Today, Ms Kaur is the interim Group Chief X Information Officer (CXIO) for University Hospitals of Leicester (UHL) and University Hospitals of Northamptonshire (UHN), which includes both Kettering General Hospital and Northampton General Hospital. It is a role that places her at the intersection of clinical practice and digital innovation — and one that, she is quick to point out, is built on her identity as a pharmacist. “I absolutely love technology and thoroughly enjoy working in the NHS”, she says.

The bridge between clinical and digital

As Group CXIO, Ms Kaur is responsible for the allied health professions, pharmacy and healthcare scientists from a digital clinical perspective. In practical terms, this means acting as a bridge between frontline clinical colleagues and the organisations’ digital and data teams — ensuring that the technology serving staff and patients is fit for purpose, safe and continuously improving.

Her portfolio also includes digital risk management and oversight of the user experience for colleagues across UHL and UHN. One of her most significant recent projects has been leading the go-live of Nervecentre, an electronic patient record system, at Northampton General Hospital — a complex transition from both paper-based and legacy digital systems. The implementation drew on learning accumulated across the East Midlands acute provider network, where Nervecentre is already in use, and was informed by a newly established digital patient reference group, which gives patients across Leicester and Northamptonshire a direct voice in shaping digital services.

Clinical safety at the core

Running through everything Ms Kaur does is a commitment to clinical safety. She sees it as inseparable from digital transformation: the shift to electronic systems introduces new risks even as it eliminates old ones and managing those risks rigorously is central to her role.

A message for the next generation

Ms Kaur’s advice for pharmacists considering a move into clinical informatics is direct. First, find a mentor — and recognise that different mentors may be needed as careers develop. Second, find your professional community. “Find your tribe, find the people within the space within the field that you want to go into … the people that are going to support you”, she advises. Above all, “be your own champion”, she adds.

Her own journey has been recognised with the Chief Clinical Information Officer of the Year award at the 2024 Digital Health Networks awards, a HSJ Digital Awards finalist placing, and inclusion in the Top 100 Digital Leaders list in 2025. She attributes a large part of her success to the support of her colleagues. “A lot of this is down to the teams I’ve been so lucky to have worked with,” she reflects. For pharmacists with an interest in digital health, her career is proof that the digital world offers both opportunity and impact. “There are lots of opportunities within this space”, she says.

About Ramandeep Kaur

Ramandeep Kaur is currently the interim Group CXIO at University Hospitals of Northamptonshire and University Hospitals of Leicester NHS Trust. She won Digital Health Networks Award CCIO of the Year in 2024 and was shortlisted for HSJ Digital Leader of the Year in 2025. She was listed in the Top 100 digital transformation leaders by Distilled Post in November 2025. She has completed the Digital Health London Pioneer Fellowship Programme, is an alumna of the NHS Digital Health Leadership Academy and has a Masters in Leadership and Innovation. She is proud to be co-vice chair of the CCIO Digital Health Network Advisory Panel, a member of the BCS, RPS, Shuri Network & UKCPA.

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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.

The post Demystifying menopause: expert insights from Dr Louise Newson appeared first on Pharmacy Update Online.

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.

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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.

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Why syringe type matters for intravitreal injections

At the GERPAC congress 2024 (held in October 2024) Dr Chennell described a study that evaluated of two types of syringes for bevacizumab solutions for intravitreal administration.  The thinking behind the study was that bevacizumab, a monoclonal antibody, could be altered or destabilised by contact with silicone oil in the syringe.

How the syringe lubricant interacts with the drug inside it

Dr Chennell’s study compared the stability of bevacizumab injection in two different types of syringe – conventional polypropylene syringes, lubricated with silicone oil and syringes that had (non-extractable) cross-linked silicone on the internal surface of the barrel of the syringes. The results showed that fewer bevacizumab particles were formed and the drug appeared to retain its initial physical characteristics in the cross-linked silicone syringes compared with the polypropylene syringes.

Why ready-to-administer syringes improve clinical care

The provision of ready-to-administer bevacizumab in syringes reduces the risks of altering or destabilising the monoclonal antibody during the preparation process and saves time in the administration process.

Unfortunately, cross-linked silicone syringes of the type used in the study are not yet available to hospital pharmacists in France in suitable packs and Dr Chennell is trying to find alternative syringe manufacturers who might be able to provide suitable products.

About Philip Chennell

Philip Chennell is a pharmacist, at the University Hospital of Clermont-Ferrand. He is currently in charge of the Quality Control and Development Laboratory of the hospital’s pharmacy. He is also Assistant Professor at the University Clermont Auvergne and a member of the Materials for Health Research Team, focusing on medical devices and content/container Interactions.

Read and watch the full series on our website or on YouTube.

The post Syringe lubricants – a little-known aspect of injection preparation appeared first on Pharmacy Update Online.

There are a number of advantages of providing bevacizumab as a ready-to-administer injection, preloaded into a syringe. First, even a brief contact with silicone oil (in polypropylene syringes) combined with the mechanical stresses of manipulating the syringe or, for example, flicking the syringe to remove air bubbles can be enough to trigger changes in the bevacizumab. Second, the clinical care process is smoothed. “By preparing these syringes directly in a pharmaceutical compounding unit it allows us to provide …… ready-to-administer syringes for the ophthalmologist or the end-user which means that they save time – they don’t have to perform the manipulation themselves. What they need to do is to just take the syringe, adjust the needle, [and] inject”, explains Dr Chennell.

Unfortunately, cross-linked silicon syringes are not yet available to hospital pharmacists in France in suitable packs. The packs that are available are designed for industrial use and are too large for use in hospital pharmacy compounding units.   “We can’t really purchase a big bag containing 1,200 syringes and expect to be able to do something with them when we see that in our clinical setting, we only use a couple of dozen every week. Okay, after a year it does add up but we don’t need 1,200 in one big go – and how would we store them? How would we keep them sterile?”, he says.

Since giving the presentation at the GERPAC congress Dr Chennell has been contacted by several colleagues in France who are also interested in this topic. He is also trying to find alternative syringe manufacturers who might be able to provide suitable products.

About Philip Chennell

Philip Chennell is a pharmacist, at the University Hospital of Clermont-Ferrand. He is currently in charge of the Quality Control and Development Laboratory of the hospital’s pharmacy. He is also Assistant Professor at the University Clermont Auvergne and a member of the Materials for Health Research Team, focusing on medical devices and content/container Interactions.

Read and watch the full series on our website or on YouTube.

The post Why ready-to-administer syringes improve clinical care appeared first on Pharmacy Update Online.

Dr Chennell’s study set out to compare the stability of bevacizumab injection in two different types of syringes. One type was the conventional polypropylene syringe type, lubricated with silicone oil. The other had (non-extractable) cross-linked silicone on the internal surface of the barrel of the syringe. “Our main hypothesis was that these cross-linked silicone syringes would induce less aggregation, ….. of the antibody so that therefore it wouldn’t impact its stability compared to normal silicone-oil-lubricated syringes”, explains Dr Chennell. Syringes (1 ml) containing 0.2 ml of bevacizumab, 25mg/ml were prepared and stored at 5°C and 32°C for three months. The contents were investigated at three days, one month and three months. In addition to visual examination of the contents, aggregation index measurements, size exclusion chromatography, subvisible particulate counting and dynamic light scattering analysis were also carried out. “These assays allowed us to …..  gain insight into …. the number of particles [and] their size but also how the antibody behaved – did it fragment or did it aggregate into high-molecular-weight species which hadn’t, for example, quite yet formed particles”, he says.

The main finding was that physical stability seemed to be superior with the cross-linked silicone syringes compared to the classical, normal, silicone-oil-lubricated syringes. Fewer bevacizumab particles were formed and the drug appeared to retain its initial physical characteristics.  These differences were likely to be linked to the presence of the silicone oil in the polypropylene syringes, he says. “I think the main conclusion …… from a pharmaceutical point of view, is that it shows, yet again, that choosing the right primary container for monoclonal antibodies, or in fact any medication, really remains [paramount] if you want to maximize patient therapeutic safety”, he adds.

About Philip Chennell

Philip Chennell is a pharmacist, at the University Hospital of Clermont-Ferrand. He is currently in charge of the Quality Control and Development Laboratory of the hospital’s pharmacy. He is also Assistant Professor at the University Clermont Auvergne and a member of the Materials for Health Research Team, focusing on medical devices and content/container Interactions.

Read and watch the full series on our website or on YouTube.

The post How the syringe lubricant interacts with the drug inside it appeared first on Pharmacy Update Online.

At the GERPAC congress 2024 (held in October 2024) Dr Chennell presented the findings from a study concerned with the evaluation of two types of syringes for bevacizumab solutions for intravitreal administration. An intravitreal injection involves injecting medication directly into the vitreous humour at the back of the eye. It is used to treat retinal diseases such as age-related macular degeneration.

Although, at first sight, this might seem straightforward, there is a risk of interaction between the silicone oil that is used to lubricate the syringe and the medication solution inside the syringe. Specifically, there is a risk that the silicone oil can migrate into the drug solution and then be injected, in this case, into the eye. If the patient has multiple injections, then there is a risk that the oil will accumulate at the back of the eye. “It has been shown that it can cause reduced visual acuity, endophthalmitis, or for example, a reversible rise of intraocular pressure. It’s also been noted that certain patients have the impression that they have, like, floaters impacting their vision”, explains Dr Chennell.

About Philip Chennell

Philip Chennell is a pharmacist, at the University Hospital of Clermont-Ferrand. He is currently in charge of the Quality Control and Development Laboratory of the hospital’s pharmacy. He is also Assistant Professor at the University Clermont Auvergne and a member of the Materials for Health Research Team, focusing on medical devices and content/container Interactions.

Read and watch the full series on our website or on YouTube.

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Why is opioid use before hip or knee replacement a problem?

Patients who require THA or TKA suffer from end stage osteoarthritis with chronic pain. Opioids often provide no better pain relief that simple analgesics and yet they carry the risk of additional side effects such as drowsiness and the risk of falls. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery.

THA and TKA are among the most common elective surgical procedures performed around the world and numbers are expected to at least double over the next decade.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice.

How OpioidHALT tackles pre-operative opioid use?

There is little published evidence for the effectiveness of opioid dose tapering. One previous retrospective study showed that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses.

The OpioidHALT study involved video or telephone consultations with a pharmacist starting three months before the date of the operation. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. Patients determined the level of opioid tapering that they wished within the framework of national guidelines i.e. 10 to 25% of the patient’s baseline opioid dose tapered per month.

What the OpioidHALT pilot study tells us

The initial consultations in the OpioidHALT study took about one hour. Follow-up appointments started one week after each dose reduction and were typically shorter, Patients were educated about how to identify and manage opioid withdrawal symptoms. “If necessary, the patient was put back on a higher opioid dose”, says Dr Liu.

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. In the intervention group there were –

• Fewer opioids consumed in hospital
• Smaller quantities of opioids supplied on discharge
• Fewer days in hospital
• Fewer patients taking opioids three months post-operation

Patients in the intervention group also had improved physical function and improved overall body pain intensity.

Why pharmacists should manage pre-operative opioid use

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.

Recordings of the consultations showed that many patients were keen to discontinue opioid use but needed help with the process. “We’ve got patients who are crying [out] to have pharmacists to be more involved in their care …. and that’s something that a lot of pharmacists can do”, says Dr Penm. He adds that the whole multidisciplinary research team says “This is a really good intervention, we should be doing this, pharmacists should be leading it”

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

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Some 575 patients were screened for inclusion in the OpioidHALT study and 442 were excluded because of low opioid use. “That is the reality of clinical trials for you”, says Dr Shania Liu. “We know that approximately a quarter of patients in [this] population don’t use opioids on a regular basis”, she adds. Nevertheless, dosage tapering is still important for the many patients who are using opioids regularly.

OpioidHALT II

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.  “What’s great about it is all of the pilot sites were so impressed by the pilot that they’ve all stayed on for this definitive trial. Other sites have also expressed interest because they’ve been so excited about it”, says Dr Penm. “We’re going to have more pharmacists, a lot more patients – and [it] will be primarily powered to look at those pain and quality of life outcomes”, he explains.

Pharmacists often improve medication regimens but rarely find out how much of an impact the changes have on patients’ lives. One of the useful and important findings in the OpioidHALT study was that the early benefits of reduced opioid use were sustained for three months. “It just shows you the value that pharmacists can provide to their patients – that when we improve their medicines we could be improving it for much, much longer than you realise and having much, much stronger impact”, says Dr Penm.

All the opioid-tapering consultations were recorded and patients’ reactions made a profound impact on Dr Penm.

“Many of them were just so grateful to have someone listen to them,  to validate what they’ve been going through with their pain and to support them through the opioids. In fact, most of them said, “I’ve never had any benefit from these but I just don’t know how to get off them – and I really would love some help”,  so I think we’ve got patients who are crying [out] to have pharmacists to be more involved in their care, to be more present, to listen to them, to validate what they’re going through – and that’s something that a lot of pharmacists can do”, he says.

In summary Dr Penm says:

“Any work of this calibre is extremely difficult to do with one person and we have a very large team. One of the unique aspects is how multidisciplinary it was – we have pharmacists, we have nurses, we have GPs, we have anaesthetists, we have physiotherapists, we have orthopaedic surgeons – and we know how rare it is to get all these people together in one spot and for all of them to say, “This is a really good intervention, we should be doing this, pharmacists should be leading it”. It’s just beautiful to hear. You don’t always hear that the pharmacist is the most obvious choice but in this case they are. They’re happy, they’re competent, they’re capable – and everyone else doesn’t want to do this because it is not their area of expertise. Well, with pharmacy we’re very comfortable because we know this, we know opioids, we see tapering, we know how to taper, we know what to expect”.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

The post Why pharmacists should manage pre-operative opioid use appeared first on Pharmacy Update Online.

The initial consultations in the OpioidHALT study – when the opioid tapering plans were developed took about one hour. Follow-up appointments started one week after each dose reduction to check on progress and safety; these were typically shorter, explains Dr Shania Liu. Opioid withdrawal symptoms were one obvious concern. Dr Liu emphasises that the tapering rate was very gradual to minimise the risks of opioid withdrawal and patients were educated about what to look out for and how to overcome withdrawal symptoms. “If necessary the patient was put back on a higher opioid dose to ….. ensure that patient safety came first”, she says.  In fact, all adverse events were recorded during the study.

OpioidHALT findings

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses, explains Dr Jonathan Penm. “We also found that currently GPs or primary care physicians are generally responsible for opioid tapering, but that’s not their happy place – they were not comfortable, they did not want to spend their time on that”, he says.  However, pharmacists were keen to undertake this work.  The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group. “As a researcher it’s very rare to see such large differences – 17% versus 90%”, says Dr Penm.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts.  Those patients whose opioid doses were tapered before surgery consumed fewer opioids in hospital and received smaller quantities of opioids at discharge.  In addition, the length of hospital stay was shorter (4 days versus 5.6 days) in the intervention group. Three months after the surgery those in the intervention group were much less likely to be taking opioids than those in the control group. They also had improved physical function and  improved overall body pain intensity. Dr Penm notes that “it’s not powered for that so we do have to be a bit cautious  – but these are very promising results”.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

The post What the OpioidHALT pilot study tells us appeared first on Pharmacy Update Online.

The case for reducing opioid treatment slowly before total hip and knee replacements is compelling, according to Dr Jonathan Penm. Many patients with osteoarthritis are taking opioids but “we know opioids are not the most effective medicine for osteoarthritis, so we’ve got a cohort of people taking a medicine that doesn’t have much evidence, that’s not very effective and comes with a lot of side effects”, he explains. Reducing the opioid doses is unlikely to make pain any worse but it could reduce the risk of harms, he adds. He notes that there is little evidence for the effectiveness of opioid dose tapering.  One previous retrospective study had shown that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses. “They might just be patients who would naturally taper who weren’t as sick and so they have better outcomes – and so we just didn’t know if these harms were reversible”, he says.

OpioidHALT – objectives and methods

The objective of OpioidHALT study was to examine the feasibility and effectiveness of a pharmacist-led intervention to taper opioid dosage before hip and knee replacement surgery, compared with usual care.  The intervention was delivered via a video or telephone consultation. “Pharmacists and patients met ‘one-on-one’ over a Zoom meeting or over a telephone call and discussed their pain management and opioid use before surgery – approximately three months before their joint replacement surgery – with the aim to gradually taper their opioid dose until the day of their surgery”, explains Dr Shania Liu.

For this pilot study a single pharmacist based in the community conducted all the consultations. The pharmacist was trained using freely available, online resources. “We recently published a training package summarising these resources so any pharmacist can access them”, says Dr Liu. The pharmacist worked with each patient to  develop an opioid tapering plan that was evaluated for safety by a pain specialist. In addition, the GP was kept in the loop at all stages. Dr Liu emphasises the patient-centred nature of the consultations. “Patients could lead the level of opioid tapering that they wished. The opioid tapering rate, however, was guided by national guidelines on opioid tapering rates. So, this was, on average, 10 to 25% of the patient’s baseline opioid dose tapered per month – so quite gradual – and we did monitor for safety”, she says. Furthermore, patients were offered simple analgesics and non-pharmacological approaches to ensure that pain was managed whilst the opioid doses were being tapered.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

The post How OpioidHALT tackles pre-operative opioid use appeared first on Pharmacy Update Online.