original blister pack of tablets being cut

Mr Mustakallio notes that these machines can handle approximately 99% of their medication packaging needs, with only a few exceptions, often due to size or weight limitations, such as some heavy antibiotic preparations.

The completed unit dose pouches, labelled with the name of the medication, batch number and expiry date, are stored in one of the five Pegasus robots, ready to be picked.

Interior of the Pegasus robot showing the stored unit dose pouches ready for picking

Patient-specific medication “rings” or “clips” are automatically assembled by the Pegasus robots in response to prescription data. These clips contain all the medications a patient needs for a particular administration time, complete with a label detailing the patient’s information, ward, administration time, and the list of medications included. The label also includes a QR code that can be scanned at the time of administration to link the prescription, the patient and the medication in a “closed loop”.

Medicines clipped together for a single patient for a specific medicine round, showing biodegradable clip and packaging

Unit dose delivery

Once assembled, these patient-specific therapies are swiftly delivered to the wards via Oulu Hospital’s extensive pneumatic tube system (PTS). The hospital has one of the largest PTS in Europe and has plans to expand further. This system allows for rapid delivery, taking only about five minutes from the pharmacy to any point in the hospital, explains Mr Mustakallio. This just-in-time delivery model minimises the need for extensive medication storage on the wards. Medications are typically delivered approximately one hour before the scheduled administration time, allowing nurses to perform double checks before administration of the doses.

For “as required” doses or emergency medications, the wards will maintain a small stock in automated dispensing cabinets (ADCs) or standard medicine cabinets. These cabinets are also integrated with software for stock control, managed by the pharmacy.  A dedicated logistics team in the pharmacy monitors these ward stocks, ensuring timely replenishment and addressing any discrepancies. This hybrid approach balances the efficiency of the unit dose system with the immediate needs of patient care.

Sustainability

A crucial consideration for any large-scale medication system is sustainability. Mr Mustakallio acknowledges the potential for increased plastic waste with unit dose packaging and emphasises the hospital’s commitment to moving towards the more easily recyclable materials, including less plastic and more paper. In fact, Sinteco has now developed plastic-free packaging materials for all unit dose drug management, including compostable plastic clips to hold the unit dose pouches together.

Mr Mustakallio also emphasises that the unit dose system is expected to reduce significantly the amount of waste medication from unused portions of original packs that has to be destroyed (under the existing system). This shift towards reducing overall medical waste is a key environmental benefit.

Project management

The unit dose project at Oulu Hospital is a meticulously planned undertaking managed by the hospital’s in-house project office, involving specialists from various departments, including pharmacy. The selection of Sinteco as the supplier followed a rigorous public healthcare tender process, with their offer deemed the best. The rollout is planned in phases, starting with a pilot involving about 100 patients. Following the pilot, the system will be implemented ward by ward, with a projected completion time of approximately one year.

The success of this ambitious project will be evaluated based on several key metrics relevant to pharmacy and nursing:

• time saved for nursing staff
• decrease in medication process mistakes
• reduction in medical waste
• economic impact on the pharmacy and the hospital as a whole

The positive anticipation from the nursing staff underscores the perceived benefits of this system in streamlining their workflows.

Conclusion

In conclusion, Oulu University Hospital’s implementation of a smart unit dose medicines distribution system represents a significant advance in hospital pharmacy practice. By leveraging sophisticated automation and integrating with hospital-wide systems, this project aims to enhance patient safety, improve nursing and pharmacy efficiency and reduce medical waste. The insights gained from this initiative will provide valuable information to pharmacists and healthcare institutions who are considering similar transformations to their medication management processes. The dedication to sustainability and the systematic approach to implementation further underscore the forward-thinking nature of this project, positioning Oulu University Hospital at the forefront of smart healthcare innovation.

Sinteco robots at Oulu hospital: L to R – Calypso OS (oral solids), Calypso Omnia (all forms) and Pegasus (storage robot). Image courtesy of Wallineva Photography

Ms McKee’s rheumatology work started when she joined a rheumatology consultant’s ward round where she answered medicines-related queries. Soon after she was asked to manage the supply of the newly-launched leflunomide and later developed a service for training people to self-inject methotrexate. By the time independent prescribing for pharmacists became a reality, the foundations for a fully-fledged clinic role were in place. She now holds four clinic sessions each week.

The key points from this interview are summarised below:

Challenges of polypharmacy in rheumatology

Polypharmacy – the use of multiple medicines – can be a problem in rheumatology as additional medications are prescribed to deal with side-effects from disease-modifying anti-inflammatory drugs (DMARDs).  This situation is often described as a ‘prescribing cascade’. “Actually, the most drugs I ever saw a patient on were 42 medications …. and that was just because things had kept being added, and nobody had looked to stop anything”, says Ms McKee. Another important aspect of polypharmacy is the potential for wastage. As medications account for about 25% of the NHS’s carbon footprint, reducing unnecessary medication use could have an important environmental impact and contribute to the ‘greener NHS’.

Methotrexate treatment

People can be hesitant about the use of methotrexate because of its potential for toxicity, in particular, immunosuppression. However, the doses used in rheumatology are lower than those used in cancer treatment and patients are carefully monitored “The aim, as we tell our patients, is to spot a problem before it becomes a problem”, says Ms McKee.

Cannabis derivatives in rheumatology

Many rheumatology patients purchase cannabis derivatives on the internet and they frequently mention this during consultations. The benefits of cannabis in rheumatology are not yet clinically proven.

Medication Adherence

Adherence can be an issue – and it might be suspected if a patient does not get the expected results with a prescribed treatment. Sometimes patients are misinformed about side-effects by neighbours or information in the press or internet and do not take their treatment as a result.

Role of Biological DMARDs

The introduction of biological DMARDs, starting with infliximab in about 2000, has revolutionised the treatment of inflammatory arthritis. “The biologics are very powerful drugs; they aim to stop the disease in its tracks and with that we prevent joint damage on down the line”, says Ms McKee. Many of the joint deformities that used to be common are now rarely seen.

Once a patient’s disease is stable the dose can be reduced and this is usually done by ‘dose extension’ i.e. lengthening the gaps between doses rather than reducing the dose amount. Some patients can be hesitant about dose extension out of fear of a flare. Simply stopping the treatment will usually result in a flare up of the disease.  Dose adjustment always requires individual assessment and sometimes off-label prescribing is necessary.

Working in the clinic

Working in the clinic calls for a capacity to ‘think on your feet’ says Ms McKee, because you can be faced with the unexpected. For example, a patient whose disease was stable on biologics mentioned in passing that she had developed night sweats. “Well, that’s a red flag immediately. You can’t let that patient go out of the door without investigating”, says Ms McKee.  Investigations were required to exclude tuberculosis and cancer.  Another example was a clergyman whose disease was well-controlled on methotrexate. He was planning to go to Africa for missionary work and asked about getting a yellow fever vaccine. As this is a live vaccine, methotrexate has to be discontinued for three months before it is given. When this was explained he decided that the risk of a flare was too great and he decided against going to Africa.

It is important to be willing to evaluate the response to treatment critically and standard treatment guidelines are useful but guidelines are black and white, whereas patients are not. “They’re grey, they’re complicated and you need to think outside the box”, she says.

Tips for success

Two key tips are – “be aware of your own limitations” and “know your drugs inside out”. Prescribing in rheumatology is complex and patients have many comorbidities; it is a specialty with many opportunities for pharmacists.  “Get in there and just do it” advises Ms McKee.

ESCP Workshop

In October 2024 Hilary McKee and Kalveer Flora ran a workshop at the ESCP Symposium in Krakow, Poland, at which they described their work as independent prescribers and invited the audience to think about how they might tackle some of the common problems that arise in rheumatology clinics.

Listen to this episode of In Discussion With on Spotify

Interest in GLP-1 receptor agonists has grown significantly over the past 12-18 months, with frequent mentions in news and online discussions. These medications are a major advance in helping people lose weight, proving effective across different patient groups.

The key points from this interview are summarised below:

1. Mechanism of action

GLP-1 receptor agonists (e.g. semaglutide) work in several ways:

• Slowing gastric emptying so that people feel full longer
• Boosting satiety so that smaller meals are satisfying
• Reducing appetite by directly influencing brain areas that control appetite.
• Balancing blood sugar – GLP-1 analogues prevent the release of glucagon, leading to more stable blood sugar levels and fewer glucose spikes after meals.

In addition, tirzepatide (Mounjaro) a dual agonist (with combined GLP-1 and GIP effects), enhances insulin secretion, especially during meals, and improves insulin sensitivity, working together with the GLP-1 effects

Clinical trials have indicated that tirzepatide results in a greater average weight loss – around 21-22%, compared to about 15% with semaglutide. Tirzepatide may be particularly suitable for obese individuals with pre-diabetes.

2. Common side effects

The most common side effects are related to delayed gastric emptying, including reflux, nausea, vomiting and constipation. Patients should be counselled about what to expect and how to manage side effects.

Long-term side effects can include muscle loss (sarcopaenia) and osteoporosis.

3. Obtaining a supply of GLP-1 RAs

An in-person, face-to-face consultation is the safest way to obtain a supply – so that BMI can be verified and the risks and benefits of GLP-1 treatment can be assessed.

These medicines are approved for adults with a BMI of 30 or a BMI of 27 with a comorbidity such as a hypertension or pre-diabetes. NHS thresholds can be higher. While the NHS route is an option, it may involve challenges, such as long waiting times and limited medication choices.

Patients should be wary of obtaining supplies of GLP-1 RAs from unregistered online providers because of the risks of counterfeit medicines and inappropriate prescribing. Patients should check that the online pharmacy is registered with the General Pharmaceutical Council (GPhC) and has a visible GPhC number on its website.

The General Pharmaceutical Council has issued Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet to strengthen safeguards for people obtaining supplies online.

4. Ongoing management

Prescribers should schedule regular follow-up appointments to evaluate treatment efficacy, monitor side effects, and adjust dosages as necessary. The following points should be covered:

Understanding the science: Discuss the importance of understanding the science behind weight loss to help patients psychologically adapt to weight loss, overcome body dysmorphia, and address fears of eating properly.

Lifestyle changes: Emphasize the importance of lifestyle modifications, including diet and exercise, for achieving sustainable weight management

Strength training: Throughout the use of these drugs, strength and muscle mass training are crucial for preventing sarcopenia.

Protein intake: Advise patients to consume protein-rich foods to help maintain muscle mass.

Referrals: If patients do not respond to maximum doses of either medication, consider referral to an endocrinologist.

Long-term strategies: Discuss strategies for maintaining weight loss after stopping medication, focusing on gradual dose reduction and continued lifestyle modifications.

5. Dosing considerations

Doses are individual and not everyone needs the maximum dose. Some people respond to one drug but not the other and switching is possible

6. Stopping treatment with GLP-1 RAs

There is very little data to help prescribers decide how to take people off the medication. The body is biologically designed to regain the weight that has been lost. Stopping treatment abruptly often leads to regain of weight. One strategy is “to come down the doses just as you went up them” to mitigate this effect.

7. Communication with GPs

Private providers of GLP-1 RAs should inform the patient’s GP (with the patient’s consent) that they are taking these medications.  There may be interactions with other medicines and it could be important if the patient becomes pregnant or is planning elective surgery.  Patients taking GLP-1 or GIP/GLP1 RAs may be at risk of aspiration under general anaesthesia (see MHRA guidance).

Conclusion

GLP-1 and GIP/GLP-1 receptor agonists represent a significant advance in the treatment obesity and related metabolic disorders. Effective use of these agents will lead to better patient outcomes and transform the way in which weight management is approached.

About Deborah Evans

Deborah Evans, a pharmacist with 40 years of experience, who specialises in women’s hormonal health and weight management. She is the superintendent pharmacist and clinical director at Remedi Health. About 80% of her time is spent in the clinic facing clients.