Posts tagged Men's Health

Do you often feel on waking that you haven’t had a good night’s sleep, despite going to bed early enough? Do you feel tired and catch yourself yawning throughout the day, although you seemingly slept for a reasonable time the night before? Or do you find you wake several times in the night, sometimes with a ‘snort’? You may be experiencing a condition known as obstructive sleep apnoea (OSA).

What is OSA?

OSA is a condition characterised by interrupted breathing while sleeping. The word ‘apnoea’ means absence of breathing and occurs when the muscles of the throat relax and the tissues slump to such an extent that the airway closes up. An episode of halted breathing is medically defined as apnoea if it lasts for at least ten seconds. Another type of breathing impairment associated with OSA is hypopnoea, meaning reduced breathing, which is when the airway is only partially obstructed by the relaxation of muscles and slumping of tissues in the throat, and functions at half capacity or less for at least ten seconds. (1)

What are the symptoms of OSA?

If you sleep alone, it is usually easier for OSA to go unnoticed, as the most obvious telltale signs occur during deep sleep. However, you may find that you wake up several times during the night, disrupting your sleep. Waking may be accompanied by a snorting or gasping sound as the brain tells the body to come out of deep sleep in response to the lack of oxygen in the blood, enabling a sudden, sharp intake of breath. You may also notice that you wake up in a sweat. (1, 2)

Another symptom is tiredness and sleepiness during the day. You may struggle to concentrate, leading to more mistakes at work. You may yawn excessively, or find yourself nodding off during quiet or dull parts of the day. If you wake several times at night you will be able to trace the tiredness back to this, but the brain sometimes tells the body to switch from deep to lighter sleep, rather than fully waking, to restore normal breathing. Deep sleep is more restful for the body, so fewer hours of deep sleep per night will increase tiredness during the day. (1, 2)

The deep sleep symptoms are often identified by another person, such as a partner, friend or relative, when you sleep in their presence. They may tell you that you snore loudly, or that it sounds like you’re struggling to take clear and complete breaths. Crucially, they can identify your episodes of apnoea, telling you that you stopped breathing for a prolonged period of time. (1)

Why does OSA happen?

Although most people experience some relaxation and slumping of the throat’s tissues and muscles during sleep, they can usually continue to breathe normally. Certain risk factors increase a person’s chance of developing OSA. (1)

Being overweight or obese is a major risk factor as excess weight carried on the neck can push the airway narrower or shut completely, and make it harder for the muscles to resist the slumping and keep the airway open. Men are at greater risk than women, again mainly due to the fact that they are more inclined to carry excess weight on the neck. This risk is more pronounced with a collar size of 17 inches or greater. (1)

Over the age of 40, risk of OSA increases for both men and women, then again for women after they reach the menopause. (1)

Natural variations in the structure of the airway or nasal cavity can be responsible for OSA. Such variations include a narrower airway than normal, enlarged tonsils or tongue, a receding jaw, a deviated nasal septum, nasal polyps and enlarged adenoids in children. OSA can also run in families. (1)

External factors such as drinking alcohol before bed, smoking and taking sedatives including sleeping tablets and anxiety medication can also make OSA more likely. (1)

Can OSA be treated?

If you think or someone else thinks you may have OSA, visit your GP. They will rule out any other causes of your symptoms and can refer you to a sleep centre for a firm diagnosis. (1)

Once you are diagnosed with OSA, your GP will advise you to make lifestyle changes if needed, or maintain your current healthy lifestyle. Losing weight, stopping smoking or reducing alcohol intake may be all that is needed to reverse OSA. Other changes such as sleeping on your side instead of your back, keeping your mouth closed and your nasal passages clear should also help. There are various aids available to facilitate directing air through the nose instead of the mouth, such as chin straps, mouth guards, mandibular advancement devices (MADs), nasal strips and saline nasal sprays. If you find you often wake up lying on your back, pillows can be purchased which are designed to prevent you from rolling from your side onto your back while you sleep. (1, 2)

If your OSA is not relieved by these changes, it may be worth considering a week’s trial of a continuous positive airway pressure (CPAP) device. This device pumps air through a mask into your airway to stop it from closing throughout the night. The trial is expensive at £100, but if it is successful you may be put on an NHS waiting list for a free CPAP of your own. CPAPs are also available to buy. Click here for more information. (1, 2)

If a variation in structure of the airway is the cause, surgery can be performed to correct this. (1)

Can OSA cause any other problems?

If not treated, OSA will continue to cause constant tiredness, poor concentration and irritability, negatively affecting your quality of life. Furthermore, it may lead to other health problems including high blood pressure, heart attacks and strokes, changes in heart rhythm, and even type 2 diabetes. (1)

If you receive a diagnosis of OSA and you drive, you’re legally obliged to inform the DVLA, as is the case with all conditions which may impair your driving. It’s possible that you’ll be asked not to drive until your symptoms are under control. (1)

Visit the Sleep Apnoea Trust website for further support.

References

1. NHS Choices. Obstructive sleep apnoea [cited 28 March 2018]. Available at: https://www.nhs.uk/conditions/obstructive-sleep-apnoea/
2. The Guardian. Seven ways to… prevent snoring [cited 28 March 2018]. Available at: https://www.theguardian.com/lifeandstyle/2018/mar/26/seven-ways-to-prevent-snoring

Author: Gabby Gallagher MPharm

Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 09/04/18

Affecting approximately 10% of UK people by the age of 25, herpes simplex type 2 (HSV-2), or genital herpes, is one of the most common sexually transmitted infections (STIs) in the country. Once a person is infected with HSV-2, their body will contain the virus for life. For some people, this may cause no further symptoms once the initial infection has cleared, but for others is it a nuisance as recurrent outbreaks can occur. Although there is no cure, HSV-2 symptoms can be managed with the right medication and self-care, allowing you to get on with your life. (1)

What is HSV-2?

HSV-2 is the main virus which causes genital herpes and is a strain of the herpes family of viruses. Other strains include HSV-1 which is responsible for cold sores but can also cause genital herpes, varicella-zoster virus which causes chickenpox and shingles, and Epstein Barr virus which is implicated in glandular fever.

Once it has found a way into the body and has caused an initial infection, HSV-2 remains within the body indefinitely. For most of this time it is in a dormant (inactivated) state within a nerve close to the initial point of infection, but outbreaks of genital herpes can occur and often have a trigger such as ill health, cuts or friction to the area, periods or UV light. (2)

What are the symptoms of genital herpes?

The earliest symptoms of genital herpes are usually a tingling or itching sensation in the genital area, followed by the formation of blisters on the area of the groin that was in contact with the infected area of the other person.

This may be the penis, vulva, anus, thighs or buttocks. These blisters burst, leaving sores which scab then heal. Under the foreskin of the penis and on the inside of the labia, ulcers will form as opposed to blisters.

As part of the initial infection there may be associated general malaise - aches and pains, fever and slightly swollen glands in the neck, armpits and groin. Discomfort when urinating and unusual discharge from the vagina are also possible symptoms. Symptoms of initial infection should clear within three weeks. (1, 2)

Subsequent outbreaks of genital herpes generally involve milder symptoms and clear up in a matter of days. (1)

How can I be tested?

If you have blisters in your genital area and think you may have genital herpes, you can attend a sexual health clinic to be tested. One of the blisters will be swabbed to obtain a sample to send off for testing. The sample can only be taken if there are blisters present. (2)

If your result comes back positive, anyone with whom you’ve been sexually active also needs to be tested. This is because symptoms of genital herpes can, in some cases, take years to appear after initial infection. If you don’t want to or can’t contact the partners yourself, the sexual health clinic may be able to contact them on your behalf. They will not reveal your identity while doing so. (2)

You can also test for genital herpes with our 7-in-1 test kit which tests for the 7 most common STI's.

How is genital herpes treated?

There is no cure for genital herpes, so the aim of treatment is to ease symptoms and sometimes shorten the duration of an outbreak.

Aciclovir, an antiviral drug, is the first line treatment. It is taken in tablet form three or five times a day, depending on the tablet strength, for five days.

The course may be extended if blisters appear after the course is started or if they have not healed sufficiently. Outbreaks can be treated with shorter courses if higher strength tablets are taken. An oral suspension and topical cream are also available. Alternative antivirals famciclovir and valaciclovir can be used orally in a similar way. (3)

For people who suffer from frequent outbreaks, antivirals can also be used for suppression to keep viral levels under control and prevent outbreaks from happening in the first place.

Instead of being taken as a course, they are taken every day for up to a year, after which treatment is halted to determine whether outbreaks return. If they do, treatment may be started again. If outbreaks keep happening despite taking suppressive treatment, your GP may consider referral to a specialist. (3)

Is there anything else I can do to ease the discomfort of an outbreak?

During an outbreak, you may benefit from the following self-care steps:

• An ice pack covered with a flannel pressed against the area can help to ease the pain of the blisters. Do this for as long as is needed or comfortable.

• You may want to try pouring water onto the groin as you urinate to reduce pain and discomfort.

• Petroleum jelly or anaesthetic cream applied to the blisters may also help with discomfort during urination. Always make sure you wash your hands thoroughly before and after touching blisters.

• Open sores are a potential site of a secondary bacterial infection. To avoid this, bathe regularly using plain or salt water.

• Wear loose-fitting underwear and clothing to avoid rubbing of the area and therefore pain and potential bacterial infection. (2)

How can I reduce the spread of genital herpes?

The most effective way to prevent infection of partners is to abstain from any sexual contact while symptoms are present, from the tingling or itching until blisters and ulcers have completely healed. This includes sexual activity involving hands, as not only does this mean the virus can be transferred to a partner’s genitals, but it is possible for it to enter the body via the hands. (1, 2)

Additionally, always use condoms for vaginal or anal sex and dams for oral sex or vulval contact between partners, even when there is no outbreak. (2)

Avoid sharing sex toys. If you do, wash the toy thoroughly and cover with a fresh condom before each use. (1)

The antiviral drug valaciclovir can also be prescribed to help make HSV-2 less transmissible to partners. (3)

Is genital herpes a threat to other aspects of my health?

Fortunately, for healthy people, genital herpes is nothing more than an annoyance. It doesn’t predispose you to other diseases, affect fertility or alter your lifespan. Nevertheless, it can cause problems for people with HIV, so people with HIV who catch herpes will be managed by a specialist. If you need any further information or support, click here or consult your GP, pharmacist or sexual health clinic. (1, 2)

References

1. Herpes Viruses Association. About herpes simplex virus [cited 16 March 2018]. Available at: https://herpes.org.uk/frequently-asked-questions/herpes-simplex-virus/
2. NHS Choices. Genital herpes [cited 16 March 2018]. Available at: https://www.nhs.uk/conditions/Genital-herpes/
3. British National Formulary (version 1.3.7) [Mobile application software]. Retrieved from: www.bnf.org

Author: Gabby Gallagher MPharm

Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 06/04/18

Infertility affects around 3.5 million UK people, but did you know that as many as one in four cases of infertility are caused by sexually transmitted infections (STIs)? The longer STIs are left untreated, the greater the risk of infertility, which is why it’s crucial to diagnose and treat STIs promptly to maintain the health and wellbeing of individuals and couples wishing to conceive. (1)

Which STIs can cause infertility?

Chlamydia and gonorrhoea are the two most common STIs in the UK, and also happen to be potential causes of infertility if left untreated.

Chlamydia

Chlamydia is the most common STI in the UK, with approximately 70% of cases being under 25 years of age. It is caused by a type of bacteria called Chlamydia trachomatis. Worryingly, it usually doesn’t cause any symptoms, meaning that people don’t know they’re infected unless they have a test. For under 25s it is recommended to have a test for chlamydia yearly or upon getting a new sexual partner. (2)

If a person with chlamydia does experience symptoms, they may include painful urination, unexpected or discoloured discharge from the vagina, penis or back passage, abdominal pain or unusual vaginal bleeding (after sex or when not on your period) in women, and painful inflamed testicles in men. (2)

If you catch chlamydia and it is left untreated, it could eventually cause infertility. In women, this is because the infection can lead to pelvic inflammatory disease (PID), a condition in which the higher portion of the reproductive system becomes inflamed, including the ovaries, fallopian tubes and uterus. PID can cause scarring of these areas, which can make it hard or sometimes impossible for an egg to be released and to reach the uterus. In men, a condition called epididymo-orchitis can develop, which is inflammation of the testicles and sperm ducts. If left untreated, it can damage these areas to the extent of causing infertility. (3)

Gonorrhoea

Gonorrhoea is another very common STI in the UK caused by the bacterium Neisseria gonorrhoeae. Symptoms are usually a thick, yellow or green, unpleasant-smelling discharge from the vagina or penis, painful urination and unusual vaginal bleeding. But, as with chlamydia, some people don’t get symptoms – this is the case for approximately 10% of men and 50% of women infected. (4)

Untreated gonorrhoea may also lead to PID in women, which in turn may lead to infertility. The infection may spread to the testicles and prostate gland in men, occasionally causing a drop in fertility or even infertility. (5)

If you think you may be at risk of having chlamydia or gonorrhoea, you have had any of the above symptoms, or you have had a recent change of sexual partner, you can arrange a test at your GP surgery, a genitourinary medicine (GUM) clinic or a sexual health clinic. Certain pharmacies, contraception clinics and young people’s services may also offer testing. (6, 7)

You can also order testing kits and treatments for a range of STIs including chlamydia and gonorrhoea from Webmed Pharmacy here.

What happens if I test positive for chlamydia or gonorrhoea?

If you have chlamydia, you’ll receive antibiotic treatment. The antibiotics usually used are azithromycin, taken as a single dose, or doxycycline, taken for a week. Other antibiotics can be used if you are allergic to the usual choices, pregnant or breastfeeding. Don’t have sex until you’ve finished the course, or for a week after taking the azithromycin single dose, as the infection may not have fully cleared up within this time. If you take the antibiotics as directed and follow the aforementioned advice, you probably won’t need to have another test to confirm whether the treatment has worked, unless your symptoms persist. (8)

For gonorrhoea, the usual choice of antibiotic treatment is a single dose of azithromycin alongside a ceftriaxone injection. You’ll most likely have a repeat test a couple of weeks later to make sure the infection has cleared – avoid sex until you’ve had a negative result from this test. (9, 10)

If you’ve tested positive for chlamydia or gonorrhoea, then any sexual partners you’ve had within the last 6 months will need to be tested and potentially treated too. If you don’t want to or can’t contact them yourself, you can seek the help of a GUM or sexual health clinic who may be able to find their details and send them a letter advising them to be tested. The letter won’t contain your name. (8, 10)

How can I protect myself from STIs?

Condoms are widely available and highly effective at protecting against STIs. Free male or female condoms are available from contraception clinics, young people’s services and sexual health clinics. Certain GUM clinics and GP surgeries may also supply free condoms. They can be used for vaginal or anal sex, or to cover the penis during oral sex. (11)

Dams are square-shaped barriers made from latex or polyurethane (also used to make condoms). They can be used during oral sex to cover the vagina or anus, or to cover the vulva during skin-to-skin contact with a partner’s vulva.

Avoid sharing sex toys, or wash and cover them with a fresh condom after each use.

Forms of contraception such as the oral contraceptive pill, copper intrauterine devices (IUDs) and spermicides are designed to protect against pregnancy only and will not offer protection from STIs.

References

1. NHS Choices. Infertility – Overview [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/infertility/

2. NHS Choices. Chlamydia – Overview [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/chlamydia/

3. NHS Choices. Chlamydia – Complications [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/chlamydia/complications/

4. NHS Choices. Gonorrhoea – Overview [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/gonorrhoea/

5. NHS Choices. Gonorrhoea – Complications [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/gonorrhoea/complications/

6. NHS Choices. Sexually transmitted infections (STIs) [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/sexually-transmitted-infections-stis/

7. FPA. Sexually transmitted infections (STIs) help [cited 2 February 2018]. Available at: https://www.fpa.org.uk/help-and-advice/sexually-transmitted-infections-stis-help

8. NHS Choices. Chlamydia – Treatment [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/chlamydia/treatment/

9. British National Formulary (version 1.3.4) [Mobile application software]. Retrieved from: www.bnf.org

10. NHS Choices. Gonorrhoea – Treatment [cited 2 February 2018]. Available at: https://www.nhs.uk/conditions/gonorrhoea/treatment/

11. FPA. Condoms (male and female) [cited 2 February 2018]. Available at: https://www.fpa.org.uk/contraception-help/condoms-male-and-female

Author: Gabby Gallagher MPharm

Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 19/02/18

One of the numerous infections that can be caused by a type of yeast known as Candida, thrush affects around 75% of women at some point in their life, and can affect men too. It can be a nuisance, causing discharge, discomfort and irritation, but if you find it’s a common occurrence it may be a sign of an underlying problem. (1)

What is thrush?

Thrush, also known as candidiasis, is the name given to a number of skin and mucous membrane infections involving Candida, which is a group of several species of yeast (fungus). In society, ‘thrush’ is generally defined as vaginal or penile candidiasis, so the same definition applies to the term ‘thrush’ in this blog hereafter. (2)

Symptoms of thrush in women include an odourless vaginal discharge with the appearance of cottage cheese, irritation and itching of the vagina and vulva, and pain or stinging on urination or during sex. For men, thrush can cause irritation and burning of the head of the penis and beneath the foreskin, pain on retraction of the foreskin, a cottage cheese-like discharge and odour. But not everyone with thrush will have all of the according symptoms listed - in fact, it is possible to have thrush without any symptoms. (2)

What causes thrush?

Candida and certain species of bacteria, known collectively as flora, live naturally in the vagina and are beneficial in that they keep the acidity of the vagina at a healthy level. However, particular factors can upset the balance of the flora and allow Candida to proliferate, leading to thrush. Such factors include antibiotics, pregnancy, being post-menopausal, poorly controlled diabetes, a compromised immune system or broken or irritated skin in the vagina. Sometimes, having sex or even periods can bring on an episode of thrush. (2)

Men may develop penile thrush through sex with a female partner who has vaginal thrush. (2)

How is thrush treated?

If you think you’ve got thrush for the first time, you’ll need to visit your GP for a diagnosis and to rule out anything else. Treatment comes in various forms, namely external and vaginal creams, pessaries and oral capsules. (2, 3)

The mainstay of treatment of thrush in women is a pessary or vaginal cream containing clotrimazole, an antifungal. The pessary or cream usually only needs to be inserted into the vagina once, as long as the high strength is used. Lower strengths are available, but they will need to be used more than once. Other, less common antifungals used in this way include econazole and miconazole. (3)

If the vaginal forms of treatment are unsuitable, fluconazole and itraconazole antifungal capsules are available. Again, fluconazole can be taken as a single dose. (3)

To ease itching and irritation of the vulva while the above treatment takes effect, creams containing antifungals such as clotrimazole can be applied to the area several times a day. (3)

To treat thrush in men, a cream containing an antifungal such as clotrimazole may be applied to the penis, or oral fluconazole can be taken as a single dose. As for women, the cream can be used alongside the capsule to ease symptoms while the capsule works. (3, 4)

If you’ve already had a diagnosis of thrush in the past, you can visit a pharmacy instead of the GP where you can buy clotrimazole-containing external and vaginal creams, clotrimazole pessaries and fluconazole capsules over the counter.

When else will I need to see the GP?

As well as experiencing symptoms for the first time, there are several other instances when you will need to see your GP or visit a sexual health clinic when you develop thrush:

If you fall into one or more of these groups, the healthcare professional you see may need to look at the area to gauge whether it’s thrush or a different infection. If they’re unsure, they may take a sample of the discharge using a cotton swab to send off for testing. If you get recurrent thrush, your GP may run tests to check if there is an underlying problem with your immune system. (2)

In men, thrush can develop into a condition called balanitis. The head of the penis and the foreskin can become red, painful and inflamed, with associated foul-smelling discharge and painful urination. If you think you have balanitis you should visit your GP. (5)

Can I prevent thrush?

There are certain steps you can take to try to prevent bouts of thrush in the future. Opt for showers as opposed to baths, use non-perfumed intimate washes or emollients rather than soap on the groin area, and dry thoroughly afterwards. Wear loose-fitting cotton underwear where possible and don’t douche or use deodorants on your intimate area. (2)

References

1. raTrust. Vaginal Thrush Overview [cited 7 February 2018]. Available at: https://ratrust.org.uk/sexual-health/stis/vaginal-thrush/overview
2. NHS Choices. Thrush in men and women [cited 7 February 2018]. Available at: https://www.nhs.uk/conditions/thrush-in-men-and-women/
3. British National Formulary (version 1.3.4) [Mobile application software]. Retrieved from: www.bnf.org
4. Canesten. Thrush in Men [cited 7 February 2018]. Available at: https://www.canesten.co.uk/
5. NHS Choices. Balanitis [cited 7 February 2018]. Available at: https://www.nhs.uk/conditions/balanitis/

Author: Gabby Gallagher MPharm

Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 09/02/18

Peptic ulcers are a condition that will affect around 10% of people at some stage in their life, more often than not when they are elderly, but it is possible for anyone of any age to be affected. Most peptic ulcers cause no more than abdominal discomfort, pain and indigestion, resolving within a couple of months of starting treatment. However, in certain cases they can have grave consequences, which is why it is important to know the signs and when to visit your GP. (1)

What are peptic ulcers?

‘Peptic ulcers’ is a collective term for gastric (stomach) and duodenal (upper small intestinal) ulcers. They are sores that occur on the lining of these areas, caused by stomach acid coming into contact with the lining. Usually, the lining is shielded from the acid by mucus, but certain factors can deplete this mucus layer. One is Helicobacter pylori, a type of bacteria which lives in the stomach lining of around half of all people. Some of these people don’t know that they’re infected because the bacteria cause no problems. For others, ulceration develops because H. pylori degrades the protective mucus, leaving the lining exposed. Another factor which can lead to peptic ulcers is taking a type of medicine called non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen, aspirin, naproxen, diclofenac and etoricoxib amongst others. It is thought that this happens because the same pain and inflammation-causing compounds which NSAIDs reduce levels of are also responsible for protecting the lining of the stomach and upper section of the small intestine. Taking high doses of NSAIDs, or taking them for a prolonged period of time, increases the chances of developing peptic ulcers in this way. Smoking can also make peptic ulceration more likely. (1, 2, 3)

How do I know if I have a peptic ulcer?

Generally, a peptic ulcer will cause a burning or gnawing-type pain that can be pinpointed to the middle of the abdomen. It may sometimes spread to other areas such as the back, neck or belly button. This pain usually occurs on an empty stomach and may be temporarily relieved by eating. Indigestion, heartburn, reduced appetite, nausea and vomiting can also occur. (1, 4)

How are peptic ulcers treated?

The first-line treatment for peptic ulcers is a drug known as a proton pump inhibitor (PPI). They work by inactivating a channel called the proton pump, which is found in the acid-producing cells of the stomach. This reduces the level of stomach acid, allowing the ulcer to heal. Commonly prescribed PPIs include omeprazole, esomeprazole, lansoprazole and pantoprazole. (5)

If the ulcer is found to have been caused by H. pylori, a course of antibiotics will need to be taken alongside a PPI, usually clarithromycin with amoxicillin or metronidazole. If successful, the H. pylori are eradicated after 7 days of treatment. (5)

If PPIs are unsuitable, a type of drug that works in a different way to reduce stomach acid may be given, namely an H2-receptor antagonist. These drugs work by binding to the H2-receptor in the stomach which also plays a part in stomach acid production. The most commonly used H2-receptor antagonist is ranitidine. (5)

When do I need to seek medical help?

If you find you are frequently experiencing the symptoms listed above, visit your GP who can assess your condition and get you started on the necessary treatment.

If you vomit blood (this can appear fresh in some cases, but dark brown and grainy in others), pass black tarry stools, or experience a piercing abdominal pain that progressively intensifies, you need to seek urgent medical help as you may have a bleeding ulcer or peritonitis, an abdominal infection caused by a ruptured lining. Make an emergency appointment with your GP or ring NHS Direct on 111. If this is not possible, visit A&E. (6)

Is there anything I can do to ease the symptoms?

Peptic ulcers take weeks to heal, so in the meantime, you can ease pain and discomfort by avoiding alcoholic drinks, smoking, and spicy, fatty or acidic foods. You may find taking an over the counter antacid suspension such as Gaviscon after meals and at bedtime helps. Also, make sure you avoid taking NSAIDs for pain relief, instead opting for paracetamol. (5)

References

For further information, click here or ask your pharmacist.

1. NHS Choices. Overview [cited 19 January 2018]. Available at: https://www.nhs.uk/conditions/stomach-ulcer/

2. NHS Choices. Causes [cited 19 January 2018]. Available at: https://www.nhs.uk/conditions/stomach-ulcer/causes/

3. UpToDate. NSAIDs (including aspirin): Pathogenesis of gastroduodenal toxicity [cited 19 January 2018]. Available at: https://www.uptodate.com/contents/nsaids-including-aspirin-pathogenesis-of-gastroduodenal-toxicity

4. NHS Choices. Symptoms [cited 19 January 2018]. Available at: https://www.nhs.uk/conditions/stomach-ulcer/symptoms/

5. NHS Choices. Treatment [cited 19 January 2018]. Available at: https://www.nhs.uk/conditions/stomach-ulcer/treatment/

6. NHS Choices. Complications [cited 19 January 2018]. Available at: https://www.nhs.uk/conditions/stomach-ulcer/complications/

   Author: Gabby Gallagher MPharm

   Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 22/01/18

HIV (human immunodeficiency virus) is no longer the death sentence it once was, thanks to the development of numerous tests and treatments over the years. However, the cocktail of drugs that those diagnosed with HIV must take daily, just to keep the virus at a low enough level to maintain a functional immune system, could be considered a life sentence. Understandably, a way to reduce this frequency of dosing is greatly desired – and recent research shows that in the future it may become reality. (1)

HIV is primarily a sexually transmitted infection, but it may also be passed from one person to another via sharing needles or sex toys, accidentally pricking oneself with a contaminated needle or via blood transfusion. It can also be passed to a baby during birth or breastfeeding if the mother is infected. People at greatest risk include homosexual men, heterosexual black African people of any gender, and anyone who shares needles or syringes with others. (2, 3)

Once HIV has found its way into the body, it hijacks specific cells in the immune system known as CD4 lymphocytes, forcing them to abandon their intended function and instead produce thousands more copies of the virus. The CD4 cells then die, releasing the newly made viruses, which go on to repeat the process again and again over a timespan of up to 10 years until CD4 levels are critically low and the immune system fails. (2)

If HIV is diagnosed early, a course of HIV medication known as post-exposure prophylaxis (PEP) can prevent the virus from taking hold, as long as it is taken within three days of first contact with the virus. If this is unsuccessful, or more than three days have elapsed, medication will need to be started as soon as possible to keep the virus under control. (2)

There is a wide range of HIV medication, also known as antiretroviral medication, available and people with HIV must take a combination of medicines daily to halt the progression of the disease and maintain health. Antiretrovirals are grouped into the following categories:

• nucleoside reverse transcriptase inhibitors (NRTIs), which include zidovudine, abacavir and lamuvidine, and work by preventing the virus’s genetic material from being copied

• non-nucleoside reverse transcriptase inhibitors (NNRTIs), including efavirenz, etravirine and rilpivirine, which work in the same way as NRTIs

• protease inhibitors, such as ritonavir, saquinavir and atazanavir, which prevent formation of new copies of the virus

• integrase inhibitors, including dolutegravir and raltegravir, which prevent the hijacking of CD4 cells by the virus. (4)

Other antiretroviral medications outside these categories include enfuvirtide and maraviroc, which work in different ways to the medications listed above. (4)

The promising news

Recent research by the Massachusetts Institute of Technology has demonstrated that in the future it may be possible to reduce the frequency of HIV medication dosing from daily to weekly by adopting a new formulation. Pigs were administered various drugs in the form of a capsule containing a star-shaped structure, which broke down much more slowly than a tablet or standard capsule, releasing the medicine gradually over as long as two weeks. Biotechnology company Lyndra is now planning to bring this success forward to human trials over the next year. Such a formulation would be life-changing for millions of people worldwide, making it easier to remember to take medication as well as freeing them of the inconvenience of taking numerous drugs daily. It is too early to know how long it may be before weekly HIV medication becomes mainstream, but this is very exciting news indeed. (1)

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References

1. BBC News (2018). ‘Once-a-week pill for HIV shows promise in animals’. Available at: http://www.bbc.co.uk/news/health-42610315

2. NHS Choices. Causes [cited 9 January 2018]. Available at: https://www.nhs.uk/conditions/hiv-and-aids/causes/

3. NHS Choices. Overview [cited 9 January 2018]. Available at: https://www.nhs.uk/conditions/hiv-and-aids/#causes-of-hiv-infection

4. British National Formulary (version 4.2) [Mobile application software]. Retrieved from: www.bnf.org

   Author: Gabby Gallagher MPharm

   Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 11/01/18

Author: Gabby Gallagher MPharm

Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 11/01/18

Cialis has become popular as an erectile dysfunction (ED) prescription medication as it is effective for 36 hours. All other medications, Viagra, Sildenafil, Levitra and Spedra are active for 4-6 hours.

Cialis is the brand name for the medication created by Eli Lilly in 2003. The active ingredient in Cialis is Tadalafil and the composition couldn’t be recreated, by law, until Eli Lilly’s production patent ended on 14th November 2017. Now it can be produced and distributed by other drug manufacturers, in the generic form of Tadalafil.

Generic forms of any medication are medically identical to the branded originals and are quality controlled to the same standards as the brand name versions; they are just as safe and effective but generally cost much less.

Tadalafil on demand is known as “the weekend pill” as, due to it's 36 hour duration of action, it can be taken on a Friday night and still be active on Sunday morning.

There is also a low dose tadalafil option taken on a daily basis, called Tadalafil daily, so you don’t have to plan ahead and can be ready for action “anytime, anyplace, anywhere”.

Cialis (tadalafil) has been licensed in the UK for over a decade. It was the third erectile dysfunction (ED) prescription medication of its type to receive a UK license, after Viagra and Levitra.  Its prolonged duration of action and the option to take a low dose daily tablet have led to Cialis(tadalafil) becoming increasingly popular and being more widely prescribed.

How does tadalafil work?

Erections are primarily achieved through blood flow.Tadalafil works by helping to relax the blood vessels in your penis and the erectile tissue itself, allowing blood to flow into your penis when you get sexually excited. It does not have an effect on your sexual desire but can greatly improve your erection when you become sexually aroused.

Is tadalafil more effective than sildenafil (generic Viagra)?

Both medications have a high success rate, helping the majority of men to regain control over their erection and have an improved sex life. Clinical trials have indicated that both are equally effective.

Does tadalafil have fewer side effects than sildenafil?

As both drugs work in the same way, they share many of the same side effects. These include facial flushing, headaches and indigestion.  However, sildenafil has an effect on your vision that doesn’t seem to affect users of tadalafil to the same extent, as it may produce a green-blue visual tinge.  Headaches also occur more commonly with sildenafil but may last longer with tadalafil.  Any side-effects experienced may last longer with tadalafil.

Is tadalafil a safe medication?

Generally, tadalafil is a safe drug but is not recommended to be taken if you have certain conditions or are taking specific medications that might interact with tadalafil. This is the same for all other phosphodiesterase type 5 inhibitors like Spedra, Viagra, Cialis, Levitra and sildenafil.

Sildenafil and tadalafil should not be taken by men who take medicines or recreational drugs containing nitrates.

Nitrates interact very adversely with all phosphodiesterase type 5 inhibitors like Spedra, Viagra, Cialis, Levitra and sildenafil. They can cause a FATAL lowering of blood pressure and should NEVER be used together.

Nitrates include medications like GTN spray, isosorbide mononitrate, nitrate patches, gel or ointment and nicorandil. These are usually prescribed for heart conditions. If you take nitrates you should consult your GP for other options for your ED. Also, the recreational drugs called "poppers" should be avoided.

Tadalafil should not be taken by men who are on medicines called alpha blockers which are sometimes used to treat prostate problems or high blood pressure. Men who take alpha blockers can use Viagra, sildenafil, Levitra or Spedra but must allow at least a six hour gap between taking the alpha blocker and the ED medication.

There is a full list of the contra-indications and interactions on the website and on the medical questionnaire that is sent to our doctor for approval.

Can I drink alcohol with tadalafil?

Having just one or two drinks is unlikely to affect tadalafil (or any other similar ED medication) or cause any health risks. However, if you drink excessively while taking tadalafil you may experience some adverse effects and not achieve as firm an erection.

The main problem you may experience by drinking too much alcohol while you take tadalafil is orthostatic hypotension. This can cause a headache, dizziness, and fainting, which can lead to you injuring yourself. Hypotension may also make your heart beat at a faster rate which can lead to severe heart problems.

This effect can occur because tadalafil and alcohol both act as vasodilators. Vasodilators are substances that lower your blood pressure by relaxing the walls of your blood vessels, which allow the blood vessels to open wider.

Orthostatic hypotension can be even more likely with tadalafil than with the other erectile dysfunction drugs as it stays in your system longer than the other ED drugs.

Does tadalafil have any advantages over other ED medications of a similar type?

The main differences between tadalafil and other ED medications of a similar type is three-fold.

1) Tadalafil’s long duration of action - 36 hours. Where other Ed products only last for 4 to 6 hours.

2)  Low dose tadalafil can be taken on a daily basis, called Tadalafil Daily, so that you don’t have to plan ahead and can be ready for any sexual activity at any time.

3) It's not affected by food.

Conclusion

Tadalafil is unique in that it can either be taken when required or on a daily basis so that no planning ahead is needed and enables spontaneity. It’s also not affected by food and since it’s now off patent it can be bought at a much lower price than Cialis.

Due to all of these advantages, tadalafil will probably knock sildenafil off the number one spot as the drug of choice for men with erectile dysfunction.

Medically reviewed by: Superintendent Pharmacist Margaret Hudson BSc(Hons)MRPharmS 19/12/17

Raynaud’s phenomenon is a highly inconvenient, annoying and somewhat incapacitating condition for the estimated ten million UK people who suffer with it. Reducing the blood supply to any of the extremities, it can cause numbness, pain and difficulty in utilising the part of the body it affects. (1)

What is Raynaud’s phenomenon and what causes it?

Raynaud’s phenomenon, often shortened to Raynaud’s, is a condition characterised by restricted blood supply to any of the extremities of the body – usually this is the fingers or toes, but it can also affect the ears, nose, lips and nipples. Depending on skin tone, the lack of blood flow to the affected extremity can cause it to turn white or paler than usual, then blue, then red as the blood supply is re-established. The area may become numb or painful, and you may experience a ‘pins and needles’ sensation (paraesthesia). These symptoms may be short-lived or persist for hours at a time. They can make simple activities which are usually taken for granted much more challenging, such as typing, buttoning up clothes and even speaking if the lips are affected. Symptoms generally start in people in their twenties to forties, but people of all ages can develop the condition. (1, 2)

The cause is the blood vessels in these areas of the body being hypersensitive to temperature changes, or changes in blood flow as a result of stress or anxiety. This in turn leads to spasm in the vessels, restricting blood supply. (1, 2)

Raynaud’s is split into two forms:

• Primary Raynaud’s develops of its own accord and affected people can usually manage the condition without input from their GP.

• Secondary Raynaud’s occurs as a result of another pre-existing condition – usually an autoimmune condition such as rheumatoid arthritis. This type of Raynaud’s is more severe than the primary type and will require medical input in the form of monitoring for sores and, in the worst case scenario, gangrene. (1, 2)

Treatment and management of Raynaud’s

The first-line approach to managing Raynaud’s is not medical treatment, but self-care:

• Make sure you wrap up warm in cold weather, paying particular attention to the hands and feet (warm gloves and socks)

• Encourage blood flow to the extremities through exercise – 30 minutes at moderate intensity five times a week is recommended

• Stopping smoking will also help to improve circulation

• Reduce stress where possible by eating well, setting time aside to do something you enjoy and relaxation techniques

• Don’t try to warm your hands and feet very quickly by putting them next to or on a radiator or other hot object, as this may cause chilblains (sore, itchy red lumps) to appear – this will only add to your discomfort! (1, 3, 4)

If self-care is not sufficient to control the symptoms, you may be prescribed a medicine called nifedipine, the only licensed treatment in this country for Raynaud’s. This medicine works by dilating the blood vessels, thereby improving circulation to the body’s extremities. It is usually taken once daily, but you may be able to take it only when you will most need it, for example in the winter months. If nifedipine turns out to be unsuitable or does not work, there are a number of unlicensed medicines available at the discretion of your doctor. (3)

In extreme cases, surgery known as sympathectomy may be considered. The nerves responsible for the blood vessel spasms associated with Raynaud’s are cut, stopping them from functioning. (3)

When to see your GP

If you have a long term condition such as an autoimmune disease or diabetes and you begin to experience the symptoms described above, see your GP as you may have secondary Raynaud’s which will need to be monitored. Equally, make an appointment if your symptoms are interfering with your everyday life and you cannot manage them on your own, or treatment has failed to improve your symptoms.

For further information, click here.

References

1. NHS Choices. Overview [cited 6 December 2017]. Available from: https://www.nhs.uk/conditions/raynauds/

2. Scleroderma & Raynaud’s UK. What is Raynaud’s? [cited 6 December 2017]. Available from: https://www.sruk.co.uk/raynauds/what-raynauds/

3. NHS Choices. Treatment [cited 6 December 2017]. Available from: https://www.nhs.uk/conditions/raynauds/treatment/

4. Scleroderma & Raynaud’s UK. Chilblains [cited 7 December 2017]. Available from: https://www.sruk.co.uk/raynauds/chilblains/

   Author: Gabby Gallagher MPharm

   Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 15/12/17

Affecting around 8,500 UK people currently, with an additional 25,000 set to be affected as they age, Huntington ’s disease is a grave diagnosis. Those with the condition will experience gradual deterioration of bodily and mental functions such as movement, thinking, understanding and behaviour until they are unable to look after themselves, and eventually die. Clearly, it is a devastating prognosis for those directly affected and their family and friends. However, will a new experimental treatment finally put an end to this deadly condition? (1, 2)

What is Huntington’s disease?

Huntington ’s disease (HD) is a neurodegenerative condition, which means it involves the destruction of cells in the central nervous system. In HD, the cells destroyed are in the brain, and since the brain controls the body’s processes, this means the body deteriorates in several ways as the disease progresses. (2)

Usually, the first symptom that a person with HD will experience is changes in behaviour. They may appear to lack empathy, experience great fluctuations in mood, struggle to concentrate and lack interest in activities, work, social situations and personal hygiene. (3)

Movement problems also appear early on in the disease, beginning as occasional twitching of the face and jerking of the arms and legs. Eating and drinking will also become a challenge as the muscles of the mouth and throat lose function. This will become more pronounced and happen more often as time goes on, but eventually, stiffness of the muscles may take over. (3)

Other symptoms implicated in HD include depression, suicidal thoughts, poor communication including slurred speech and difficulty verbalising ideas, and sexual problems ranging from reduced sex drive to lewd behaviour. (3)

In the final stages of the disease, people with HD will need round-the-clock care. The most common cause of death at this point is infection, primarily pneumonia. Life expectancy after diagnosis is between ten and 25 years. (2, 3)

What is the cause?

HD is an inherited genetic disease, so it is passed down from parent to child in DNA (genetic material) at the point of conception. Our DNA is split into 23 pairs of chromosomes, all containing genes (sequences of DNA that act as a ‘code’ for proteins, the building blocks of the body). On each chromosome in pair number 4 is located a gene that codes for a protein called huntingtin, essential for the structure of the brain’s nerve cells. It is a faulty version of this gene that produces a toxic form of huntingtin that instead kills cells in the basal ganglia and cortex regions of the brain, leading to HD. This faulty gene is a dominant allele, which means you only need one copy of the gene within the pair to develop HD. Any children of a person with one safe copy and one faulty copy of the gene have a 50% chance of inheriting the disease themselves. In the very rare instance that the parent has two faulty copies, all of their children will go on to develop HD. (4, 5)

Treatment: the promising news

Up until now, the only treatment for HD was supportive, helping to ease the symptoms rather than preventing progression or curing the condition. Such treatments include antidepressants and antipsychotics. But on 11th December 2017, the news broke that a drug trialled at University College London had been successful in reducing the levels of the toxic huntingtin protein in the brain, and the licence has been bought by the pharmaceutical company Roche to take up larger trials, then hopefully production and supply. This is groundbreaking in the field of neurodegenerative disease, as it is believed that similar drugs may be able to be developed for other conditions involving toxic proteins such as Alzheimer’s disease and Parkinson’s disease. (1, 2, 6)

In the trial, the experimental drug was injected into the cerebrospinal fluid of patients with HD each month for four months. Of the 46 patients, approximately 12 were administered a placebo (an injection containing no drug). Samples of cerebrospinal fluid were taken after each dose, and the levels of corrupt huntingtin were lower each time in patients given the drug. (6)

The drug works by inactivating the messenger RNA (another type of genetic material similar to DNA) which translates the ‘codes’ in the genes into the toxic huntingtin protein. (1, 6)

It is hoped that if the drug makes it to mainstream use, it could be given at regular intervals to people with the faulty gene before symptoms appear, meaning their brain will be protected from the devastating effects of toxic huntingtin and they will be able to live a life free of HD. (6)

For further help and support, visit the Huntington’s Disease Association’s website here.

Picture: pixaboy.com

References

1. Gallagher J (2017). ‘Huntington’s breakthrough may stop disease’, BBC News. Available at: http://www.bbc.co.uk/news/health-42308341

2. NHS Choices. Overview [cited 11 December 2017]. Available at: https://www.nhs.uk/conditions/huntingtons-disease/

3. NHS Choices. Symptoms [cited 11 December 2017]. Available at: https://www.nhs.uk/conditions/huntingtons-disease/symptoms/

4. Huntington’s Disease Association. What causes Huntington’s disease? [cited 11 December 2017]. Available at: https://www.hda.org.uk/huntingtons-disease/what-is-huntingtons-disease/what-causes-huntingtons-disease

5. NHS Choices. Causes [cited 11 December 2017]. Available at: https://www.nhs.uk/conditions/huntingdons-disease/causes/

6. Devlin H (2017). ‘Excitement as trial shows Huntington’s drug could slow progress of disease’, The Guardian. Available at: https://www.theguardian.com/science/2017/dec/11/excitement-as-huntingtons-drug-shown-to-slow-progress-of-devastating-disease

   Author: Gabby Gallagher MPharm

   Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 14/12/17

Approximately 600,000 people in the UK are living with epilepsy, and to this day, the cause in the majority of sufferers cannot be established. Fortunately, there are a whole host of treatments that can greatly assist in the management of this debilitating condition. (1)

What is epilepsy?

Epilepsy means that a person is prone to experiencing epileptic seizures (fits). A seizure occurs when there is a sudden surge in electrical activity in the brain and its electrical signals, which are vital for normal biological processes, become muddled. Seizures manifest themselves in various ways depending on the area of the brain in which these surges occur and the signalling pathways affected. (1,2)

Focal seizures begin on one side of the brain. Usually, they only last for up to two minutes. Symptoms can vary greatly and a person may experience one or more symptoms, including but not limited to stiffness, rhythmic movements, limpness or jerking in part of the body, changes in senses or hallucinations, a sense that the body is distorted, déjà vu and confusion. (3)

Tonic-clonic seizures are the ‘typical’ jerky seizures that people are generally familiar with. They can be focal or bilateral, meaning they may start on one or both sides of the brain. They are characterised by two phases – the ‘tonic’ phase, when the person may cry out and bite the inside of their mouth, then become stiff, unconscious and fall if standing; and the ‘clonic’ phase, involving rhythmic jerking, breathing difficulties and sometimes soiling oneself. They usually last no longer than three minutes. If they exceed five minutes, call 999 for an ambulance, unless you know for definite that seizures of this length which end by themselves are normal for the particular person. (4)

Tonic seizures follow the same course as the ‘tonic’ part of the aforementioned tonic-clonic seizure. They generally last no longer than one minute. (5)

Atonic seizures are the opposite of tonic seizures, with the body going limp instead of stiff. The affected person may fall or their head or knees may slump. They are normally up to two seconds long. (6)

Absence seizures begin on both sides of the brain and are split into typical and atypical forms. Typical absence seizures feature sudden abandonment of current activities, a very short loss of consciousness (but no falling) and then the appearance of daydreaming. There may also be fluttering of the eyelids, minor body jerking or repetitive movements. During a typical absence seizure, the affected person is unaware of what is going on around them and other people will be unable to interact with them. These seizures are short, lasting approximately 10 seconds, but can occur in hundreds in a single day. Atypical absence seizures have a greater duration of around 30 seconds, and tend to come on and wear off gradually. Movement is possible, but this will be clumsy in appearance due to limpness of the muscles. It may also be possible for other people to interact with the affected person. (7)

When is medical assistance needed?

As mentioned previously, a seizure exceeding five minutes in length warrants urgent medical attention, unless you know for a fact that the person regularly experiences seizures this long that subside on their own. (2, 4)

Other instances when you will need to call 999 and ask for an ambulance are as follows:

• A person experiencing their first seizure

• More than one seizure occurring without any recovery in between (this is a symptom of a condition called status epilepticus which requires urgent treatment)

• Breathing is affected

• Significant injury (2)

How is epilepsy treated?

The mainstay of treatment for epilepsy is antiepileptic drug therapy, of which there are a vast range of options. Antiepileptics alter the amount of certain chemicals within the brain, having a knock-on effect on electrical activity. The specific antiepileptic drug prescribed for a person will be determined by the seizures experienced, their age and whether they are likely to become pregnant in the near future, amongst other factors.

• Clonazepam and valproate can be used to treat any form of epilepsy. Clonazepam works by potentiating a specific inhibitory signalling chemical in the brain known as gamma-aminobutyric acid (GABA). This in turn reduces electrical activity. Valproate raises GABA levels and blocks chemical transport channels in the brain. Due to the risk of serious harm to unborn babies if taken in pregnancy, valproate is avoided in women of childbearing potential unless other medicines have failed to control the epilepsy.

• Tonic-clonic seizures can be treated withclonazepam, valproate, carbamazepine, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone and topiramate. Most block movement of chemicals through transport channels in the brain, with topiramate and lamotrigine also blocking receptors and enzymes associated with electrical activity. Phenobarbital enhances the effects of GABA. Phenytoin has many side effects, including depression, brittle bones and lupus, and has many interactions with other medicines including antacids and warfarin.

• Clonazepam, valproate, carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, topiramate and zonisamide can be used for focal seizures. The ways in which gabapentin, levetiracetam and zonisamide work are less clear, but most likely involve blocking of chemical channels.

• Clonazepam, valproate and ethosuximide can be given to treat absence seizures. Ethosuximide is a chemical channel blocker.

• There are several antiepileptic drugs which are used as adjuncts, meaning that they are not used as treatments alone, but rather to improve the effects of other antiepileptics. Such drugs include clobazam, brivaracetam, eslicarbazepine, perampanel, pregabalin, tiagabine and vigabatrin. (8)

If treatment is unsuccessful, brain surgery may be considered. If safe, the part of the brain responsible for seizures is removed. (9)

If brain surgery is unsuitable, vagus nerve stimulation (VNS) is another option. An electrical device is implanted in the chest and wired up to the vagus nerve. Electrical activity from this device overrides that of the brain, reducing the likelihood of developing a seizure. (9)

Deep brain stimulation, like VNS, uses an electrical implant, but wired up to the brain. Like VNS it is designed to override the faulty electrical activity of the brain, but carries more risks so is usually a last resort. (9)

Can anything else be done to prevent seizures?

As well as making sure you stick to taking your antiepileptic drugs as prescribed, you may also be able to identify certain triggers for your seizures. You can then try to avoid these triggers with the aim of reducing your seizure frequency. You may find it helpful to keep a diary of the time and place where you experience each seizure and any activities you undertake in the lead up to them to assist you in the identification of such triggers. (10)

Also, ensure you keep up to date with your medical reviews so that you and your doctor can address any problems and determine whether you’re getting the best treatment for your needs. (10)

For further information and support, click here.

References

1. Epilepsy action. What is epilepsy? [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/what-is-epilepsy

2. NHS Choices. Overview [cited 16 November 2017]. Available from: https://www.nhs.uk/conditions/epilepsy/

3. Epilepsy action. Focal seizures [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/focal-seizures

4. Epilepsy action. Tonic-clonic seizures [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/tonic-clonic

5. Epilepsy action. Tonic seizures [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/tonic-seizures

6. Epilepsy action. Atonic seizures [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/atonic-seizures

7. Epilepsy action. Absence seizures [cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/absence-seizures

8. Epilepsy action. Epilepsy medicines available in the United Kingdom [cited 20 November 2017]. Available from: https://www.epilepsy.org.uk/info/treatment/uk-anti-epileptic-drugs-list

9. NHS Choices. Treatment [cited 20 November 2017]. Available from: https://www.nhs.uk/conditions/epilepsy/treatment/

10. NHS Choices. Living with [cited 21 November 2017]. Available from: https://www.nhs.uk/conditions/epilepsy/living-with/

    Author: Gabby Gallagher MPharm

    Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 27/11/17