Coeliac Screening Program Team Coaching Module Bringing professional services to life in your pharmacy Version 3.0 February 2016

Overview What is coeliac disease? Many effects of coeliac disease How can we help? Team Roles Role Play Quiz Provides and overview about what we will be going through for the team training module

Coeliac Disease Coeliac disease is an autoimmune condition where the body is intolerant to gluten. An autoimmune diseases is a condition where the body’s immune system will cause damage to itself. For people with coeliac disease their immune system will cause damage to their small intestine when exposed to gluten.

What happens when someone with coeliac disease eats gluten? When gluten is ingested the person’s immune system is activated. This immune response results in the immune system incorrectly attacking the villi in the small intestine. The damage to the villi reduces the area where nutrients can be absorbed in the small intestine. Brief explanation about the damage eating gluten causes to the villi in the small intestine.

Who can get Coeliac Disease? Anyone can get coeliac disease. They just require the three factors which influence activation of coeliac disease: Inherited exposure - 30% of the general population Exposure to unknown external factors such as stress or changes in lifestyle Exposure to gluten In order for someone to suffer from coeliac disease they need 3 things to happen. Firstly they have to be susceptible to the disease through their genetics. Secondly they must be exposed to unknown external factors, not everyone who is genetically susceptible has coeliac disease. Lastly, they must eat some gluten to be affected.

Many effects of Coeliac Disease Unmanaged coeliac disease can cause a variety of symptoms and long term complications on all areas of the body.

Many effects of Coeliac Disease Mouth Ulcers: Chronic mouth ulcers may be a sign of the malnutrition which may result from coeliac disease. Reflux: Reflux or heartburn is common in people with coeliac disease as a result of the damage caused to the gastrointestinal system by the immune system when gluten is ingested. Diarrhoea: For those with coeliac disease, diarrhoea is a common symptom when they ingest gluten. Constipation: It is very common for people with coeliac disease to experience bouts of constipation when gluten is ingested. For some this can be chronic. Other autoimmune diseases: if someone with coeliac disease continues to eat gluten, their immune system remains overactive. This increases their risk of other autoimmune diseases such as rheumatoid arthritis. Unexpected weight loss: The immune reaction caused by ingesting gluten results in inflammation of the small intestine. When inflamed there is poor absorption of nutrients which can result in people with coeliac disease unexpectedly and unintentionally losing weight. Pregnancy complications: Complications in pregnancy are 8 times more likely for someone with poorly managed Coeliac disease. Irregular menstrual periods: for women with coeliac disease, irregular and often painful menstrual periods can be common.

Many effects of Coeliac Disease Fatigue: Many people with coeliac disease frequently experience fatigue. This is due to the poor absorption of nutrients from food. Type 1 diabetes: 10% of people with type 1 diabetes also have coeliac disease. Abdominal Pain/Bloating: as a result of the inflammation caused to the small intestine, many people with coeliac disease experience abdominal pain, cramping and bloating. For some this can be severe. Anaemia Due to the malabsorption of nutrients, people with coeliac disease are more likely to also have anaemia. Osteoporosis: a person with coeliac disease has a higher risk of osteoporosis due to poor absorption of calcium and vitamin D. Itchy skin rash: Itchy skin rashes are common for people with coeliac disease and are caused by the overactive immune reaction caused by gluten. Joint or muscle pain/stiffness: poor absorption of nutrients and minerals can cause joint and muscle pain for people with coeliac disease. Numbness/tingling in hands/feet: Calcium is one of the many things which is poorly absorbed in people with coeliac disease. As a result this can cause numbness or a tingling sensation in the hands or feet.

Our exclusive coeliac screening service How can we help? Our exclusive coeliac screening service The service uses the SimtomaX screening test which: Is non invasive A finger prick blood sample is used Provides rapid, clear results 10 minutes Visual interpretation Amcal pharmacies are now exclusively offering the coeliac screening service. This screening program is easy to complete, only requires a finger prick and a small blood sample and gets results in 10 minutes.

Why offer Coeliac Screening? Around 90% undiagnosed It takes an average of 4 years to be diagnosed Customers consult an average of 8 healthcare professionals Improve diagnosis and provide additional services By providing the coeliac screening service we are able to improve the diagnosis of coeliac disease and offer customers some additional professional services as well. For some people this diagnosis can take up to 4 years, by using in pharmacy coeliac screening we can rule out coeliac disease as an option as well as provide expert symptom relief for someone with a negative test, whilst at the same time provide a referral pathway to those with a positive result.

Identify Assess Screen Advise The Process Explain the process of the coeliac screening program. Emphasise the role each team member has throughout the process and the importance of a whole team approach to getting great results.

Identify The first step for the coeliac screening program is to identify patients to speak to about coeliac screening. Suitable patients may be: Looking for a solution for a symptom of coeliac disease Managing a condition associated with coeliac disease. Some of the common categories you may find patients looking at are: The gastrointestinal category The medicated skin care category The vitamins category

Assess Assess a patients suitability by complete the coeliac pre-screening questionnaire. The pre-screening questionnaire reviews: Patients diet Family history Symptoms and Conditions associated with coeliac disease Those currently on a gluten free diet should not take the test. Patients will need to eat some gluten for at least 10 days. If their symptoms are too painful during this time they should be referred to their GP. Any member of the pharmacy team can complete this with the customer. In order to complete the test the customer should complete a screening questionnaire to see whether they are appropriate. The question is regarding the gluten free diet is important as, if someone is on a gluten free diet the test will come up as negative regardless of whether they are coeliac or not. In order for them to take the test, they should eat gluten for a minimum of 10 days.

Screen The pharmacist will complete the coeliac disease screening test with the patient. The test: Takes 10 minutes Only requires a finger prick test Highly accurate and is used by GP’s and gastroenterologists overseas Completed one on one with the pharmacist At the end of the test the pharmacist will advise on the next steps based on the test results, this may involve a referral to the GP.

Advise The pharmacist will advise the patients on the next steps for the patient. This may involve: Referral to the GP for further testing Expert advice on symptom management It is recommended to follow up with the patient next time they are in the pharmacy. SimtomaX Results

Treatment of Coeliac Disease There is currently no cure for coeliac disease. Someone who has coeliac disease will continue to have a lifelong sensitivity to gluten. In order to reduce symptoms anyone diagnosed with Coeliac Disease should avoid any products containing gluten and follow a gluten free diet. There is currently a large range of gluten free products available. There is currently no cure for coeliac disease, currently the only management strategy is to maintain a strict gluten free diet. This means avoid any foods which contain wheat, barley or rye based products as well as those which list ‘may contain gluten’ due to the possible risk of cross contamination

Gluten-Free for Everyone A gluten-free diet is not for everyone, it should be maintained by only by those who have coeliac disease. Recent research has shown that for someone who hasn’t been diagnosed with coeliac disease a gluten free diet can have health implications due to excessive sugar and lack of essential nutrients. Most of the health benefits are thought to be due to a decrease in carbohydrate intake rather than gluten itself. For those people who have been diagnosed with coeliac disease you should refer them to their dietician for advice on getting all the required nutrients including the required fibre content. It is important not to recommend a gluten free diet to those who have not been diagnosed with coeliac disease. Recent research has shown that this may have poor results for a persons health in particular due to an increase in sugar intake and missing out on key nutrients. These studies have shown that the key health benefit from a gluten free diet is due to a decreased intake of carbohydrates rather than a decrease in gluten consumption. For any customer diagnosed with coeliac disease or thinking of going on a gluten free diet you should suggest they visit a dietician for advice on getting all the required nutrients in their diet.

Pharmacy Team Roles Pharmacy Team Pharmacist Use dispensary prompt card to highlight any patients appropriate for coeliac disease screening Initiate conversation about coeliac disease Complete the pre-screening questionnaire with patients Refer anyone who is appropriate for a coeliac disease screening Pharmacist Complete the coeliac screening test with the patient Provide expert advice or referral based on the result of the coeliac test Follow up with the patient either over the phone or next time they are in the pharmacy

Dialogue Guide Approach: “Did you know that bloating is a symptom of coeliac disease?” “90% of those with Coeliac disease are undiagnosed” “Coeliac disease is often confused with IBS” “Have any of your family members been diagnosed with coeliac disease? There is a strong genetic component” “We are now able to screen for coeliac disease in pharmacy”

Dialogue Guide “If unmanaged coeliac disease can increase the risk of malnutrition, osteoporosis and deficiency's in key vitamins and minerals” “Eating a gluten free diet can be poor for your health if you haven’t been diagnosed with coeliac disease” “If you do not have coeliac disease you may be spending unnecessary money on gluten free products and missing out on key nutrients. We can help you determine whether a gluten free diet is right for you” “On average it can take up to 4 years for diagnosis and can cost on average over $400” “We can help by providing a non invasive screening with a result in 10 minutes”

Dialogue guide Explain the test “The test is a quick blood test, which uses a small blood sample from your finger” “Response is provided in 10 minutes” “If the test is positive the pharmacist will provide you with a referral letter to your GP” “If the test is negative we will help to provide you with good symptom management.”

Role Play Role play with a team member using the in-pharmacy engagement tool to introduce coeliac disease screening

In Summary In pharmacy coeliac screening will help to speed up the diagnosis of coeliac disease There are a wide range of patients suffering from a wide range of symptoms who will be suitable for the coeliac screening program Gluten free diets aren’t appropriate for everyone. These may be causing serious health implications for people Diarrhoea Constipation Bloating/Gas Fatigue Abdominal Pain Muscle pain IBS Skin rash Weight loss Quickly run through the key points of the presentation emphasising that there is an opportunity to make a difference to some people’s life’s and with a team approach the store can succeed.

Coeliac Screening Team Quiz

Question 1 Which of the following are symptoms of coeliac disease: Select the most correct response: Which of the following are symptoms of coeliac disease: Itchy Skin Rash Painful and/or irregular periods Muscle pain or stiffness All of the above Answer: D

Question 2 Have an inherited genetic susceptibility Select the most correct response: Anyone can be affected by coeliac disease as long as they? Have an inherited genetic susceptibility Are exposed to an unknown external factor such as stress Are exposed to gluten All of the above D – All of the above

Question 3 Select the most correct response: People should start a gluten free diet without consulting their doctor. True False Answer: False