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Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists

ASCEPT Clinical Pharmacology Weekend Clinical Toxicology

25 & 26 May 2013

St Vincent’s Private Clinic Level 4 Function Room 438 Victoria Street Darlinghurst, Sydney, NSW

ASCEPT Secretariat Jen Coulls Suite 25, Level 1 213 Greenhill Road, Eastwood 5063 Tel: 08 8274 3741 Fax: 08 271 2884 Email: [email protected] Website: www.ascept.org


ASCEPT Clinical Pharmacology Weekend Goal:

To provide professional education at a level appropriate for advanced trainees in Clinical Pharmacology and relevant to practitioners in Clinical Pharmacology

Date:

Saturday 25 to Sunday 26 May 2013

Venue:

St Vincent’s Private Clinic, 438 Victoria Street, Darlinghurst NSW. Located at Level 4 Function Room

Theme:

Adverse Drug Reactions

Organising Committee:

Jonathan Brett Paul Chin Matt Doogue Sarah Hilmer Catherine Lucas

Guest Speakers:

Murray Barclay, Clinical Pharmacologist, Gastroenterologist and Clinical Professor, Christchurch Hospital and University of Otago Christchurch Nick Buckley, Professor of Medicine, Medical Professorial Unit, POW Hospital Clinical School, University of NSW Andrew Dawson, Director National Poisons Register & Clinical Toxicology, Royal Prince Alfred Hospital, Sydney; Clinical Professor of Medicine, Sydney Medical School, University of Sydney Ric Day, Professor, Director, Department of Clinical Pharmacology & Toxicology, Therapeutics Centre, St Vincent's Hospital, Sydney Matt Doogue, Associate Professor, Clinical Endocrinologist, University of Otago, Christchurch

Pharmacologist

and

Sarah Hilmer, Staff Specialist, Clinical Pharmacology and Aged Care, Royal North Shore Hospital; Associate Professor, Northern Clinical School, Sydney Medical School, The University of Sydney, New South Wales Bridin Murnion, Head of Department, Drug Health Services, Concord Repatriation General Hospital; Staff Specialist, Drug Health Services, Royal Prince Alfred Hospital; Clinical Senior Lecturer, Discipline of Addiction Medicine, Faculty of Medicine University of Sydney 2


Sallie Pearson, Associate Professor, Head, Pharmacoepidemiology and Pharmaceutical Policy Research Group, University of Sydney Elizabeth Phillips, Institute for Immunology & Infectious Diseases, Murdoch University, Perth; Clinical Professor, The University of Western Australia Peter Pillans Associate Professor, Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Queensland David Reith, Associate Professor, Dunedin School of Medicine, University of Otago

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Attendee List Shirantha Adikari

The Queen Elizabeth Hospital

Nimmi Athuraliya

Calvary Mater Hospital

Murray Barclay

University of Otago, Christchurch

Jonathan Brett

Royal Prince Alfred Hospital

Nick Buckley

University of New South Wales

Paul Chin

Christchurch Hospital

Ian Collins

Dr Collins’ Rooms

Andrew Dawson

Royal Prince Alfred Hospital

Ric Day

St Vincent's Hospital

Matt Doogue

University of Otago, Christchurch

Andrew Finch

Princess Alexandra Hospital

Madlen Gazarian

University of New South Wales

Sarah Hilmer

Royal North Shore Hospital

Ingrid Hopper

Clinical Pharmacology Unit, Monash

Joel Iedema

Redland Hospital

Claire Johnston

Royal North Shore Hospital

Ganessan Kichenadasse

Flinders Medical Centre

Poh-Kooi Loh

Royal Perth Hospital

Catherine Lucas

St Vincent’s Hospital

Mitchell McKean

Royal Brisbane Hospital

Arduino Mangoni


David Metz

Royal Children’s Hospital Victoria

John Miners


Bridin Murnion

Concord Repatriation General Hospital

Sallie Pearson

University of Sydney

Elizabeth Phillips

Murdoch University

Peter Pillans

Princess Alexandra Hospital

David Reith

University of Otago, Dunedin

Pei Rong

Austin Health

Tilenka Thynne

Royal Adelaide Hospital

Kenneth Williams

St Vincent’s Hospital

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Clinical Pharmacology Weekend 2013 Programme Saturday 25 May 08:00 - 08:30

Registration Session 1 – Chair: Andrew Dawson

08:30 - 09:10

Opening speech – Peter Pillans

09:10 - 09:50

Assessing and classifying ADRs – Elizabeth Phillips

09:50 - 10:30

Prescribing and ADRs – Ric Day

10:30 – 11:00

Morning Tea

11:00 – 13:00

Session 2, Trainee Presentations – Chair: Bridin Murnion

11:00 - 11:30

Quetiapine-Induced Agranulocytosis – Andrew Finch Psychotropics Agents, Enzyme Systems and Side Effects that Mimic Disease: Have we created an epidemic? – Arlene Taylor (via Skype) Diurnal Blood Pressure Patterns in Heart Failure Patients – Pei Rong

11:30 - 12:00 12:00 - 12:30 12:30 - 13:00 13:00 - 13:50

Tachyarrhythmia Post Synthetic Cannabinoid Inhalation – Catherine Lucas Lunch Session 3 – Chair: John Miners

13:50 - 14:30

Pharmacovigilance: NZ experience – David Reith

14:30 - 15:10

Pharmacovigilance and data linkage in Australia – Sallie Pearson

15:10 - 15:50

DAEN example – Peter Pillans

15:50 - 16:00

Afternoon tea

16:00 -17:30

Session 4, The Great Debate – Chair: Matt Doogue “Consultants are more dangerous prescribers than trainees” Affirmative: Nick Buckley, Andrew Dawson, Bridin Murnion Negative: Andrew Finch, Catherine Lucas, Jonathan Brett Dinner – Thai Lemongrass, 70 Stanley Street, Darlinghurst

19:00

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Sunday 26 May 08:00 - 08:30 08:30 – 09:30 08:30 - 09:00 09:00 - 09:30 09:30 - 10:00 10:00 - 10:30 10:30 – 11:00 11:00 - 11:40 11:40 - 12:20 12:20 - 13:00 13:00 - 13:15

Registration Session 5, Trainee Presentations – Chair: Joel Iedema Rare Adverse Effect of a Chemotherapy Drug – Ganessan Kichenadasse Pregnancy categorisation: can we do it better? – Mitchell McKean Is naltrexone the ideal agent to treat alcohol dependence in Aboriginal and Torres Strait Islander Australians? – Jonathan Brett Pharmacovigilance and Indigenous Australians: There are no data. – Tilenka Thynne Morning Tea Session 6 – Chair: Nick Buckley Azathioprine example – Murray Barclay ADRs in older people – Sarah Hilmer ADR assessment: different goals, different methods - Matt Doogue Closing Remarks - Catherine Lucas, Trainee Representative, STC in Clinical Pharmacology, Sydney

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Opening Speech Associate Professor Peter Pillans, Princess Alexandra Hospital, Brisbane, Queensland

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Assessing and Classifying ADRs Professor Elizabeth Phillips, Institute for Immunology & Infectious Diseases, Murdoch University ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Prescribing and ADRs Professor Richard Day, Clinical Pharmacology, St Vincent's Hospital, University of NSW In order to do better in reducing the toll from adverse drug reactions (ADRs), we need to reduce the chance that they might occur. A powerful approach is by practicing ‘Quality Use of Medicines’ (QUM). We as clinical pharmacologists need to be fully versed about QUM and the important elements so that we can advocate for its implementation with our students, colleagues, patients and communities. Prescriber education needs to extend well beyond the classical clinical pharmacology curriculum in order to achieve a reasonable level of understanding of QUM by our medical graduates. The engagement of stakeholders beyond the patient and prescriber and the importance of helping all players to become concordant in their approach and input into an individual patient’s therapy is undervalued and we need to be involved in rectifying this. Marshalling of support to achieve this goal by for example, supporting and championing the NPS and what it can provide to help is an important opportunity. A key principle of QUM that needs strong advocacy and professional input is the individualization of pharmacotherapy – this, when achieved, is an important protection against ADRs. The clinical pharmacologist needs to be active not only in analysing pharmacokinetic/ pharmacodynamic aspects of a patient’s needs but also in assisting in getting the optimal approach to pharmacotherapy, as defined by QUM, instituted. There are many parts of this puzzle – when more pieces are in place, ADRs will be less frequent.

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Trainee Presentations Quetiapine-Induced Agranulocytosis Andrew Finch, Princess Alexandra Hospital, Brisbane, Queensland Agranulocytosis and neutropenia are recognized adverse drug effects of antipsychotic medications1. Quetiapine is one of the several clozapine-inspired atypical antipsychotic drugs introduced for the treatment of schizophrenia, and acute manic episodes associated with bipolar disorder in adult patients2. A case is presented in which a 38-year-old Caucasian female developed severe agranulocytosis after 4 weeks of high dose quetiapine. Naranjo’s ADR algorithm categorized the agranulocytosis with quetiapine as ‘probable’. A review of the literature, possible pathophysiologic mechanisms2 and the use of G-CSF3 are also discussed. Topics for Discussion: •

Pathophysiology of agranulocytosis – is it a class effect?

Key Literature: 1. 2. 3.

Andersohn F, Konsen C, Garbe E. Systematic review: Agranulocytosis induced by nonchemotherapy drugs. Annals of Internal Medicine 2007;146:657-‐65. Li X, Cameron MD. Potential role of a quetiapine metabolite in quetiapine-‐induced neutropenia and agranulocytosis. Chemical Research in Toxicology 2012;25:1004-‐11. Andres E, Maloisel F, Zimmer J. The role of haematopoietic growth factors granulocyte colony-‐stimulating factor and granulocyte-‐macrophage colony-‐stimulating factor in the mangement of drug-‐induced agranulocytosis. British Journal of Haematology 2010;150:3-‐8.

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Psychotropic Agents, Enzyme Systems and Side Effects that Mimic Disease: Have we created an epidemic? Arlene Taylor, Lyell McEwin Hospital, Adelaide SA Selective serotonin reuptake inhibitors (SSRIs) have been increasingly prescribed for depression, and other mental health issues, since the 1990s. The majority of these medications are metabolised by one of three cytochrome P450 systems (CYP2D6, CYP2C19 and CYP2C9). Other psychotropic agents used in the same conditions, including the newer atypical antipsychotics, are also predominantly metabolised via these systems. Individual genotypes, and resulting phenotypes, for these systems are variable; particularly in the case of CYP2D6. We have the ability, in Australia, to test individuals for their genotype relating to these CYP enzyme systems. Metabolism profiles can vary from poor through to ultra-rapid. Poor metabolisers are at risk of toxicities from parent drugs, while ultra-rapid metabolisers may be at risk of toxicities from metabolites or failure to respond to treatment. Akathisia is an unpleasant condition associated with feelings of inner restlessness, and sometimes associated with physical manifestations such as being unable to remain motionless. It is a common but under identified side effect of many psychotropic agents; more commonly occurring in those with altered CYPP450 metabolism. Akathisia has been associated with self-harming and suicidal behaviours and can be misidentified as an agitated depression or manic presentation. In some cases of akathisia the entire presentation may reflect symptoms of mental illness. As well as being at increased risk of experiencing akathisia when placed on psychotropic medications, individuals with altered metaboliser profiles are more at risk of neuroleptic malignant syndrome (NMS) and serotonergic toxicity. Two cases where akathisia and NMS/serotonergic toxicity were not identified early in the course of treatment are presented. In both cases the individuals involved experienced significant deterioration in their mental health status following psychotropic agents being prescribed and a subsequent improvement following removal of these agents. Both patients also exhibited mild symptomology consistent with either NMS or serotonergic toxicity which resolved on cessation of these medications. Topics for Discussion: 1. Should CYPP450 enzyme system genotyping for CYP2D6, 2C19 and 2C9 prior to initiation of psychotropic agents in individuals be introduced in order to identify those at increased risk of akathisia and other adverse effects? 2. What proportion of patients ‘stuck’ in our mental health system with seemingly refractory/treatment resistant conditions are in fact experiencing an adverse drug reaction caused by the medications being used to ‘manage’ their symptoms? 3. Are we obliged to review patients chronically under care in our mental health system and assess whether their genotype may be affecting their health/treatment outcomes?

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Diurnal Blood Pressure Patterns in Heart Failure Patients Pei Rong, Bernadette Cranswick, Bassem Dawood, Min Yin Goh, Christopher O’Callaghan. Department of Clinical Pharmacology, Austin Health, Heidelberg, Victoria The constant and prominent feature of blood pressure diurnal variation through 24-hour monitoring in normotensive man is a fall in blood pressure at night. Impaired diurnal blood pressure variation is a risk factor for developing heart failure. The effect of established heart failure on circadian blood pressure variation is unknown. In this preliminary retrospective observational study, we studied 36 in-patients who were admitted to the General Medical wards with new or pre-existing diagnosis of heart failure. All patients had twenty-four-hour ambulatory blood pressure monitoring performed early in the admission. The average age of the patients was 81.6±7 years old (mean ± SEM). Only 4 patients (11.1%) had intact diurnal blood pressure variation. A reversed dipping pattern (where the night pressure was higher than the day pressure) was seen in 18 patients (50%) and the remainder (n=14, 39%) had night pressures that were 90-100% of the day pressures. The average day blood pressure was 118±22 mm Hg (systolic) and 62.6±12 mm Hg (diastolic). The average night pressure was 118±20 mm Hg (systolic) and 62.1± 8.9 mm Hg (diastolic). Of the patients who had reversed dipping, the night systolic pressure was 8.1±7.7 mm Hg greater than the day pressure. Heart failure in acutely admitted patients is characterised by reversal of the usual diurnal change in blood pressure. These changes may be a potential target for chronotherapy.

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Tachyarrhythmia Post Synthetic Cannabinoid Inhalation Catherine Lucas, St Vincent’s Hospital, Sydney, NSW Background: Synthetic cannabinoids, an important class of the rapidly emerging array of psychoactive substances, are functionally similar to tetra-hydro cannabinol. They may be sprayed in liquid solution onto a mixture of “smokable herbs”1 and sold as “herbal” or “incense” products. Promoted as legal alternatives to cannabis, they are not easily detectable in urine or blood samples.2 There is little information on whether they actually contain the herbal ingredients listed and their potency may vary widely.3 One such product is Puff herbal incense; purported ingredients include Zornia latifolia, Lagochilus inebrians, Scutellaria nana, Pedicularis densiflora, Eschscholzia lemmonii and Nymphaea caerulea. There is little data regarding adverse effects or long term sequelae of synthetic cannabinoids. Most data pertain to compound JWH-018.3 Emerging reports of emergency presentations document tachycardia, agitation, excess sedation4 and myocardial infarction.5 We report the case of a 24 year old male with no significant medical history whom presented with palpitations, chest discomfort, dyspnoea and bilateral arm "tingling” after ingestion of an unidentified Chinese weight loss tablet fourteen hours prior to the onset of symptoms, approximately 40 grams of ethanol and an unspecified quantity of Puff herbal incense via inhalation. On examination, the patient was pale and diaphoretic with no neurological deficit, sinus tachycardia of 170 beats per minute, blood pressure of 160/85mm Hg, respiratory rate of 40 breaths per minute and SpO of 98 % on room air. 2

Initial ECG demonstrated sinus tachycardia; ECG approximately one hour after arrival demonstrated supraventricular tachycardia. The patient received three boluses of adenosine. ECG 11 minutes after the third bolus demonstrated sinus tachycardia. Biochemistry, troponin T, thyroid function tests and chest x-ray were unremarkable. Urine drug screen was negative for amphetamines, opiates, cocaine and cannabis. The patient was discharged after remaining normocardic, normotensive and asymptomatic for approximately 16 hours. Despite the confounder of potential amphetamine ingestion, the temporal relationship between synthetic cannabinoid inhalation and onset of symptoms is suggestive of causation. There is a need for greater health professional awareness and patient education regarding potential harms of novel psychoactive substances. Improved access to toxicological expertise 13


and analysis is important. Collection of routine data on morbidity associated with these substances should be encouraged. Topics for Discussion: 1. Potential harms associated with synthetic cannabinoids. 2. Challenges associated with obtaining information regarding herbal ingredients. 3. Regulatory options in relation to controlling existing and emerging synthetic analogue drugs. Key Literature: 1. 2. 3. 4. 5.

Dargan P, Hudson S, Ramsey J, Wood D. The impact of changes in UK classification of the synthetic cannabinoid receptor agonists in ‘Spice’. International Journal of Drug Policy 2011; 22: 274-277. Fattore L, Fratta W. Beyond THC: the new generation of cannabinoid designer drugs. Frontiers in Behavioral Neuroscience 2011; 5:1-12. Gibbons S. ‘Legal Highs’ – novel and emerging psychoactive drugs: a chemical overview for the toxicologist. Clinical Toxicology 2012; 50: 15–24. Pierre JM. Cannabis, synthetic Cannabinoids, and psychosis risk: What the evidence says. Current Psychiatry 2011; 10: 49-57. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics 2011 DOI: 10.1542/peds.2010-3823.

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Pharmacovigilance: NZ Experience Associate Professor David Reith, Dunedin School of Medicine, University of Otago

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Pharmacovigilance and Data Linkage in Australia Associate Professor Sallie Pearson, University of Sydney Sallie is a health service researcher and behavioural scientist with more than 15 years of experience in quality use of medicines research. Her interests include prescriber behaviour change, post-market surveillance of medicines and evaluating the impact of pharmaceutical policy interventions. Sallie completed her doctoral training at the University of Newcastle, Australia (1998) and her Postdoctoral Fellowship in Pharmaceutical Policy at Harvard Medical School (2000-2001). On her return to Australia she worked as a consultant to the WHO Collaborating Centre in Pharmaceutical Policy Boston and Medicare Australia. She established the Pharmacoepidemiology and Pharmaceutical Policy Research Group in 2006 and joined the Faculty of Pharmacy, University of Sydney in 2012. She is currently a Cancer Institute NSW Career Development Fellow. Sallie will discuss the growing use of linked routinely collected data to explore drug safety. In particular she will discuss Australia's contributions to the field to date and the challenges of undertaking population-based drug safety studies in the local environment. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Database of Adverse Event Notifications (DAEN) Example Associate Professor Peter Pillans, Princess Alexandra Hospital, Brisbane, Queensland

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Trainee Presentations Ifosfamide – Do we know how to use it safely? Ganessan Kichenadasse, Flinders Medical Centre, Adelaide. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Pregnancy categorisation: can we do it better? Mitchell McKean, Royal Brisbane Hospital, Brisbane, QLD. Pharmaceutical agents used during pregnancy can have a wide variety of effects on the foetus from transient changes in biological parameters to foetal demise. The Australian categorisation system for prescribing medicines in pregnancy aims to account for birth defects, unwanted pharmacological effects and problems in later life. However, this classification is made at the time of registration and often the medication has not been used in pregnant women. We will look at the limitations of the current categorisation system and discuss possible alternatives for the future.

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Is naltrexone the ideal agent to treat alcohol dependence in Aboriginal and Torres Strait Islander Australians? Jonathan Brett, Royal Prince Alfred Hospital, Sydney, NSW There is growing concern within Aboriginal and Torres Strait Islander (Indigenous) communities about the current level of alcohol misuse. Survey data on prevalence of alcohol consumption shows that although fewer Indigenous Australians drink alcohol compared to the non-Indigenous population, those who do drink tend to do so to risky levels [1]. The multiple barriers to health care along with deficiencies in alcohol treatment service quantity, quality, cultural appropriateness and geographical distribution mean that there is a significant gap between need and service provision. Based on an aggregate analysis of PBS and survey data, only 5% of dependent drinkers in Australia are prescribed alcohol pharmacotherapies [2]. There are many reasons for this, including a perceived lack of efficacy [3] and lack of awareness of their role among health professionals and the public. Despite efforts to close the gap in terms of equity of access to medications for Indigenous Australians, significant barriers remain to quality use of medicines and adherence [4]. Although no data on the use of alcohol relapse prevention pharmacotherapies for Indigenous Australians exist, anecdotally this is even lower than in the non-Indigenous population. Here we present the case for the use of naltrexone in alcohol dependent Indigenous Australians. We explore the neurobiological and epigenetic consequences of exposure to early stressful life events and maltreatment that may make naltrexone a particularly effective treatment [5]. Anecdotally family history of alcohol misuse is also more common in Indigenous Australian populations and we discuss the possible environmental and genetic interactions that make naltrexone an appealing option [6]. Other practical arguments for facilitating naltrexone use are discussed. Lastly we explore the efficacy of depot naltrexone for alcohol as a possibility to overcome access and compliance issues. Areas for further research are highlighted. Key Literature: 1. 2. 3. 4. 5. 6.

Chikritzhs, T. and M. Brady, Fact or fiction? A critique of the National Aboriginal and Torres Strait Islander social survey 2002. Drug and Alcohol Review, 2006. 25(3): p. 277-287. Doran, M., New pharmacotherapies for alcohol dependence: are they being used and what do they cost? The Medical Journal of Australia, 2003. 179(4): p. 218-224. Mark, T.L., H.R. Kranzler, and X. Song, Understanding US addiction physiciansâ€™ low rate of naltrexone prescription. Drug and alcohol dependence, 2003. 71(3): p. 219-228. Davidson, P.M., et al., Improving medication uptake in Aboriginal and Torres Strait Islander peoples. Heart, Lung and Circulation, 2010. 19(5): p. 372-377. Enoch, M.-A., The role of early life stress as a predictor for alcohol and drug dependence. Psychopharmacology, 2011. 214(1): p. 17-31. Heilig, M., et al., Pharmacogenetic approaches to the treatment of alcohol addiction. Nature Reviews Neuroscience, 2011. 12(11): p. 670-684.

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Pharmacovigilance and Indigenous Australians: There are no data. T Thynne1, G Gabb2, EW Poh3, S Shakib1 1 Department of Clinical Pharmacology, 2Department of General Medicine, Information Service, Royal Adelaide Hospital

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Medicines

Background: Indigenous Australians are at high risk of cardiovascular disease and premature death. Our traditional cardiovascular risk calculators underestimate this risk. National guidelines recommend a lower threshold for screening and treating cardiovascular risk factors such as hyperlipidaemia in the Aboriginal and Torres Strait Islander (ATSI) population. Strategies to improve access to medication, including the Indigenous Chronic Disease Package, have recently been implemented. There is, however, little information available regarding the scope and frequency of adverse drug reactions (ADRs) in the ATSI population. This is despite race being well recognised as a risk factor for ADRs in other populations. Aims: To identify cases of serious ADRs with cardiovascular medication in ATSI patients and to review the current Australian pharmacovigilance recommendations for this population. Methods: All ADRs reported to our hospital medicine information service from January 2011 to April 2013 involving ATSI patients and cardiovascular medication were identified and reviewed. The Therapeutic Goods Administration recommendations in relation to pharmacovigilance and racial status and current reporting procedures were reviewed. Results: There were 12 reports involving ADRs due to cardiovascular medication and 5 of these involved ATSI patients. There were 3 cases of angioedema in the setting of angiotensin converting enzyme inhibitor therapy (perindopril). There were 2 cases of statin-associated myotoxicity (atorvastatin). There is little information in the medical literature on ADRs and medication safety in the ATSI population. Spontaneous reporting of ADRs by racial status has been possible since 2008. Australian pharmacovigilance guidelines do not currently have any special reporting requirements or recommendations for ethnic groups, including Aboriginal and Torres Strait Islanders. Conclusion: Serious ADRs due to cardiovascular medications have occurred in ATSI patients. There is potential for widespread use of cardiovascular drugs in this high cardiovascular risk population. Strategies to reduce the large burden of cardiovascular disease for Indigenous Australians need to include an active focus on drug safety and therapeutic risk management. Potential solutions will be discussed.

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Key Literature: 1. 2. 3.

Australian Government, Department of Health and Ageing, Therapeutic Goods Administration. Australian requirements and recommendations for pharmacovigilance responsibilities of sponsors of medicines 2013. Canberra. Banks E, Pearson SA. A life-cycle approach to monitoring benefits and harms of medicines. Med J Aust. 2012;197(6):313-4. Tonkin A, Barter P, Best J, Boyden A, Furler J, Hossack K, et al. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: position statement on lipid management--2005. Heart Lung Circ. 2005;14(4):27591.

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Azathioprine and 6-mercaptopurine - Interesting ADR genetics, kinetics, dynamics, monitoring, modelling and more. Professor Murray Barclay, Departments of Clinical Pharmacology and Gastroenterology, Christchurch Hospital, Christchurch [Murray Barclay is a Clinical Pharmacologist, Gastroenterologist and Clinical Professor at Christchurch Hospital and University of Otago Christchurch, New Zealand. Research interests include pharmacogenetics, thiopurines, methotrexate, inflammatory bowel disease, medicines in gastroenterology and rheumatology, and drug concentration monitoring. He has around 140 journal publications and has an interest in web-based interactive education in medicine, developing interactivemedicine.org.nz and icp.org.nz (with Prof. Evan Begg).] The thiopurines azathioprine and 6-mercaptopurine have been used for over 50 years, now mainly as immunomodulators in autoimmune conditions such as inflammatory bowel disease and rheumatoid arthritis, and in organ transplant. In some patient populations, treatment is stopped due to serious adverse reactions in up to 30% of cases. Treatment may be ineffective in a further 20% of cases. Despite this, the thiopurines remain early first line treatment for some of the aforementioned conditions. Adverse reactions include bone marrow suppression, pancreatitis, hepatitis, skin rash and severe flu-like illness. Some reaction types are related to genotypic status for TPMT and other enzymes in the thiopurine pathway. Others relate to HLA genotype. Genotype and/or phenotype may therefore predict some reactions, eg. TPMT. Use of combination treatment with allopurinol can also prevent some reactions. With growing knowledge of the genetics, kinetics and pharmacology of the thiopurine pathway, and by dose adjustment guided by measured thiopurine metabolite concentrations, it is becoming possible to use these drugs more safely and effectively.

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ADRs in Older People Associate Professor Sarah Hilmer, Royal North Shore Hospital, Sydney, New South Wales ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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ADR assessment: different goals, different methods Associate Professor Matt Doogue, University of Otago, Christchurch Clinical management of adverse drug reactions, pharmacovigilance and academic clinical pharmacology have different goals. Clinical management is about diagnosis and management of an individual patient. Pharmacovigilance is about diagnosis and management of populations. Academic clinical pharmacology is about characteristics of patient/s and drug/s contributing to an ADR and extrapolating further. The methodologies to achieve these goals are necessarily different. This talk will follow other presentations and focus on detailed descriptors of ADRs. Key Literature: 1. 2. 3. 4.

Aronson JK, Ferner RE. Joining the DoTS: new approach to classifying adverse drug reactions. BMJ. 2003 Nov 22;327(7425):1222-5 Ferner RE, Aronson JK. EIDOS: a mechanistic classification of adverse drug effects. Drug Saf. 2010 Jan 1;33(1):15-23. Schnyder B, Pichler W. Mechanisms of Drug-Induced Allergy. Mayo Clin Proc. 2009;84(3):268-272. Naranjo CA, Busto U, Sellers EM, Sandor P, Roberts EA, Janecek E, Domecq C, Greenblatt DJ. A method for estimating the probability of adverse drug reactions. Clin. Pharmacol. Ther. 1981; 30(2):239-245.

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