IPN January 2017

January 2017 Volume 9  Issue 1

THE INDEPENDENT VOICE OF PHARMACY

In this issue:

Available in pharmacy

NEWS: HSE to make all GP surgeries paperless Page 4

PROFILE: Kate O’Connell TD Pharmacist, Page 9

REPORT: Overview of the Codemisused Project Page 18 But emergency contraception has.

CPD: Migraine…. not just a headache Page 31

FEATURE: Management of Menopause Page 40

ellaOne® is the most effective emergency contraceptive pill1

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Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie. Adverse events should also be reported to HRA UK & Ireland Ltd on Freephone: 1800 812 984 or email: med.info.ie@hra-pharma.com

*unprotected sexual intercourse

1. Glasier AF et al. Lancet 2010; 375: 555-62.

Date of preparation: March 2016

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Contents Page 6:

Cannabis Bill passes first stage Overview of the Codemisused Project

9

Page 22: IPN Confidential

Page 28: IPN Awards 2017

Page 36:

The era of independent Pharmacy

14

PUBLISHER IPN Communications Ireland Ltd. Clifton House, Lower Fitzwilliam Street Dublin 2 00353 (01) 6690562 MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com EDITOR - Kelly Jo Eastwood kjeastwood@hotmail.com

58

EDITORIAL DEPARTMENT editorial@ipnirishpharmacynews.ie IPN JOURNALIST - Paulie Doyle ACCOUNTS - Jon Dickinson accounts@ipncommunication.com COMMERCIAL MANAGER Barry Maguire Barry@ipnirishpharmacynews.ie ADVERTISING MANAGER Nicola McGarvey nicola@ipnirishpharmacynews.ie SALES AND MARKETING Aisling Twomey aisling@ipnirishpharmacynews.ie CONTRIBUTORS Conor Hogan | Padraig McGuinness Gareth O’Callaghan MPSI Eamonn Brady MPSI Rachel Dungan MPSI Deirdre O’Donnell | Ken Phelan

Regulars

A new year is like a blank book, and the pen is in your hands.

It is your chance to write a new successful story for yourself.

As January begins, IPN are busy getting the final arrangements sorted for the OTC Awards and drum roll please; the Irish Pharmacy Awards will be taking place on Saturday 20 May 2017.

We are announcing the categories in this issue. Turn to page 28 and 29 for the details.

Applications will be invited from early January 2017 on the dedicated Awards website www.irishpharmacyawards.ie

Page 18:

DESIGN DIRECTOR Ian Stoddart Design

Foreword

Irish Pharmacy IRISH News is circulated PHARMACY to all independent, NEWS multiple and hospital pharmacist, government officials and departments, pharmacy managers, manufactures and wholesalers.

Buyers of pharmacy groups and healthcare outlets.

Circulation is free to all pharmacists subscription rate for Irish Pharmacy News ¤60 plus vat per year.

All rights reserved by Irish Pharmacy News.

All material published in Irish Pharmacy News is copyright and no part of this magazine may be reproduced, stored in a retrieval system of transmitted in any form without written permission.

IPN Communications Ltd. have taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

Don’t miss your chance to be involved in the biggest night of the year for Pharmacy!

Meanwhile, in this issue of IPN, we carry a full set of clinical features on skincare, chronic pain, bi-polar and menopause.

December and January have been quiet months in terms of news, but changes are coming in the world of prescribing. Turn to page 4 to see IPN Scoop that the HSE project plan to make all GP surgeries paperless. The patient’s information will be sent directly to your IT System, relieving the problems and time wasted in deciphering doctors handwriting or patient’s confusions. The initial trial has begun and the hope is to roll this out to all locations during 2017.

The controversial Cannabis for Medicinal Use Regulation Bill has passed its first stage at the Dail, however this is just the first step towards legislation in Ireland. IPN spoke with one the proposers of the Bill, Gino Kenny TD. The Bill has received support from Sinn Fein, The Green Party and Social Democrats. Turn to Page 6 for the full details.

Our profile this month is Kate O’Connell, Community Pharmacist at the Rathgar Pharmacy in Dublin. In the February 2016 General Election, she was elected to the 32nd Dáil to represent the constituency of Dublin Bay South for Fine Gael. She currently serves on Committee on the Future of Healthcare and Health Committee. See page 9 and 10 for her views on the current political climate and how this effects Pharmacy.

It is something you will encounter every day of your working life – sales of codeine. You may suspect that a regular customer may be abusing codeine and have had conversations with them before. Turn to page 18 to read a report from the IMS Superintendent Pharmacist of the Year Padraig McGuiness on the work of the CODEMISUSED Project and what steps can be taken to help them.

Is the Era of Independent Pharmacy Over? Is the question that was raised at a recent Pharmacy breakfast seminar. We have an in-depth look at the event on page 36.

IPN would like to take this opportunity to wish all our readers a happy and successful new year. We look forward to continuing to be your voice and bringing you the most up to date news, reports, and features.

Aisling Twomey

CPD: Migraine

31

Feature: VMS

47

Non Clinical CPD

55

Feature: Menopause

43

Feature: Depression

49

Product Profiles

62

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News The HSE to make all GP surgeries news brief ‘paperless’ by 2017 PHARMACY AND BEAUTY SECTOR EXPERIENCING ‘MIXED TRADING’ The Pharmacy and Beauty sector experienced very mixed trading, with a minority of stores reporting some modest growth while the majority are tracking backwards, it has been reported

by Retail Excellence Ireland.

Overall the sector is over stocked and trading down.

Many of the pharmacy groups have gone into pre-Christmas sale, a measure never seen before.

In general, retail industry sales have decreased compared to this time last year.

Contributory factors include a post Brexit and Trump erosion in consumer sentiment, a significant increase in online shopping into the United Kingdom and the forward movement of spending into the Black Friday weekend, according to Retail Excellence Ireland.

Logistics companies are reporting a 30% to 80% increase in packages arriving into the country from the United Kingdom and this has had an obvious and significantly damaging impact on the local economy.

The largest like for like increases in parcel deliveries for Christmas 2016 were recorded in Counties Wexford, Tipperary and Laois.

Commenting on the trading update Lynn Drumgoole, Retail Excellence Communications Director said: “It is disappointing to report that most sectors within the Irish Retail Industry are currently trading down against this time last year. We have witnessed a significant increase in shopping with .co. uk websites in November due to weakened sterling.

“We have also seen a measured increase in Black Friday shopping at discounted prices. These reasons, added to a general deterioration in customer sentiment, have resulted in a challenged retail situation so far in December.”

4

“The move will see pharmacists using an easily accessible database, which will hold all of a patient’s information.

“Patients will still get a piece of paper, but it will have bar code, which the Pharmacist will scan and then all the patient’s relevant information will appear on a screen” said Richard Corbridge, speaking to Irish Pharmacy News. “The systems are already deployed, so really this just an upgrade to the system.”

The transition will attempt to minimize the potential for human error when prescriptions are handed in by patients to pharmacies, and also try to put less stress on Doctors, who find themselves trying to source increasingly scarce equipment required to give out prescriptions.

“The biggest problem that we’re trying to support is that Doctors are trying to buy printers and parts that aren’t really available anymore,” Corbridge said. “This will also relieve prescription errors in transcription – it goes straight into a Pharmacist IT system.

This a patient safety initiative.”

Human error is quite a concern for Pharmacists, due to the complexity and volume of prescriptions each year. 20 million prescriptions that are filled annually, and more than eight out of ten (85%) older people are taking five or more medicines (polypharmacy) on admission to hospital.

In addition, 62% of people over 65 years of age have one or more

chronic illnesses; and more than 8% of all emergency admissions to hospital are medicine related.

Nearly a quarter (23%) of pre-admission medicines are omitted or incorrectly notified on admission, while hospital discharge prescription errors have been reported for up to half (50%) of all patients. Going forward, Pharmacists in Ireland will continue to use technology to reduce the chances of human error. “There’s one Pharmacy in Kerry that has robotics, and patients can use a barcode to have a robot give them the correct medication through a shoot,” says Corbridge. However, he says, some GPs may not use the new technology. “About 3% of GPs aren’t digital so there will be difficulty getting all of Ireland’s Pharmacists on board. Some of

them don’t use technology. So, this is not a mandate, this is an option that will be available to GP’s, should they want to use it. However this project is an excellent example of how the eHealth ecosystem in Ireland can encourage competing vendors to work together with GPs, to deliver innovative solutions for patients and clinicians. The go live next week shows what can be achieved when we all work together to build a better health system. “We are excited to see this go live in Mallow and we will work to roll this solution out to all locations during the course of 2017. We are delighted to have worked with CompleteGP, McLernons, the Healthlink team and PCRS on this project.”

Donegal Pharmacists censured by PSI Two Donegal pharmacists have been censured by the Pharmaceutical Society of Ireland (PSI) for supplying a medication without prescription, it has recently been reported in national press.

Both Pharmacists supplied a woman referred to as Patient A, who is now deceased, with a drug without a prescription over a period of 14 months, the inquiry heard.

The medication in question can potentially causes serious side- effects to patients.

Both men had expressed regret, and had taken steps to ensure it would not happen again, Gabriel Gavigan, Senior Counsel for both Pharmacists, said There is no medical evidence indicating that the Pharmacists’ actions in any way caused or contributed to Patient A’s death.The fitness-to-practice committee asked that both Pharmacists do not repeat

their actions, as well bring in an independent auditor every year for five years, and attend continued professional development training.

Stewart Magee and Gerard McCormick of Magee’s Pharmacy, Upper Main Street, Letterkenny, Co Donegal, were found guilty of poor professional performance at a disciplinary inquiry held by the PSI in Dublin.

It was found that Mr McCormick failed to ensure that adequate procedures were taken to ensure the safe and appropriate supply of medications to a patient.

The medication in question was Enbrel, which is used to treat

patients suffering from rheumatoid arthritis and other chronic autoimmune conditions. It requires a high level of supervision, as it has several serious potential side-effects, such as decreasing the body’s ability to fight off serious infection.

Pharmacists are required to check for a prescription each time Enbrel is supplied to a patient.

Between January 2011 and May 2012, Patient A was supplied with Enbrel 11 times without a valid prescription.

In August 2012, Patient A was diagnosed with pneumonia and cancer, and has died since.

News Irish survey reveals some patients not identifying pharmacists as caregivers A recent survey by the Irish Heart Foundation has found that several patients did not identify their pharmacist as playing a noteworthy role as caregivers.

The report examines the experiences of people with heart failure in the community, and “paints a stark picture of a growing community of often unsupported heart failure sufferers trying hard to cope with inadequate services, barriers to proper care, a dearth of community supports and particularly psychological support.

And yet, it also shows that people living with the condition are stoic and highly motivated to maximise their health and quality of life.”

supply me with all the medication that I need … Because I said they are very obliging like that that’s all I can say you know, but I don’t know how other than filling your prescriptions that we give them, what they could do. I don’t know.”

The report notes that some of the interviewees did not identify that their pharmacists had a significant role in the management of their heart failure. For these patients, the pharmacy was the place from which they collected the medications that had been prescribed by doctors.

Another patient described how a pharmacist had prevented him from taking a lethal dose of medication: “He said to me ‘that’s not right’. I said ‘why?’ ‘Well they are prescribing 600 milligrams that’s a fatal dose’. So, he rang the hospital. It was 600mg, should have been 200. Yes, he’s as sharp as a razor. He’s great and then a few other times when there was stuff looking for and he said that

During an interview, one patient said, of pharmacists: “Well, they

However, for patients who did identify pharmacists as having an important role, pharmacists represent a crucial safety net for prescribing errors. They were also impressed by their knowledge.

‘that doesn’t go with what you are on’.”

“No, he is very good believe me,” he continues. “So yes we would go around to talk to him looking for advice, or what does he think. An approachable and knowledgeable pharmacist was also seen as a valuable source of information for patients.

“Ah well, he’s only ‘round the corner from me, and again he’s absolutely brilliant, you know.

You can go up and discuss your medication with him and he will. He’s as good as any GP or anything like that. He understands all the medication, what clashes with what, and what will won’t suit, you know, and that’s reassuring as well.”

Irish Heart Foundation would be keen to engage with Pharmacists to see this can be rectified.

National Clinical Programme for Epilepsy launched by HSE The HSE National Clinical Programme for Epilepsy has launched its Model of Care on December 1st.

The Model of Care sets out a vision for the transformation of epilepsy care in Ireland to provide the best patient centred care for all people with epilepsy in the right place, at the right time, sharing the best available information.

This model of care is a blueprint for how Epilepsy services will be developed and continuously improved nationally.

According to the HSE, the Epilepsy Programme has three core aims: To improve access to expert care and information; to improve the quality of care across the healthcare spectrum from prevention, through to managed primary care to complex surgical care for difficult epilepsy; and, to improve value conscious care by shifting care where possible from expensive hospital cased care to the community.

The key innovations of the Clinical Programme for Epilepsy include: the creation of a cohort of registered advanced nurse practitioners (RANPs) to compliment the current medical expertise to help in the chronic disease management of epilepsy and to integrate it with care in the community; the development of the Epilepsy Electronic Patient Record. More than 6,500 patients

are now registered on Epilepsy EPR. 12 modules of functionality have been developed to support delivery of epilepsy services; and, the development and implementation in 2 sites of the Acute Seizure Integrated Care Pathway (ICP).

Speaking about this new model of care, Minister for Health Simon Harris, said: “The model of care launched today takes an integrated approach to epilepsy healthcare. It spans primary and acute settings and reflects the varying needs of people with chronic disease. It will be a blueprint for epilepsy services and will ensure that the best value and most appropriate care is provided for all.”

While a number of the recommendations within the Model of Care are currently being addressed, its full implementation will see significant changes in the way epilepsy care is delivered across the country. It will place community and hospital staff working together to support persons with Epilepsy in a care setting appropriate to them and their needs.

These care settings include those at a Local level, which includes the patient’s GP, Primary Care Health and social care professionals and

news brief IRISH HIV ADVOCACY GROUP ‘NOT SURPRISED’ BY HIV MYTH SURVEY The Director HIV Ireland has said that he is ‘not surprised’ by the findings of a recent survey exploring myths surrounding HIV and AIDs in the UK. The survey, conducted by the Terrence Higgins Trust, found that public perceptions of the illness are still like those of the 1980’s – despite the medical progress that has been made in fighting the disease.

Of over 2,000 adults surveyed, 20% stated that they believed HIV can be transmitted by kissing. 30% of respondents believed that sharing a toothbrush with someone who is HIV positive can pass on the virus, while one in 10 think thought HIV can be transmitted by sharing scissors or clippers at the hairdressers with someone who is HIV positive.

“Ultimately, I’m not surprised,” said Niall Mulligan, Director of HIV Ireland, speaking with Irish Pharmacy News.

nurses, Community Rehabilitation Teams, the nearest Acute General Hospital and support provided

by Epilepsy Ireland, the national advocacy service for people with epilepsy; Group Epilepsy/ Neurology Services, hospitals with an epilepsy service (existing or proposed) collaborate to function as a Group Neurology Service, operating as a Clinical Network in each of the six Hospital Groups.

“And probably some of the main reasons I’m not surprised is because HIV has gone off the public radar, and a lot of that would be linked in to the fact that treatment is so good, and the impact that HIV had in the 80’s was so much more catastrophic. There’s been a vacuum of knowledge because of this.”

Also included are National Tertiary Centres – Tertiary centres will generally have teams with sub specialism in some of the low volume / high complexity conditions within epilepsy.

Mr Mulligan went on to say that he believes much work is to be done around HIV awareness and ending stigma attached to the disease.

Dr Áine Carroll, HSE National Director for Clinical Strategy and Programmes said: “The success of the epilepsy programme is a real ‘good news story’ within the HSE which shows that change is possible. Not only changing what we know, but changing what we do and how we do it.

Seeing the shared care of patients across a number of care settings - outpatients, acute hospital, residential services, virtual encounters – encompass what integrated care should look like.

It gives us hope that if change can be seen in this one area of practice, it can be replicated widely across the health service.”

“There’s so much to be done, why do people believe that HIV can be transmitted from a toothbrush? Because no one has told them otherwise. The most pervasive belief is that it no longer is an issue.

“That complacency, that people think it’s no longer an issue.

Take the politician in the North for instance, who recently stated that he had thought that HIV is only something gay men could contract. That’s simply not true.”

5

News news brief BECTON DICKINSON AND COMPANY ANNOUNCE 100 NEW IRISH JOBS BD (Becton, Dickinson and Company), has announced its plans to open a new research and development (R&D) Centre of Excellence in Limerick, bringing 100 new jobs to the city.

The ¤21 million investment in the new Centre of Excellence includes an extensive renovation of the former UniGolf facility in the National Technology Park.

Once completed, it is planned to house more than 200 high-tech positions, which includes more than 100 BD jobs that already exist in Limerick and the 100 new positions.

The project is supported by the Department of Jobs, Enterprise & Innovation through Industrial Development Agency (IDA) Ireland.

The BD Limerick Centre of Excellence will initially be focused on product and software development, clinical research instrumentation and prototype development, primarily for the company’s Life Sciences businesses.

Ellen Strahlman, MD, MHSc, Executive Vice President R&D and Chief Medical Officer for BD said: “Ireland is an important part of our growth plans, and the Limerick Centre of Excellence is foundational in our objective to build an agile, world-class global organization to deliver an R&D portfolio that drives growth.

This will require significant hiring of R&D associates, collaboration with local universities and the development of new technical capabilities.

“Areas served by activities and products arising from our new R&D Centre of Excellence will include the fields of microbiology and molecular biology, clinical and cellular research analysis, and industrial microbiology.

“Customers will include hospitals, laboratories and clinics, reference laboratories, industrial laboratories, physicians’ office practices, alternate site health care, academic and government institutions, and research facilities. Limerick will be very important for our strategic growth.”

6

Medicinal Cannabis Bill passes Dáil A Bill which would legalise cannabis for medical purposes has passed the second stage of the Dáil, amid calls from activists and politicians.

The Cannabis for Medicinal Use Regulation Bill, which was proposed by TDs Gino Kenny and Richard Boyd Barrett of AAA-PBP, also received support from Sinn Féin, the Green Party and the Social Democrats.

Meanwhile, while Fianna Fáil, did not support the bail in the Dáil, their Health Spokesman Billy Kelleher said his party supported the overall policy of the Bill.

As the Bill has now passed the second stage, it will proceed to the Oireachtas Health Committee, where it will be discussed by its members.

Speaking to Irish Pharmacy News about the Bill, People Before Profit TD Gino Kenny said: “I think it’s great that it happened, and it’s great that it got an all-party consensus - it’s been very, very positive since I put the Bill forward.

“What surprised me the most was the sheer amount of people that can really benefit from this.

The purpose of this Bill is to allow as many people as possible to have access to cannabis, for medical purposes - the research is there that it works, and it’s great that they will finally see the benefits of it.

“I think it’s the right place and the right time, the likes of Vera Twomey’s campaign have the power to change Government policy and legislation.”

Vera Twomey is a young woman whose daughter suffers from a rare form of epilepsy, and has found great relief from seizures from cannabis based medicine.

Twomey has campaigned for cannabis legalisation for medical purposes.

Speaking in the Dáil, Health Minister Simon Harris said that the government would not oppose the Bill. He also has requested research on the matter from that the Health Products Regulatory Authority (HPRA).

Specifically, Minister Harris says he has asked the HPRA for an overview of: products that have been authorised in other countries; the wider ongoing and emerging clinical research in new indications and evidence of efficacy; the different regulatory

regimes in place in countries which allow cannabis to be used for medicinal purposes, and, legislative changes that would be required to allow use of cannabis for medicinal purposes in Ireland.

The HPRA’s report is to be completed by the end of January 2017, after which it will proceed to committee stage.

Speaking about the Bill, Minister Harris said: “I am anxious to proceed as quickly as possible, however, it is important that we have expert advice to underpin decisions on how best to move forward. That is why I have asked the Health Products Regulatory Authority to provide me with the scientific and clinical advice necessary for me to consider amendments to the current statutory controls on medicinal cannabis.

“I expect to receive their recommendations by the end of January 2017. I would like to recognise that the Joint Committee on Health is also considering this matter.”

Over 90% of Irish people support the legalisation of the drug on medical grounds, according to a recent survey by Red C. “The people have compassion enough to provide necessary treatment for those who need it, it’s now up to legislators to follow their lead”, Tom Curran, a Deputy Director of Help Not Harm said.

Some TDs however, have voiced suspicion towards the Bill. Dr

Michael Harty called the Bill ‘a Trojan Horse’, which is “is designed to legalise recreational drug use in the guise of legalising it for medicinal use”.

Gino Kenny said: “Cannabis as a medicine has the uncommon property of having no lethal dose which means that it has never killed any patient, ever. There is a huge advantage in this, such as substituting cannabis for more dangerous drugs in terms of dependency and death, such as opioid painkillers and benzodiazepine sedatives. The benefit of fewer side-effects and overdoses is already being seen in countries which improve access to medicinal cannabis.

A statement from the PSI, when IPN requested comment, said: “The PSI has a responsibility to support the implementation of new legislation that impacts pharmacists. Pharmacists have a vital role in the safe and effective use and availability of medicines, and regulations are already in place to ensure the safe storage, supply to patients and documentation of controlled drugs.

“Ultimately, where a new drug is to be made available to patients through pharmacists, the PSI will support pharmacists by communicating changes arising in pharmacy practice and by providing any necessary guidance to support their role.”

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Profile

Kate O’Connell talks challenges facing Irish Healthcare Kate O’Connell is a Pharmacist and owner of Rathgar Late Night Pharmacy. She is also Fine Gael Politician, Teachta Dála (TD) for the Dublin Bay South constituency, and was elected to the 32nd Dáil in February of 2016. Here, she speaks with IPN about her background in Pharmacy, the role of Pharmacists in healthcare, drug prices, and the challenges facing the Health Service in 2017.

Although O’Connell is now a TD, she says she had been involved in politics initially as an “extracurricular activity”. The demands of running a Pharmacy meant that she had previously been prevented from entering the political arena.

“I’d always been very much in politics, my family was” she says, speaking to IPN. “And I’ve always had a big interest in current affairs and politics, but hadn’t really the time, because of the constraints of running your own business. I mean, back in the day when we had the two shops we would have worked nearly every day, taking a day off every so often. So, I suppose there wasn’t much time for anything else in my life at that point. And I’d no children at the time, so we were literally working flat out!

“I had been involved in Westmeath where I’m from originally, because my father was a councillor. Then I moved my membership up to Dublin as an extracurricular activity, rather than with a view for running for politics.”

Before her venture into politics, O’Connell began studying Pharmacy abroad, in Brighton in 1999. “I qualified four years later, and went on to do a hospital prereg, based in Surrey and Sussex Trust” she says. “I loved hospital Pharmacy and the way it had progressed in the UK compared to Ireland. Then during my summers, I worked as a care assistant in a hospital in Tullamore. So, I also had a knowledge of the hospital setting in Ireland.”

“Then eventually, I began to long for home and met someone. So, I returned to Ireland and worked as a locum for a period of time. Then we were able to open our first Pharmacy in 2006 in Sandyford this was followed a year later in Rathgar.”

Currently, in addition to her role in the Dáil, O’Connell employs about 13 people between two shops, including four full time Pharmacists.

Kate O’Connell TD and Owner/Pharmacist Rathgar Late Night Pharmacy “There was a big learning curve,” she says, discussing the initial difficulties of starting a Pharmacy.

“But my husband came from a family who were immersed in Pharmacy for a long time, so we had a bit of expertise to help us starting out...Then the cuts happened - the contract cuts - the FEMPI came in, and there were massive cuts to re-imbursement and free structure.

“So, I supposed we started off with expectations of a contract being a certain way, and then things changed rapidly. So, we headed into a period of a lot of uncertainty.

Then we had the Pharmacy strike

in 2009, which was quite a difficult time. I’d been involved in the union a bit before that, and felt that that strike fractured the profession a lot. We got on with it, and the shop has grown.”

Healthcare and pharmaceuticals have been particularly topical in Ireland in the past number of months. As a member of the Oireachtas Health Committee, O’Connell is currently dealing with, among numerous other issues, a bill that would legalise medical cannabis which was put before the Dáil, and calls from some to review the distribution of the HPV vaccine.

“I have huge concerns about the [cannabis] bill. To me, as a newly elected TD, I had huge difficulty with it. For one, I didn’t see any need for a new regulator – this should be regulated by the Pharmaceutical Society, like every other drug,” she says of Gino Kenny and Richard Boyd Barret’s bill.

“I also don’t think that there’s any need for a cannabis research institute…I’m not sure whether the bill has a function long term, maybe it’s good to get people to discuss it, and to get the conversation. My understanding is that HPRA are the body that are

9

Profile We also have huge demographic strains, a huge amount of waiting lists and unmet need.

This seems to be escalating all the time. tremendous difficulties. Going forward, she sees the employment of healthcare professionals of a desirable standard as a challenge the government and the health service will have to face.

“First off, one of the greatest challenges for the health service now is recruitment – we have a huge staffing issue,” she says.

“We have a brain drain. We’ve graduates that were paid for by this state to be educated in this country who are going to work in other jurisdictions. We have used that in the past but they always came back. And now people aren’t coming back.”

“I’m told that not many people are applying for vacant posts, and that when people do apply they’re not of the optimum standard. Obviously, the key to any successful l organisation – any community Pharmacist knows this – is the people who work in it.

And if you don’t have the proper staff, people with the proper qualifications, any system is going to suffer.

Kate O’Connell TD

authorized for the regulation of medicines, so I see that as their job…. And, to deal with Senator Croughwell’s issue…I’m open to looking at it, if it was my call.

But I really don’t see ambiguity anymore. And when it comes to the role of Pharmacists and vaccines, the flu vaccine has been such a success in the Pharmacy.”

Going forward into 2017, O’Connell says that Pharmacists can have an expanded role in Irish Healthcare, but that we must be wary of new roles detracting from their other functions, and provide adequate training. Pharmacists, for instance, she says, can have an expanded role in giving out vaccinations, but that “there some issues. I wouldn’t have been comfortable, and I don’t speak for all Pharmacists, with administering a vaccine to a small baby before I had my own children.

I wouldn’t have been comfortable handling babies like that. I think there’s a particular skillset there.

“So, if Pharmacists do go down that route, we do require, I believe

10

specific training, and quite a lot of training. But I don’t see why, where the risks are low, that travel vaccines and such things can’t be done in a Community Pharmacy setting,” she says.

O’Connell says that going forward, people must be cognisant of the fact that a community Pharmacist is only one person. “We have to think about the role we have anyway, supervising the sales of over the counter medicines, prescription checking, and counselling. How many things can a community Pharmacist be doing at the same time?” she says. “If you’re doing a huge volume of flu vaccines, and then you’re in consultations all day, who’s in the dispensary and looking after the counter. We need to be sure that whatever additional roles we’re taking on, it’s not to the detriment of something we already do.”

In her capacity as a member of the Health Committee, O’Connell is also dealing with an Irish Health Service currently facing

“We also have huge demographic strains, a huge amount of waiting lists and unmet need. This seems to escalating all the time. Funding obviously is a major issue. Any model we’re looking at, we need to be cognisant of the fact that we’re one of the top spenders per head in the OECD at the minute. Outcomes seem to be good, when you measure them against international standards, but somewhere in the middle, there’s an awful lot of chaos and confusion, and I think that’s the big challenge for us.”

She adds that there is work to be done with regard to the organisation of the Irish health service.

“I’m very pro the hospital group setup,” she says. “But I have, and the committee I believe have, huge issues with the alignment of community and regional health organisations with hospitals. I think if we’re dividing the country into seven hospital groups, that yes there has be a bit of flexibility there, but if you look at the northwest, the regional health organisations’ borders align with hospital groups. The key there is a defined population.

“I think it’s fundamental to any organisation of health services in any country that you have a defined population that you’re looking at all the time. There are issues with the current structures, in that that’s currently not the case.

The Midwest is the only place that has that.”

The current model of care, according to O’Connell, should shift to having a greater emphasis on community care, and that Pharmacists have a very important role to play in doing so.

“One thing that’s clear,” she says, “is that there must be a shift from people turning up in an acute hospital setting into the community and into primary care, and Pharmacists have a vital role to play in primary care.

I fundamentally believe in role of community Pharmacists in the towns and villages around the country. I don’t think we can ever talk about primary care in Ireland without acknowledging the role played by Pharmacists” O’Connell’s colleague, Minister for Health Simon Harris is currently making efforts to secure the so called ‘miracle drug’ Orkambi for a cheaper price for Irish patients with Cystic Fibrosis. She says that collective bargaining with pharmaceutical companies is very important going forward to ensure the best care for people who need it.

“One of the great issues with pricing any meds in Ireland is that it’s a barrier to people entering the market. I’m all for collective bargaining when it comes to the price of drugs. I don’t see why Ireland would be going to negotiate with Vertex, why the UK or Australia would be going separately.

“High tech drugs have proliferated in the past number of years. Once Orkambi is dealt with – and I hope it is dealt with properly and that people get it a reasonable – another drug is going to come along. We need to organise bargaining for the price of drugs collectively, because it’s not going to go away. How we deal with this sets a precedent for the future.”

Y For Co ug h AN AT HOME syrup

ON THE GO pastilles

Buttercup Bronchostop Cough Syrup contains thyme herb extract and marshmallow root extract. A traditional herbal medicinal product for the relief of coughs, such as chesty, dry, tickly, irritating coughs and catarrh, exclusively based upon long-standing use. Adults and children over 12 years: 15ml every 4 hours. Max dose 90ml per day. Not recommended for children under 12 years. Seek medical advice if symptoms persist after 7 days or if dyspnoea, fever or purulent sputum occurs. Contraindications: Known hypersensitivity to ingredients, rare hereditary intolerance to some sugars. Caution: Contains methyl parahydroxybenzoate and propyl parahydroxybenzoate, which may cause allergic reactions. Side effects: Stomach disorders. TR 2006/1/1. TR Holder: Kwizda Pharma GmbH, Effingergasse 21, A-1160 Vienna, Austria. RRP (ex.VAT) 120ml €6.99 200ml €9.99 SPC: www.medicines.ie/medicine/16380/SPC/ Buttercup+Bronchostop+Cough+Syrup Buttercup Bronchostop Berry Flavour Cough Pastilles contain thyme herb extract. A traditional herbal medicinal product for the relief of coughs, such as chesty, dry, tickly, irritating coughs and catarrh, exclusively based upon long-standing use. Adults and children over 12 years: 1 - 2 pastilles every 4 hours. Max dose 12 pastilles per day. Not recommended for children under 12 years. Seek medical advice if symptoms persist after 7 days or if dyspnoea, fever or purulent sputum occurs. Contraindications: Known hypersensitivity to ingredients, rare hereditary intolerance to some sugars. Caution: Contains 0.6 g fructose per 2 pastille dose – to be taken into consideration in those with diabetes mellitus. Side effects: Stomach disorders. TR 2006/1/2. TR Holder: Kwizda Pharma GmbH, Effingergasse 21, A-1160 Vienna, Austria. RRP (ex. VAT) 10s €3.99 20s €5.99 SPC: www.medicines.ie/ medicine/16381/SPC/ Buttercup+Bronchostop+Berry+Flavour+Cough+Pastilles/

News

Future Stars of Pharmacy The Master of Conferring ceremony has taken place in the Convention Centre Dublin on Thursday 17th November 2016. A total of 147 interns were conferred with a Master of Pharmacy (MPharm) by the Royal College of Surgeons in Ireland and the National University of Ireland.

PharmaConex hosts Seminar for new Pharmacy Graduates Sinead Ryan, MPSI and a Locum with PharmaConex offered insight into a ‘Day in the Life of a Locum’. She also highlighted helpful websites and tools available to support all Pharmacists, including the IPU. Catriona Bradley from the IIOP to discuss CPD. Catriona encouraged audience engagement by offering the attendees the chance to find out exactly what they wanted to know about Continuing Professional Development.

PharmaConex recently hosted a seminar for new pharmacy graduates. The event, designed to offer New Pharmacy Graduates a chance to gain some practical insight before progressing on their career path was later extended to all Pharmacists due to expressions of interest from Locums.

The first speaker was Claire Murphy from the Allcare Pharmacy Network. Claire covered Quality and Practice Guidance. Claire also

discussed the Core Competency Framework and the availability of the PSI Pharmacy Practice Manual on the website. Sinead Magner and Linda O’Brien joined the event from LIoydsPharmacy and spoke about working as a Pharmacist for a large Pharmacy group. They detailed some of the differences between working for a group versus as a Locum.

The closing speaker was Rachel Dungan, Pharmacist Coach from

4front.ie, who discussed how Locums also have an opportunity to make a real impact and influence during their shifts. The PharmaConex team were very grateful for the generosity of the speakers who gave up their valuable time to offer insight at the event. The attendees and speakers had a chance to network and were able to receive some expert training from the Pharmaconex team.

and Payroll – What you need to do to ensure you are set up correctly; PharmaConex Booking System – Navigating bookings through the online programme; Introduction to the Dispensing Systems – McLernons, QicScript & TouchStore. Due to positive feedback for the event PharmaConex plan to hold similar events in the 2017.

This training included ; Tax

New Additions for McCabes Pharmacy Group Board Joining Roy McCabe MPSI and Sharen McCabe Chairperson, the following Executives have been appointed to The Board of the of the McCabes Pharmacy Group: • Mr Paul Candon Chief Executive Officer

• Mr Conor McDonald ACA, Company Secretary

• Mrs Deborah Osborne Commercial Director

Deirdre Burns (Non-Executive Director) is Pharmacist by profession, with over 25 years of experience at Board level and Senior Leadership roles in Pharmacy, Healthcare, FMCG and Telecommunication. She

• Ms Ciara McCabe MPSI • Ms Deirdre Burns MPSNI Non-Executive Director to the Board

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has previously held positions including; Managing Director Boots Ireland, Supply Chain Director Walgreens Boots Alliance, and Retail Director EE/ BT Mobile in The United Kingdom. She now has an impressive Non-Executive portfolio working predominantly with global Private Equity companies, spending much of her time in London.

In addition to the Board appointments Mr Chris Monaghan joins McCabes Pharmacy Group as Group Operation Manager on Monday December 12th. Chris has previously held senior Operations roles with Tesco, Lidl, Superquinn and Topaz and brings a wealth of Retail experience.

ADVERTISING FEATURE

Quitting smoking is the single biggest thing smokers can do to improve their health. It has been shown that smokers are up to four times more likely to quit with the help of a healthcare professional than with willpower alone.5 Research shows that, to be successful, smokers need behavioural support and evidence-based advice from their healthcare professional.5,6,7 Combining this valuable support with a proven cessation aid can increase the chances of quitting. Pharmacists are often the first point of call for smokers looking to quit and consequently best placed to offer such advice and support.

New study. New data. New perspectives?

Smoking cessation medicines, such as Champix® (varenicline), have been shown to be one of the most effective methods to stop smoking, when combined with support from a healthcare professional.8 New data, such as EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study), supports this claim. EAGLES was a randomised, double-blind, triple-dummy, placebo and active controlled trial to compare the relative neuropsychiatric (NPS) profile and efficacy of varenicline and bupropion vs placebo in over 8,000 smokers with or without a diagnosis of psychiatric disorders. The primary endpoint

CHAMPIX® Film-Coated Tablets (varenicline tartrate) ABBREVIATED PRESCRIBING INFORMATION – IE (See Champix Summary of Product Characteristics for full Prescribing Information) Please refer to the SmPC before prescribing Champix 0.5 mg and 1 mg.

Presentation: White, capsular-shaped, biconvex tablets debossed with “Pfizer” on one side and “CHX 0.5” on the other side and light blue, capsular-shaped, biconvex tablets debossed with “Pfizer” on one side and “CHX 1.0” on the other side. Indications: Champix is indicated for smoking cessation in adults. Dosage: The recommended dose is 1 mg varenicline twice daily following a 1-week titration as follows: Days 1-3: 0.5 mg once daily, Days 4-7: 0.5 mg twice daily and Day 8 – End of treatment: 1 mg twice daily. The patient should set a date to stop smoking. Dosing should usually start 1-2 weeks before this date. Patients who are not willing or able to set the target quit date within 1-2 weeks, could be offered to start treatment and then choose their own quit date within 5 weeks.

Patients should be treated with Champix for 12 weeks. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment at 1 mg twice daily may be considered for the maintenance of abstinence. A gradual approach to quitting smoking with Champix should be considered for patients who are not able or willing to quit abruptly. Patients should reduce smoking during the first 12 weeks of treatment and quit by the end of that treatment period.

Patients should then continue taking Champix for an additional 12 weeks for a total of 24 weeks of treatment. Patients who are motivated to quit and who did not succeed in stopping smoking during prior Champix therapy, or who relapsed after treatment, may benefit from another quit attempt with Champix. Patients who cannot tolerate adverse effects may have the dose lowered temporarily or permanently to 0.5 mg twice daily. Following the end of treatment, dose tapering may be considered in patients with a high risk of relapse. Renal impairment; Mild to moderate renal impairment: No dosage adjustment is necessary. Patients with moderate renal impairment who experience intolerable adverse events: Dosing may be reduced to 1 mg once daily. Severe renal impairment: 1 mg once daily is recommended. Dosing should begin at 0.5 mg once daily for the first 3 days then increased to 1 mg once daily. Patients with end stage renal disease: Treatment is not recommended. Hepatic impairment and elderly patients; No dosage adjustment is necessary. Paediatric patients; Not recommended in patients below the age of 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Warnings and precautions: Effect of smoking cessation; Stopping smoking may alter the pharmacokinetics or pharmacodynamics of some medicinal products, for which dosage adjustment may be necessary (examples include theophylline, warfarin and insulin).

Changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, depression, suicidal ideation and behaviour and suicide attempts have been reported in patients attempting to quit smoking with Champix in the post-marketing experience. A large randomised, double-blind, active and placebo-controlled study was conducted to compare the risk of serious neuropsychiatric events in patients with and without a history of psychiatric disorder treated for smoking cessation

Date of preparation: December 2016 Job code: PP-CHM-IRL-0068

-3

-2 -1

1

2

3.81

3

4

Weeks 9–12

15.7

3.59

1.78

9.4

-0.24

0

Bupropion vs. placebo

1.59

21.8

-0.42

CHAMPIX vs. placebo

16.2

Bupropion vs. placebo

1.21

23.4

CHAMPIX vs. placebo

-0.08

CHAMPIX (N=2,037) Bupropion (N=2,034) NRT Patch (N=2,038) Placebo (N=2,035)

12.5

-1.37

40 35 30 25 20 15 10 5 0

33.5

-1.28 -0.15

22.6

-2.40

Continuous Abstinence Rate (%)

Many smokers looking to quit become trapped in a cycle of failure as their methods do not address the physical and psychological challenges associated with successfully quitting smoking.3 They often try to quit alone4 – not seeking help from a healthcare professional, such as a pharmacist, who is best placed to provide support and advice.4

Psychiatric cohort

The burden of tobacco on morbidity and mortality is preventable and significant – yet tobacco consumption remains the single largest avoidable health risk in Europe. It claims 700,000 lives every year,1 and costs European public healthcare an estimated €25.3 billion annually to treat tobacco-related diseases.2

Nonpsychiatric cohort

New evidence to set patients free from the confines of smoking

Weeks 9–24

Risk Difference with 95% CI

Overall (N=8,144)

was the incidence of a composite measure of 16 moderate and severe NPS adverse events, with the main efficacy endpoint being carbon monoxide confirmed continuous abstinence rate for weeks 9-12.8

the community or hospital setting are in an ideal positon to offer evidence-based advice to help smokers make an informed decision and can draw on data such as EAGLES. In a time when smoking is still so prevalent across Europe, it is imperative that patients are offered the best evidence-based support and care available from a healthcare professional, coupled with effective smoking cessation aids. These data allow pharmacists to have confidence to recommend that smokers looking to quit speak to their primary care physician about varenicline.

Data from EAGLES showed that varenicline was not associated with a significantly increased risk of NPS adverse events vs placebo in smokers with or without a history of psychiatric disorders.8 It also showed superior continuous abstinence rates for varenicline vs bupropion (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.52–2.01), NRT patch (OR 1.68; 95% CI 1.46–1.93) and placebo (OR 3.61; 95% CI 3.07–4.24) at the end of treatment (week 9–12; p<0.0001). Continuous abstinence rates for varenicline were also superior to bupropion, NRT patch and placebo at follow-up (weeks 9–24; p<0.0001).8 The safety and efficacy of varenicline has been studied across 39 clinical trials with 10,000 patients receiving varenicline.9 Varenicline can shield smokers from cravings and withdrawal symptoms10 while breaking down the positive reinforcement of smoking.10 How EAGLES impacts the pharmacy setting These data, from the largest randomised, placebocontrolled smoking cessation clinical trial published to date,8 highlight the benefits of varenicline for patients looking to quit smoking. Pharmacists in

with varenicline, bupropion, nicotine replacement therapy patch (NRT) or placebo. The primary safety endpoint was a composite of neuropsychiatric adverse events that have been reported in post-marketing experience. The use of varenicline in patients with or without a history of psychiatric disorder was not associated with an increased risk of serious neuropsychiatric adverse events in the composite primary endpoint compared with placebo. Depressed mood, rarely including suicidal ideation and suicide attempt, may be a symptom of nicotine withdrawal. Clinicians should be aware of the possible emergence of serious neuropsychiatric symptoms in patients attempting to quit smoking with or without treatment. If serious neuropsychiatric symptoms occur whilst on varenicline treatment, patients should discontinue varenicline immediately and contact a healthcare professional for re-evaluation of treatment. Smoking cessation, with or without pharmacotherapy, has been associated with exacerbation of underlying psychiatric illness (e.g. depression). Champix smoking cessation studies have provided data in patients with a history of psychiatric disorders. In a smoking cessation clinical trial, neuropsychiatric adverse events were reported more frequently in patients with a history of psychiatric disorders compared to those without a history of psychiatric disorders, regardless of treatment. Care should be taken with patients with a history of psychiatric illness and patients should be advised accordingly. Patients taking Champix should be instructed to notify their doctor of new or worsening cardiovascular symptoms and to seek immediate medical attention if they experience signs and symptoms of myocardial infarction or stroke. In clinical trials and post-marketing experience there have been reports of seizures in patients with or without a history of seizures, treated with Champix. Champix should be used cautiously in patients with a history of seizures or other conditions that potentially lower the seizure threshold. At the end of treatment, discontinuation of Champix was associated with an increase in irritability, urge to smoke, depression, and/or insomnia in up to 3% of patients, therefore dose tapering may be considered. There have been post-marketing reports of hypersensitivity reactions including angioedema and reports of rare but severe cutaneous reactions, including Stevens-Johnson Syndrome and Erythema Multiforme in patients using varenicline. Patients experiencing these symptoms should discontinue treatment with varenicline and contact a health care provider immediately. Fertility, pregnancy and lactation: Champix should not be used during pregnancy.

Women of child bearing potential should avoid becoming pregnant during treatment with Champix. It is unknown whether varenicline is excreted in human breast milk. Champix should only be prescribed to breast feeding mothers when the benefit outweighs the risk. There are no clinical data on the effects of varenicline on fertility. Non-clinical data revealed no hazard for humans based on standard male and female fertility studies in the rat. Driving and operating machinery: Champix may have minor or moderate influence on the ability to drive and use machines. Champix may cause dizziness and somnolence and therefore may influence the ability to drive and use machines. Patients are advised not to drive, operate complex machinery or engage in other potentially hazardous activities until it is known whether this medicinal product affects their ability to perform these activities.

Side-Effects: Very commonly reported side effects were nasopharyngitis, abnormal dreams, insomnia, headache and nausea. Commonly reported side-effects were bronchitis, sinusitis, weight

REFERENCES 1 European Commission. Special Eurobarometer 429 – Attitudes of Europeans towards tobacco and electronic cigarettes. Available at http://ec.europa.eu/public_opinion/archives/ebs/ ebs_429_en.pdf Last accessed November 2016.

2 European Commission. Special Eurobarometer – Citizens’ Summary, Proposal for a revision of the Tobacco Products Directive, 2012. Available at http://ec.europa.eu/health/tobacco/docs/ com_2012_788_citizens_summary_en.pdf Last accessed November 2016.

Smokefree. Quitting is Hard. Available at https://smokefree.gov/why-quitting-is-hard Last accessed November 2016.

3

Smith, AL, Carter SM, Chapman S et al. Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers, BMJ Open, 2015, 5:e007301 doi:10.1136/ bmjopen-2014-007301 4

5 West R, Stop smoking services: increased chances of quitting. NCSCT Briefing #8. London; National Centre for Smoking Cessation and Training, 2012. Available at http://www.ncsct.co.uk/ usr/pub/Briefing%208.pdf Last accessed November 2016.

6 Cochrane.org. Does a combination of stop smoking medication and behavioural support help smokers to stop? Available at: http://www.cochrane.org/CD008286/TOBACCO_doescombination-stop-smoking-medication-and-behavioural-support-help-smokers-stop Last accessed November 2016 7 Walsh RA and Sanson-Fisher RW, Encouraging people to stop smoking, World Health Organisation, Geneva, 2001: p1-55.

8 Anthenelli RM, Benowitz NL,West R et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016; 387:2507-2520 9 Cahill K, Lindson-Hawley N, Thomas KH et al. Nicotine receptor partial agonists for smoking cessation (Review). Cochrane Database of systematic reviews. 2016, issue 5 CD006103

West R, Baker CL, Cappelleri JC et al. Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms and rewarding effects of smoking during a quit attempt.

Psychopharmacology 2008;197:371-377

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increased, decreased appetite, increased appetite, somnolence, dizziness, dysgeusia, dyspnoea, cough, gastrooesophageal reflux disease, vomiting, constipation, diarrhoea, abdominal distension, abdominal pain, toothache, , dyspepsia, flatulence, dry mouth, rash, pruritis, arthralgia, myalgia, back pain, chest pain, fatigue and abnormal liver function tests. Other side effects were, diabetes mellitus, suicidal ideation, seizures, cerebrovascular accident, angina pectoris, atrial fibrillation, electrocardiogram ST segment depression, myocardial infarction, haematemesis, haematochezia, Stevens Johnson Syndrome, angioedema and decreased platelet count. For full list of side effects see SmPC. Overdose: Standard supportive measures to be adopted as required. Varenicline has been shown to be dialyzed in patients with end stage renal disease, however, there is no experience in dialysis following overdose. Legal category: S1A. Package quantity; Marketing Authorisation numbers: Pack of 56 0.5 mg tablets HDPE Bottle (EU/1/06/360/001) Pack of 56 1mg tablets Card (EU/1/06/360/016) Pack of 53 11 x 0.5 mg and 42 x 1mg tablets Card (EU/1/06/360/023) Marketing Authorisation Holder: Pfizer Limited, Sandwich, Kent, CT13 9NJ, United Kingdom.

For further information on this medicine please contact: Pfizer Medical Information on 1800 633 363 or at EUMEDINFO@pfizer.com. For queries regarding product availability please contact: Pfizer Healthcare Ireland, Pfizer Building 9, Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24 + 353 1 4676500.

Last revised: 06/2016 Ref: CI 18_0

News PSI report ‘endeavours to plan for where pharmacy will be’ The Pharmaceutical Society of Ireland (PSI), the regulator of pharmacists and pharmacies, has published a major report discussing how pharmacists can best meet the needs of patients and the public into the future.

The 126-page report contains ‘significant’ recommendations with regard to the planning and delivery of patient care and pharmacy services in Ireland.

“Future Pharmacy Practice in Ireland - Meeting Patient Needs” is the result of a research project commenced in late 2015, which included an ‘extensive consultation process involving patients, healthcare professionals, Pharmacists, other regulatory bodies, as well as engagement with policymakers such as the Department of Health, and the HSE’.

The report acknowledges that some key enablers are needed to support the development of future pharmacy practice, including on-going research, regulation and governance, education, continuing professional development and continued investment in IT. The report also identifies that leadership by the profession and collaboration between healthcare professionals is a critical element in securing progress in the best interests of patients, the public and the wider health service.

In the process of compiling the report, submissions were also received from 141 Pharmacists or pharmacies about innovations already being undertaken in community and hospital practices to help improve patients’ medicine management and provide health promotion services. The consultation process, the PSI said, “also highlighted where policy-makers believe Pharmacists could contribute most valuable to the healthcare system to ensure that the needs of patients are met in the most cost-effective way.”

Speaking at the launch, PSI register Niall Byrne said: “We believe the PSI can, and it should, serve the broad public interest by facilitating in a safe manner expanded roles for Pharmacists, and

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Dr Norman Morrow, Chair of PSI Steering Group on Future Pharmacy Project and PSI Registrar (CEO) Mr Niall Byrne

for pharmacy practice. So, we are about change, we are about development, we’re not about the status-quo, we’re not accepting the world as it happens to be.”

Irish healthcare is facing several significant challenges, including a rapidly ageing population and escalating demands. The number of people aged over 65 is expected to grow by circa 3% per year over the next 10-15 years, while 40% of the population is forecast to have at least one chronic illness by 2020.

Pharmacy currently plays an enormous role in the overall context of Irish healthcare.

There are over 1,900 registered pharmacies in Ireland, with 1800 community pharmacies, and over 2 million people visit a community pharmacy every month.

Dr Norman Morrow, former Chief Pharmaceutical Officer at the Department of Health, Social Services and Public Safety in

Northern Ireland chaired the special steering group appointed by the PSI to oversee the project of writing the new report.

facing the country… The ultimate goal is an improvement in the health and welfare of the population.”

Speaking at the event, he said: “Wayne Gretzky is a Canadian ice-hockey player, reputed to be the greatest that there’s ever been. He was asked on one occasion why he thought he was better than a lot of his contemporaries who were also brilliant hockey players – he said he wasn’t sure, but that it probably had something to do with most of the hockey players going to where the puck is, and that he endeavoured to go where the puck was going to be. And that idea has been very influential in this report.

The report, the PSI said, seeks to anticipate patients’ healthcare and medicines needs in the future, and the project examined the role Pharmacists might play in public health and patient care improvements and healthcare system efficiencies that would benefit the public. The report also informs the role the PSI will play in supporting Pharmacists’ education and practice standards to meet these changes.

“….This report is not designed to be self-serving or to present a ‘wish list’ of services. Instead it puts patient in the centre, to see how their needs can be best met and recognises that pharmacy is part of the solution to the formidable healthcare challenges

Medicines are the most common healthcare intervention within the health system. However, the ever-increasing choice of medication treatments brings added complexity and potential risks to the safe and effective use of medicines.

The safe and effective use of medicine is an issue of utmost importance for Pharmacists:

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News

Front row (l-r): Ms Kate O’Flaherty, Director of Health and Wellbeing Programme, Office of Chief Medical Officer, Department of Health; Dr Norman Morrow, Chair, Project Steering Group; Ms Katie Murphy, Patient Representative, Cystic Fibrosis Ireland; Ms Leonie Clarke, Industry/Regulator Pharmacist Representative Back row (l-r): Kate Mulvenna, Head of Pharmacy Function, Primary Care Reimbursement Service, HSE; Ms. Maria Egan, Senior Pharmacist, Medicines, Controlled Drugs and Pharmacy Legislation Unit, Department of Health; Mr Keith O’Hourihane, Community Subgroup Chair; Dr Paul Gorecki, PSI Council Representative; Ms Elaine Conyard, Hospital Subgroup Chair; Professor Stephen Byrne, Head of School of Pharmacy, University College Cork

62% of people over 65 years of age have one or more chronic illnesses; more than 8% of all emergency admissions to hospital are medicine related; more than eight out of ten (85%) older people are taking five or more medicines (polypharmacy) on admission to hospital, and nearly a quarter (23%) of pre-admission medicines are omitted or incorrectly notified on admission. Hospital discharge prescription errors have been reported for up to half (50%) of all patients.

The recommendations outline how Pharmacists could provide greater assistance for patients in managing their chronic diseases (such as diabetes, asthma), as part of structured medicine management initiatives in hospitals and in the community for patients taking multiple or complex medicines. More than eight out of ten (85%) older people are taking five or more medicines (polypharmacy) on admission to hospital.

Katie Murphy, who is a research and development officer at Cystic Fibrosis Ireland, and herself has cystic fibrosis, then spoke and gave her perspective on the role of pharmacy in her treatments. She said: “The role that Pharmacists play is really important…it’s kind of like a gatekeeper between normality, my day-to-day life… and the reality of cystic fibrosis. [The Pharmacy] keeps me well. I get my treatment, I go in day-to-day, it’s normal and they advise me what I should be taking, how I

16

should be taking it, and all is well.”

“But there’s also the reality of cystic fibrosis, and it bites very hard sometimes. When I become sick, Pharmacists equally play an important role…For a lot of people with a chronic illness, for any times they’re unwell it’s quite burdensome to manage all the treatments you’re expected to take. And no one takes a step back and says ‘wait she’s on a ridiculous amount of treatments at the moment… In my experience the Pharmacists are absolutely vital, because they’re looking at it from a holistic perspective.”

The report anticipates that physical settings for services and patient care, delivered by Pharmacists are also likely to evolve with changing healthcare delivery patterns and patient need. International experience has shown an increase in Pharmacists successfully working and providing medicines expertise in GP surgeries, in nursing homes and in tandem with domiciliary care.

The new roles for Pharmacists that are recommended in the latest report would see Pharmacists provide their expertise in assisting patients to manage their chronic diseases, and improve adherence to prescribed medicines by structured medicines initiatives, availing of ongoing disease monitoring and where appropriate, patients accessing medicines through supplementary prescribing

by Pharmacists, which allows therapy or medicines continuation in collaboration with a patient’s GP. The report also recommends that Pharmacists contribute to health and wellbeing initiatives through structured population health information and awareness campaigns, as well as providing reliable and informed information to the public on preventative medicine to support the maintenance and improvement of the health of the public.

Significant changes have occurred in recent years in pharmacy practice including the availability of emergency hormonal contraception from Pharmacists without prescription, the expanded role of community Pharmacists vaccinating against seasonal influenza, and hospital Pharmacists being more closely involved in the prescribing process as part of multidisciplinary teams.

Pharmacists can also assist in the managing of what are complex medicines regimes throughout the patient care pathway via structured initiatives such as medication reviews for at-risk and vulnerable patients in the community and local settings e.g. nursing homes. the greater use and sharing of Pharmacists’ medicines expertise through education of both patients and other healthcare professionals in acute settings, to increase safety, reduce medication errors, ease transfer of care and optimise the use and impact of medicines for patients.

Dr Ann Frankish, PSI President, speaking at the launch of the report said: “As the regulator we have a role in furthering quality public healthcare provision and facilitating an evolving Pharmacist role where there is clear patient care value. Having examined the evidence available, this report presents the opportunities that would make the best use of Pharmacists’ knowledge and expertise, both in community and hospital settings, as well as their extensive network. We have also highlighted the greater role that Pharmacists can play as part of multidisciplinary teams, which ultimately contributes to patient safety and also provides cost savings to the health service. “…With an estimated 2 million visits to a pharmacy by the public per month Pharmacists are the most accessed healthcare professional. We believe that maximising this regular contact would assist the implementation of the national health and wellbeing strategy by enabling Pharmacists to support patients, protect and improve their health.”

The PSI Council appointed a Steering Group to oversee the Future Pharmacy Practice project. Its members were: Dr Norman Morrow (Chair) Chief Pharmaceutical Officer Northern Ireland (retired) Ms Teresa Cody* Department of Health Mr Eugene Lennon/Ms Maria Egan, Department of Health Ms Kate O’Flaherty, Department of Health Ms Kate Mulvenna, Health Service Executive Dr Catriona Bradley, Irish Institute of Pharmacy Mr Keith O’Hourihane (Community Subgroup Chair) Pharmacy First Plus Ms Elaine Conyard (Hospital Subgroup Chair) Our Lady of Lourdes Hospital Ms Leonie Clarke Industry/ Regulatory Consultant Prof Stephen Byrne University College Cork Ms Katie Murphy Cystic Fibrosis Ireland Dr Ruairi Hanley Medical Council Representative Dr Paul Gorecki PSI Council Representative * Ms Cody resigned from the Steering group in December 2015, following her change in role in Department of Health.

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DateDate prepared: prepared: February February 20162016

Report

Codeine - The Respectable Drug Addiction?

To sell or not to sell?

Written by Pádraig McGuinness MPharm

It is something every Community Pharmacist will encounter every day of their working life – sales of codeine. Some might be the regular customer you suspect may be abusing and have had conversations with before, others you believe are genuinely in pain and require the codeine element of the combination, and others you know in your heart are not using codeine for the right indications but are selling you the good story. Furthermore, since the introduction in 2010 of the PSI guidelines in this area, we, as Pharmacists, are now all more acutely aware of who is buying codeine products, having to be involved in every sale.

academic institutions over the same period. The aim was to use academic research methods and marry them with the on the ground practicalities. The project proved to be very successful, and an excellent model on how industry and academia can work together to use the best academic evidence base with practical solutions.

Padraig McGuinness, Superintendent Pharmacist, CARA Pharmacy

CODEMISUSED is a European Union funded collaboration (Marie Curie Industry Academia Partnership and Pathways) between academics and Pharmacists across three jurisdictions – Ireland, the United Kingdom and South Africa. In Ireland the partners were Principal Investigator Dr Marie Claire Van Hout and her team at Waterford Institute of Technology, and myself and our team at CARA Pharmacy.

The aim of the project was

18

to explore, using the widest collection of stakeholders ever brought under one project in this area, the issues of codeine use, misuse and dependence, and to present workable solutions to this hidden public health issue. This research fund of ¤2.04 million supported the exchange of knowledge between academics and Pharmacists in each country. Academics came and worked with us in retail pharmacies during the three years, and our staff seconded to

There were many work packages involved in the project, and I wanted to share with you some of the initial findings. Firstly a massive thank you to the 464 Irish Pharmacists who took part in our pharmacy research, a representative sample of just under 10% of the total register.

There were some staggering results, that were mirrored across all three jurisdictions, and which appear to show that we as a profession are not trained sufficiently to deal with suspected and actual codeine misuse. In fact, 85% of us responded saying that we have no formal training in this area, with 62% confirming there was a further need for more training. Many say they relied on company SOPs to direct their practice in this area – a reminder to those writing these SOPs to be mindful of the current research.

What is striking, but perhaps not surprising, is that more than half of us report to sell codeine to customers we suspect to be misusing, with the warning that we will not be selling them again. Many pharmacy staff

(65%) report that customers can be aggressive when sales are refused and 80% have come across defensive customers when sales are challenged.

This undoubtedly must have an impact on the decision to refuse or not. It is encouraging to see however that 80% of Irish Pharmacists provide brief intervention advice where they suspect codeine misuse.

This is higher than in the other jurisdictions studied. One speculates that this is the PSI guidelines in action. This should all be in the context that 70% of Pharmacists surveyed believe that the codeine they sell has a medium to high risk of misuse.

That’s three quarters of all Pharmacists in Ireland believe that >30% of the codeine they sell is potentially misused. A staggering statistic.

When asked what they buy their codeine for, it might interest Pharmacists in Ireland to know that 7% of respondents buy the medication for sleep – though of course this is not disclosed at the pharmacy counter when purchasing. This is more than double that of the UK – where alternative products marketed for sleep assistance (for example sedating antihistamines) are available. A further 2% of respondents in Ireland say they buy codeine products to help them relax. So in essence, these two statistics alone, suggest to us that just shy of 10% of codeine purchased is misused for the wrong indication.

8

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Report

This codeine misuse places us all in a difficult ethical positions, and our research across all stake holders tells us this.

Our options have real impacts on patient safety but also on patient relationships. This is perhaps even more noticeable in smaller rural communities, where customers are known well to the Pharmacist on duty.

The phenomena of “Pharmacy Hopping” and “Pharmacy Tourism” are well documented in our findings – from both Pharmacists and also from previous codeine misusers.

And so, there is an argument to sell with brief intervention – as it may be more effective than refusing the sale where the customer simply goes down the street or to a different town with a different story. Then there is the option of not supplying – again with the risk of the patient going elsewhere with a more informed story, but at least you will have perhaps acted to deter that patient from misusing the medication.

One wonders if the constant justification of need of the medicine, eventually resonate with the customer that perhaps another medication may be safer and more appropriate.

In Ireland, 63% of pharmacy customers report that they know it causes addiction – highest when compared against the other countries, again perhaps a nod to the PSI guidelines in action. That said almost 60% of pharmacy customers believe that codeine products are safe to use, and so perhaps more public health information and education is first on the shopping list.

What is clear from the research from the other side of the counter, from those who have been through the addiction, is that codeine misuse is a life devastating problem. Everything from GI ulceration, liver disease, headache, constipation and drowsiness as well as the social consequences and financial

cost taking its toll on those who misuse. The qualitative research from those addicted to codeine, reveals shocking statements from misusers such as, “In my time of addiction, I knew what Pharmacist was on and in what place and what name/s I used last time” “The best part was that the paracetemol would freeze and all the rest of the water was just golden heaven to drink off” (a statement in relation to removing codeine from combination products to abuse).

This element of the research in particular was the most eye opening for me as a practicing Pharmacist, and opened a whole world of underground addiction that we as Pharmacists have no idea about when we run the product through the cash register.

So, what about tightening control and considering a P to POM switch. Nearly two thirds of Irish GPs surveyed are telling us that codeine products should be reclassified to POM. In fact 32% of pharmacy customers agree with them and Pharmacists have also highlighted this as an easier to control option. GPs tell us that approx. half of them find it difficult to identify OTC codeine users and that 50% record it in the patient notes when they are alerted. (A lesson here perhaps for more integrated care with primary care professionals in a locality.)

While P to POM switch is one option open to suggestion, several have highlighted many issues with this approach. Firstly, with a proportion of customers addicted to these substances, to withdraw them without having the correct supports in place could be disastrous. Less than half of GPs believe codeine addiction can be handled in their practice, with only 26% aware of best practice and less than 20% reporting locally available professional services.

This option may even lead to even more online and black market purchasing of codeine related products. Our research shows that there is already an undercurrent of illegal codeine procurement including cross border pharmacy tourism and pharmacy stockpiling while on holidays in Spain.

Is a community Pharmacist led service of reduction and management feasible if it was fully funded and advanced training provided? Similar to the detox programs available for nicotine. How would that work in practice, where patients have access to several pharmacy outlets with no technological real-time link?

South Africa offers a solution where Pharmacists use an online system to track sale of codeine for every customer and this is shared across pharmacies with a cap of 4grams per person per month. 74% of Irish Pharmacists believe in a centralised approach. But this system, although in its infancy in SA, still has its challenges – with not every pharmacy opting into the project and customers getting to know where they can side step the recording mechanism. But, it does perhaps offer a compromise solution to allow those that do need the medication OTC to access it without higher doctor consultation fees, while also restricting it from those at risk of misuse, or at least identifying them for early intervention.

It may seem that the project has presented more questions than answers! But what it has done is develop a huge body of 360 degree evidence from all the stakeholders in this “respectable addiction”. We are very much looking forward to continuing to present a menu of evidence based options of solutions to codeine addiction as the project draws to a close next year.

This will then be forwarded to the regulators, who have been keeping a keen eye on the projects results. Hopefully in time, with the right resources and training, Pharmacists can take a leading role in fighting this devastating silent addiction.

For more information about the project as it publishes its final results in the coming months, visit us at http://www.codemisused.org/

Padraig McGuinness is the Superintendent Pharmacist of the CARA Pharmacy Group. Contact him on Padraig@carapharmacy.com

news brief PHARMACIST GETS 4-YEAR SUSPENDED SENTENCE AFTER FATALLY GIVING WRONG MEDS A Pharmacist who gave the wrong pills to a woman, resulting in her death, has been sentenced to a four-month jail term, suspended for two years, it has been reported.

It is understood that his is the first prosecution of its kind in Northern Ireland.

The family of 67-year-old Ethna Walsh said they hoped “hard lessons” would be learned from her “unnecessary” death.

Martin White, of Belfast Road, Muckamore, admitted to giving her the wrong medication on February 6, 2014. She later died in hospital.

Instead of receiving the COPD medication, Prednisolone, Mrs Walsh was given Propranolol.

Her family said that they welcomed “the resolution of the criminal proceedings arising from the death and acknowledge the admission of culpability and guilt on behalf of Mr White”.

The judge said the dispensing of the wrong drug for her lung condition was caused a number of factors, including a momentary lapse in concentration.

He added that back at home Mr Walsh gave his wife some of the tablets which she took, but within moments had difficulty in breathing and became unwell. He immediately phoned for an ambulance, and although rushed to hospital she later died.

Defence QC John Kearney revealed that since the tragedy White has been too frightened to return to work because he was so racked with guilt and has been receiving psychiatric help.

21

News Entrepreneur of the Year Accolade for Meaghers MD Oonagh O’Hagan, Managing Director of Meagher’s Pharmacy Group, has won the prestigious Entrepreneur of the Year accolade at the 2016 IMAGE Businesswoman of the Year Awards. This crowns off a very successful year for Oonagh and Meagher’s team. award and OTC Retailer of the Year accolade at the 2016 Irish Pharmacy Awards.

Meagher’s Pharmacy business began with the acquisition of a single pharmacy on Baggott Street in 2001. The group has now grown to a total of eight Meagher’s Pharmacy outlets across Dublin, under the direction of owner Oonagh O’Hagan, a former Chairman of Retail Excellence Ireland.

In March this year the Group added two new pharmacies; the long-established Kinvara Pharmacy off the Navan Road in Dublin 7, and a state-of-the-art new pharmacy in the Whitty Building at the Mater University Hospital in the city.

With over twenty new pharmacy and retail jobs have been created this year in the Meagher’s Pharmacy Group, with plans to double store numbers within the next five years in the growing business, which currently employs 85 people, including twenty Pharmacists. This year the group has been touched by tragedy as they lost a one of their team members Donna Fox, who was tragically injured on her way to work at the Meagher’s Barrow Street.

The progressive pharmacy chain has also been recognised in Deloitte’s Best Managed Companies 2016 roll of honour for the second year in a row; was shortlisted for the 2016 European Business Awards; won a Newstalk award of ¤10,000 free advertising space with the radio station; and won both the Pharmacy Chain Business Development

Oonagh puts her team at the centre of her success “ Being acknowledged for entrepreneurship and strategic business development is very rewarding, although our wider business planning team must also take the credit, along with our customer focused front-line staff” O’Hagan said on accepting the award.

Oonagh O’Hagan, Managing Director of Meagher’s Pharmacy Group

As one challenging year draws to a close it seems timely to delude ourselves with an illusory crystal ball, to see what the sectors future might hold. Of 1850 stores nationally, 1300 the majority are in the hands of practicing pharmacists and their families.

A few trends are clear in analysing and predicting trends. Management Consultants can run a SWOT analysis of strengths, weaknesses, opportunities and threats. But we as the ones who face the patients - can take stock too.

The rise and consequent fall of chains / groups at the expense of independents has been loudly proclaimed; but reality is not so clear.

There are clear benefits in buying power and the perception of mass brands and marketing, but I believe the best independents will continue to thrive because their values, ethics, flexibility and sheer localness to their ‘locale’ can always win out.

Big UK chains such as Tesco have been given a bloody nose by the Irish market before. This is not the English shires and a one size fits all strategy is often clumsy and unsympathetic. Speaking Irish (or indeed Polish or Portuguese), can be a competitive advantage in certain communities if staff members have fluency and empathy.

The ‘foreign’ chains are often led by ex-supermarket management.

Their profit only culture clashes with pharmacies hybrid model of patient care and ethical professionalism. This dissonance

22

can lead to confrontation with the regulators and indeed their own staff cohorts who vote with their feet to leave.

Independent thinking may be frowned upon by head office as SOP’s can be blunt implements.

A grounded committed local independent can deliver unprecedented service levels because their roots run deep in communities via GAA, soccer or rugby, or through churches or other community involvement.

grab market share it’s an exercise in short termism if there’s little margin or loyalty from a remote commuter, chasing a few euro saving as against the extra time petrol and parking required to gain an illusory saving.

I’ve recently regained some ‘snow bird’ retired civil servants script business who always claimed that their tablets are “cheaper in Spain.”

Inevitably the PCRS Cuts have bit so hard on some items that we’re now cheaper in Ireland.

As long as they can strive to re-invent, refine and reconnect with their locale and their service offering there’s no reason why they cannot continue to prosper.

The unforeseen consequence of over-zealous cuts is the re appearance of parallel exporting from Ireland to Europe as some lines are too cheap here.

The new bigger chains have gained the most traction in newer anonymous commuter belts and in shopping centre locations. Their impersonal targets of car driving mums and the ‘worried well’ with social media offers and lost leaders can pick up retail sales.

But it’s a fickle transitory audience, that doesn’t deliver prescription volumes or indeed repeat predictable business.

My message to independents is to be proud of your personal brand and heritage. Don’t be shy to tell your story and expound your values publicly to your audience and remind your community of your longevity and service continuity, for example, long associations with sports club shirt sponsorship

It can be a little like a trendy night club audience moving onto the next happening hip place.

The rush to the bottom on below cost selling of private prescriptions is a case in point. In attempting to

I believe diversification and sub specialism will continue. Trying to be all things to all people as a generalist is challenging.

In towns, some pharmacies are seen as cosmetic retailers whilst another is seen as the go to for sound advice or procuring difficult prescriptions others baulk at. I

know which camp I’d rather be in!

Advanced services & holistic care will drive change.

Macroeconomic factors are supposedly changing in retailers favour, some positive growth indicators are levelled with wage rises, low interest rates, Brexit fears and uncertainty.

Paradoxically such uncertainty presents opportunity as weak sterling makes bulk importation cheaper on toiletries, which can be passed onto the consumer or to enhance margin.

The threat side looks stacked against all professions with ever increasing regulation and intrusion by state agencies into all aspects of enterprise. The pendulum of excessive regulation will duly swing back when a judge inevitably rules a poor patient outcome was caused by a scared over regulated health care professional.

In conclusion I think the future is bright for those smart enough to reinvent whilst still adhering to core service values and ethics. Putting the patient and their needs front and centre not lost in bureaucracy and process.

Never give up

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Dose: Adults: One capsule daily preferably with food. Usual course of treatment 8-12 weeks. Children: Not recommended. Contraindications: Hypersensitivity to any of the ingredients. Disturbances of calcium e.g. hypercalcaemia and hypercalciuria, haemochromatosis, iron overload syndrome, hypervitaminosis A or D, concomitant retinoid or vitamin D therapy, renal insufficiency and pregnancy. Contains arachis oil; capsules should not be taken by patients known to be allergic to peanut or soya. Precautions: Patients with a family history of haemochromatosis should seek medical advice before taking the product. Patients receiving other medication should consult a doctor before taking the product. Excessive doses of vitamin A or D may lead to hypervitaminosis and an allowance should be made for intake of vitamins A or D from other sources. Prolonged use is not recommended. Consult a doctor if symptoms have not improved after 4 weeks. Patients taking warfarin (or other coumarin anticoagulants) should have increased monitoring of their INR levels when starting or stopping treatment with ginseng containing products. Capsules contain a small amount of lactose; patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Pharmaton Capsules. Pregnancy & lactation: Not recommended during pregnancy or lactation. Side-effects: Headache, dizziness, gastrointestinal reactions (such as nausea, stomach pain, vomiting and diarrhoea) and hypersensitivity reactions (such as rash and pruritus). Marketing authorisation holder: Boehringer Ingelheim Ltd, Ellesfield Avenue, Bracknell, Berkshire, RG12 8YS, United Kingdom. Pack sizes: Packs of 30 and 100 capsules. PA 7/66/1. Legal status: Retail sale through pharmacies.

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Visit www.enstilar.ie Abbreviated Prescribing Information for Enstilar® 50 micrograms/g + 0.5 mg/g cutaneous foam Please refer to the full Summary of Product Characteristics (SmPC) (www.medicines.ie) before prescribing.

Indication: Topical treatment of psoriasis vulgaris in adults.

Active ingredients: 50 µg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate).

Dosage and administration: Apply by spraying onto affected area once daily. Recommended treatment period is 4 weeks. The daily maximum dose of Enstilar should not exceed 15 g, i.e. one 60 g can should last for at least 4 days. 15 g corresponds to the amount administered from the can if the actuator is fully depressed for approximately one minute. A twosecond application delivers approximately 0.5 g. As a guide, 0.5 g of foam should cover an area of skin roughly corresponding to the surface area of an adult hand. If using other calcipotriol-containing medical products in addition to Enstilar, the total dose of all calcipotriol-containing products should not exceed 15 g per day. Total body surface area treated should not exceed 30%. Safety and efficacy in patients with severe renal insufficiency or severe hepatic disorders have not been evaluated. Safety and efficacy in children below 18 years have not been established. Shake the can for a few seconds before use. Apply by spraying, holding the can at least 3 cm from the skin, in any orientation except horizontally. Spray directly onto each affected skin area and rub in gently. Wash hands after use (unless Enstilar is used to treat the hands) to avoid accidentally spreading to other parts of the body. Avoid application under occlusive dressings since systemic absorption of corticosteroids increases. It is recommended not to take a shower or bath immediately after application.

Contraindications: Hypersensitivity to the active substances or any of the excipients. Erythrodermic and pustular psoriasis. Patients with known disorders of calcium metabolism. Viral (e.g. herpes or varicella) skin lesions, fungal or bacterial skin infections, parasitic infections, skin manifestations in relation to tuberculosis, perioral dermatitis, atrophic skin, striae atrophicae, fragility of skin veins, ichthyosis, acne vulgaris, acne rosacea, rosacea, ulcers and wounds.

Precautions and warnings: Adverse reactions found in connection with systemic corticosteroid treatment, e.g. adrenocortical suppression or impaired glycaemic control of diabetes mellitus, may occur also during

topical corticosteroid treatment due to systemic absorption. Application under occlusive dressings should be avoided since it increases the systemic absorption of corticosteroids. Application on large areas of damaged skin, or on mucous membranes or in skin folds should be avoided since it increases the systemic absorption of corticosteroids. Due to the content of calcipotriol, hypercalcaemia may occur. Serum calcium is normalised when treatment is discontinued. The risk of hypercalcaemia is minimal when the maximum daily dose of Enstilar (15 g) is not exceeded. Enstilar contains a potent group III-steroid and concurrent treatment with other steroids on the same treatment area must be avoided. Skin on the face and genitals are very sensitive to corticosteroids. Enstilar should not be used in these areas. Instruct the patient in the correct use of the product to avoid application and accidental transfer to the face, mouth and eyes. Wash hands after each application to avoid accidental transfer to these areas.

When lesions become secondarily infected, they should be treated with antimicrobiological therapy. However, if infection worsens, treatment with corticosteroids should be discontinued. When treating psoriasis with topical corticosteroids, there may be a risk of rebound effects when discontinuing treatment. Medical supervision should therefore continue in the posttreatment period. Long-term use of corticosteroids may increase the risk of local and systemic adverse reactions. Treatment should be discontinued in case of adverse reactions related to long-term use of corticosteroid.

There is no experience with the use of Enstilar in guttate psoriasis. During Enstilar treatment, physicians are recommended to advise patients to limit or avoid excessive exposure to either natural or artificial sunlight. Topical calcipotriol should be used with UVR only if the physician and patient consider that the potential benefits outweigh the potential risks. Enstilar contains butylhydroxytoluene (E321), which may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes.

Pregnancy and lactation: There are no adequate data from the use of Enstilar in pregnant women. Enstilar should only be used during pregnancy when the potential benefit justifies the potential risk. Caution should be exercised when prescribing Enstilar to women who breast-feed. The patient should be instructed not to use Enstilar on the breast when breast-feeding.

Side effects: There are no common adverse reactions based on the clinical studies. The most frequently reported adverse reactions are application site

reactions. Uncommon (≥1/1,000 to <1/100): Folliculitis, hypersensitivity, hypercalcaemia, skin hypopigmentation, rebound effect, application site pruritus, application site irritation. Not known frequency: Hair colour changes. Calcipotriol: Adverse reactions include application site reactions, pruritus, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, psoriasis aggravated, photosensitivity and hypersensitivity reactions, including very rare cases of angioedema and facial oedema.

Systemic effects after topical use may appear very rarely causing hypercalcaemia or hypercalciuria. Betamethasone (as dipropionate): Local reactions can occur after topical use, especially during prolonged application, including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation and colloid milia. When treating psoriasis with topical corticosteroids, there may be a risk of generalised pustular psoriasis. Systemic reactions due to topical use of corticosteroids are rare in adults; however, they can be severe.

Adrenocortical suppression, cataract, infections, impaired glycaemic control of diabetes mellitus, and increase of intra-ocular pressure can occur, especially after long-term treatment. Systemic reactions occur more frequently when applied under occlusion (plastic, skin folds), when applied on large areas, and during long-term treatment.

Precautions for storage: Do not store above 30°C. Extremely flammable aerosol. Pressurised container. May burst if heated. Protect from sunlight.

Do not expose to temperatures exceeding 50°C. Do not pierce or burn, even after use. Do not spray on an open flame or other ignition source. Keep away from sparks/open flames. No smoking.

Legal category: POM. Marketing authorisation number and holder: PA 1025/5/1. LEO Pharma A/S, Ballerup, Denmark.

Last revised: May 2016 Further information can be found in the Summary of Product Characteristics or from: LEO Pharma, Cashel Road, Dublin 12, Ireland. e-mail: medical-info.ie@leo-pharma.com ® Registered trademark MAT-04850 Date of preparation: September 2016

Reporting of Suspected Adverse Reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www.hpra.ie, e-mail: medsafety@hpra.ie. Adverse events should also be reported to Drug Safety at LEO Pharma by calling +353 1 4908924 or e-mail medical-info.ie@leo-pharma.com

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Feature An overview of Psoriasis, Rosacea and Eczema Supervising pharmacist of O’ Flynns Pharmacy, Ardee, Co. Louth, Gareth O’Callaghan discusses how Pharmacists can best identify the symptoms of, and effectively treat, psoriasis, rosacea and eczema.

Gareth O’Callaghan, Supervising Pharmacist of O’Flynn’s Pharmacy

Psoriasis Psoriasis is a chronic, systemic, inflammatory skin disorder estimated to affect more than 73000 people in Ireland.

In people suffering psoriasis, the skin cells in the epidermis proliferate at an abnormally high rate, resulting in the formation of areas with a build up of silvery scale. Combined with increased blood flow to the skin and thickening of the epidermis this results in the formation of red, raised plaques. Psoriasis most commonly affects the elbows, knees, scalp and sacrum but may affect any part of the skin surface on the body. Psoriasis is thought to have it’s origin in auto-immune as well as genetic factors. From a hereditary perspective, if one parent has psoriasis, then the chances of their child being affected by it is about 10%. If both parents have the condition then this rises to 50%. Environmental factors such as stress or microbial infection (especially streptococcal infection of the throat)can sometimes play a role in its development.

Psoriasis – 2 Main Types 1. Plaque psoriasis This is the most common form affecting more than 90% of patients presenting with psoriasis. It is characterised by the formation of scaly plaques usually around the knees, elbows, scalp and sacrum. Plaques can be itchy and painful and may sometimes bleed.

2. Guttate Psoriasis

Psoriasis

Characterised by sudden onset with the appearance of small, read, droplet shaped patches less than 1.5cm in diameter.

- Chronic, Systemic, Inflammatory skin condition

Other types of psoriasis include pustular, inverse and erythrodermic psoriasis.

- Autoimmune disease

Potential Triggers

- May be hereditary

- Positive family history

- Incurable but manageable

- Streptococcal throat infection – especially with guttate psoriasis

- Not contagious - Associated with psoriatic arthritis

- Emotional stress – e.g. bereavement or other major life events

- Linked to development of depression

- Drugs – Lithium, Beta-blockers, some anti-malarials

Psoriasis is usually GP diagnosed but in some cases may require specialist referral to a dermatologist.

- Skin injury – graze, cut, insect bite, burn - Climate – worsens in cold, improves in warm

- Lifestyle – Alcohol consumption, smoking, obesity Treatment of psoriasis 1st Line First line treatment involves the use of topical preparations which either reduce cell reproduction, inflammation or both. Emollients are used to keep the skin moist and ease discomfort.

Topical corticosteroids reduce inflammation. Examples are Hydrocortisone (OTC), and betamethasone (POM). Vitamin D analogues e.g. calcipotriol (new to OTC) are very effective at improving symptoms. Calcipotriol works by slowing the rate of cell growth thereby flattening plaques and removing scale. Older preparations incorporating coal tar or dithranol are still used to great benefit but are less pleasant to use than some of the newer preparations on the market.

2nd Line Phytotherapy – Ultraviolet A (PUVA) irradiation of the skin improves the condition, reducing plaque formation.

3rd Line Systemic therapy utilises immunosuppressant drugs such as methotrexate, ciclosporin and the vitamin A derivative acitretin.

The role of the Pharmacist in the management of psoriasis is firstly to assist with diagnosis and GP referral where required.

Advising on the appropriate use of topical preparations available over the counter can go along way towards managing the patient who presents to the pharmacy with psoriasis. If systemic therapy is warranted, the Pharmacist is uniquely positioned to monitor the patients progress, the occurrence of any side effects and to guard against interactions with any other concomitant medication. Advice on lifestyle eg Alcohol intake reduction, smoking cessation and weight reduction can help the patient to effectively manage the condition.

4th Line Biologic Agents – Etanercept, Adalimumab, nfliximab and ustekinumab are monoclonal antibodies which when used can begin to improve symptoms within weeks.

Rosacea Rosacea presents as a rash usually affecting the face, occurring predominantly in middle aged, fair skinned people.

It presents more frequently in women but is more severe when it occurs in men. Areas commonly affected are the forehead, cheeks,

25

Feature chin and nose. Affected areas are reddened with dilated blood vessels, red bumps and pus filled spots. Inflammation of the eyes or eyelids may be present.

Exposure to sunlight is typically a trigger for the development of psoriasis.

Treatment 1. Topical Topical treatment using agents containing metronidazole, azelaic acid and ivermectin are often used. Ivermectin is a relatively new treatment which can be more effective and less irritating than metronidazole. Side effects of these preparations include burning sensation in the skin, itchiness and dryness.

2. Oral antibiotics Tetracycline, oxytetracycline, doxycycline and erythromycin are used in 4 to 6 week courses.

Side effects may include nausea, vomiting, diarrhoea, abdominal pain and anorexia.

3. Isotretionoin Usually used in severe acne it may be prescribed at lower doses by consultant dermatologists to treat rosacea.

Side effects to watch out for include: Dry skin, conjunctivitis, headache, joint pain, haematuria and mood changes. It is vital in guarding the safety of the patient that the Pharmacist is on alert for these side effects while monitoring the effectiveness of treatment.

Eczema Eczema is group of skin conditions which present with areas of itchy and inflamed skin. Atopic Dermatitis occurs when the skins ability to perform its function as a barrier becomes impaired.

This results in dry skin with an increased susceptibility to infection by bacteria or viruses. Dry skin will benefit from the daily use of emollient preparations.

GENERIC NAME

Very High Potency I

Betamethasone dipropionate-augmented 0.05% - Oint.

Clobetasol propionate 0.05% - Cream and Ointment

High Potency II

Betamethasone dipropionate 0.05% - Ointment Desoximetasone 0.25% - Cream Flucinonide 0.05% - Cream and Ointment Mometasone furoate 0.1% - Ointment

III

Betamethasone dipropionate 0.05% - Cream Betamethasone valerate 0.01% - Ointment Fluticasone propionate 0.005% - Ointment

Emotional Stress - This is known to exacerbate eczema and cause flare ups.

Mid Potency IV

Flucinolone acetonide 0.025% - Ointment Mometasone furoate 0.1% - Cream Triamcinolone acetonide 0.1% - Cream

Complications - skin may become infected, often with staphylococcal aureus resulting weepy, yellow crusts. This will require treatment with a topical antibiotic such as fusidic acid with often combined with a steroid such as hydrocortisone. Infection with the herpes simplex virus results in a sudden and painful flare up of the condition with small, weeping sores – doctor referral and treatment with oral acyclovir is required.

V

Betamethasone valerate 0.1% - Cream Fluocinolone acetonide 0.025% - Cream Fluticasone propionate 0.05% - Cream

Low Potency VI

Alclometasone dipropionate 0.05% - Ointment Clobetasone butyrate 0.05% - Cream Desonide 0.05% - Cream and Ointment

VII

Hydrocortisone or hydrocortisone acetate 1% - Cream and Ointment Hydrocortisone or hydrocortisone aceponate 0.0127% - Cream

Food - This is worth looking at especially in children under 5 years. Allergenic foods such as cows milk, eggs, chicken, nuts and some food colourings can be factors in the manifestation of eczema. It is important to rationally determine in consultation with a doctor if any of these foods is responsible for the child’s eczema rather than simply excluding them all from their diet.

Treatment of Eczema

Dry skin must be kept moist. This is accomplished using emollients several times a day. It is important to emphasise to the patient the maintenance of good moisturising routine even when the skin is clear.

Examples of emollients commonly used are silcocks base and aqueous cream. Emollients protect the skin from irritants and restore moisture.

Soap substitutes such as those based on liquid paraffin are good as cleansers and do not irritate or dry the skin. They can be added to a warm bath or applied directly to damp skin.

Topical Steroids

Trigger factors in the development or exacerbation of eczema

A variety of preparations containing corticosteroids such as hydrocortisone, betamethasone, clobetasone and clobetasol are used to treat flare ups of eczema.

Care must be taken to use steroids correctly. They should be used only once or twice daily and usually for a period of only days or weeks.

They should be applied only to the affected areas. It is important to use the correct potency of steroid for the appropriate duration. Using a steroid of too low a potency for a long continuous period may result in skin damage while failing to adequately alleviate symptoms.

Allergens - house dust mites, moulds, pollen, some foods, dander from pets

The table above (table 1) outlines the relative potencies of different topical corticosteroids.

Atopic Eczema Atopic Eczema firstly manifests as an itch. Scratching then causes many of the physical changes observed on the skin. Itching may be severe enough to affect sleeping, causing significant distress to the sufferer.

Adopted from: Pocket Guide TO MEDICATIONS USED IN DERMATOLOGY ANDREW J.SCHEMEN, DAVID L. SEVERSON – 4TH edition, 1994

Emollients

- Common - Affects 1 in 5 children and 1 in 12 adults in Ireland

Table 1 Potency Ranking of Some Commonly Used Topical Corticosteroid CLASS

Eczema - Non contagious

26

Irritants - Tobacco smoke, soaps, shampoos, washing powders, cosmetics, toiletries and some types of clothing.

Antihistamines Antihistamines such as fexofenadine are useful but are sedating and should be given at night. They should be used on a short term basis.

Wet Wraps This involves wrapping the affected areas in wet bandages after application of emollients and/ or topical steroids to areas of red, weeping eczema.

They offer the following benefits: 1. Skin cooling – provides relief from itching and reduces inflammation.

2. Moisturising – provide deeper and longer lasting moisturising effect.

3. Steroid absorption – steroid absorption is enhanced.

4. Mechanical protection – guard against scratching and gives the skin greater opportunity to heal.

Phytotherapy Ultraviolet A or B light therapy works by reducing the rate of cell growth thereby reducing scale formation on the skin. This is not the same as sun lamp exposure which is strictly not recommended in eczema.

Antibiotics Antibiotics may be required for skin infections due to eczema

flare-ups. Oral antibiotics are used in severe infection while topical treatment may be adequate in more moderate cases.

Topical Immunomodulators This line of therapy may be embarked upon when topical steroids fail to produce adequate relief. Tacrolimus is the immunomodulator used in Ireland for the treatment of eczema. It is generally used under the guidance of a dermatologist. Applied topically it may cause some stinging upon application which usually only occurs with initial applications. Tacrolimus use brings a greater risk of skin infection and should never be used where skin is infected.

Systemic Treatment Where topical treatment is ineffective, treatment with oral preparations may be indicated.

Azathioprine and Ciclosporin work by immunosuppression and are to be therefore used with caution and monitored carefully. Oral steroids can be used to alleviate severe flare-ups but should only be given over a short duration.

The Pharmacist is well placed to advise patients on appropriate strategies to manage eczema as well as monitoring treatment progress and being alert as to the development of any adverse events.

EUCERIN® 100 YEARS OF INNOVATIVE SKIN SCIENCE Eucerin is the dermatologist-recommended skin care brand based on honest skin science. Through working with dermatologists and using advanced technological expertise, Eucerin ensures reliable and highly effective product innovations to the highest dermatological standards.

By choosing active ingredients by the strength of their clinical proof, Eucerin is synonymous with excellent product quality and the combination of effectiveness and superior skin tolerability.

TREATMENT Eucerin Dry Skin Intensive 10% w/w Urea Treatment Lotion

Relief for DRY SKIN

Eucerin Dry Skin Intensive 10% w/w Urea Treatment Cream

Body Dry skin affects millions of people and is especially common in children under 10 and people over 60. Between these ages Eucerin Dry Skin Intensive 10% w/w Urea Treatment significantly more women that men suffer from dry skin.

Lotion

Different factors can compromise skin’s Face External Factors

Eucerin Dry Skin Intensive natural 10% barrier. w/w Urea Treatment Cream

InternalEucerin Factors Dry Skin Intensive w/w Urea Treatment genetic10% influences Lotion

weather UV exposure

Eucerin Dry Skin Intensive hormonal influences

Scalp

certain detergents certain medications

10% w/w Urea Treatment Cream

age diet

Eucerin Dry Skin Intensive 10% w/w Urea Treatment

certainLotion illnesses

Eucerin Dry Skin Intensive 10% w/w Urea Treatment Lotion

Eucerin® DRY SKIN Feet

Eucerin Dry Skin Intensive 10% w/w Urea Treatment Cream

The Eucerin® Dry Skin application chart below will help you choose the right product for the affected part of the body, ensuring that you benefit from the most effective formulation to help protect against and care for dry and very dry skin.

TREATMENT Eucerin® Intensive Lotion 10% w/w Cutaneous Emulsion

Face

Body

Scalp

Why does Urea make Eucerin® so effective?

Urea is a natural moisturiser found in healthy skin.

Dry skin usually has insufficient urea.

Eucerin Dry Skin Replenishing Face Cream Urea with binds 5% Urea water molecules

in the skin, maintaining its natural moisture and suppleness Eucerin Drybalance Skin Replenishing Face Cream Night with 5% Urea

Applying emollient cream containing Urea directly rehydrates the Eucerin Dry Skin Shampoo skin to soften and reduce cracking and roughness with 5% Urea

Urea helps to reduce the cycle of itching and irritation caused by dry skin, as well as reducing the skin’s moisture loss Eucerin Dry Skin Intensive Hand Cream with 5% Urea

Eucerin Dry Skin Intensive Foot Cream with 10% Urea

Insufficient Urea - the skin loses moisture

Urea is added and binds moisture into the skin

Eucerin® Dry Skin Replenishing Cream with 5% Urea Eucerin® Dry Skin Replenishing Face Cream with 5% Urea

Feet

Hand

Eucerin® Intensive 10% w/w Urea Treatment Cream

Eucerin Dry Skin Bath & Shower Therapy with 20% Omega

Eucerin Dry Skin Replenishing Cream with 5% Urea

MANAGEMENT

Can also be available on prescription.

*

COMPLEMENTARY

Eucerin Dry Skin Intensive 10% w/w Urea Treatment Cream

Hand

*

MANAGEMENT

Body

Face

Face

Eucerin® Dry Skin Replenishing Face Cream Night with 5% Urea with lactate Face

Body

Hand

Scalp

Feet

Can also be available on prescription.

Excellent efficacy and skin compatibility have been documented in clinical studies on dry and very dry skin.

Eucerin® Dry Skin Intensive Hand Cream with 5% Urea

Eucerin® Dry Skin Intensive Foot Cream with 10% Urea

Hand

Feet

1 Source: Lancet 2006, 368: 733-43 2 Source: Eucerin® Clinical Study, BDF assessment centre, March 2013 3 Source: In house study carried out by Beiersdorf * Licensing product information relating to Eucerin Intensive 10% w/w Urea Treatment Cream and Eucerin Intensive Lotion 10% w/w Cutaneous Emulsion.

Marketing authorisation holder: Beiersdorf UK Ltd, Birmingham B37 7YS, UK. Active ingredients: Urea EP 10% w/w. Directions: Apply twice daily to the affected areas of the skin. Indications: For the treatment of Ichthyosis, Xeroderma, Hyperkeratosis and Atopic Eczema/Dermatitis and other dry skin conditions. Precautions: Do not use if sensitive to any of the ingredients in cream or lotion. Do not use on broken, inflamed skin. Do not apply to large areas of skin on patients with renal insufficiency. This cream or lotion could increase the penetration of some substances, such as medicines known as corticosteroids, dithranol or fluorouracil. Avoid contact with the eyes or other sensitive areas. Keep out of reach of children. For external use only. Legal category: P PA 1159/1/1 (Cream) P PA1159/1/2 (Lotion).

To report any adverse reaction, please contact BDF Consumer Relations on 0044 845 6448556. Eucerin is a registered trademark. Revised September 2015.

www.eucerin.ie

Eucerin® Dry Skin Replenishing Body Wash with 5% Urea

Body

Awards The Irish Pharmacy

2017

IPN is delighted to announce the launch of the 2017 Irish Pharmacy Awards The sixth annual Irish Pharmacy Awards showcase the extraordinary talent and hard work Irish Pharmacists are undertaking throughout the country. Established in 2012 as a way to showcase the success of community pharmacy within Ireland, the Irish Pharmacy Awards recognise the top-performing professionals and teams within this sector. Hosted by Irish Pharmacy News, these national awards honour Pharmacists, Technicians,

Pharmacy teams and industry advocates who are defining the future of community Pharmacy.

Irish Pharmacy Award winners reflect the industry’s determination to revitalise and enhance their status within the wider healthcare arena. These awards are unique in their combined measurement of professional success in innovation, dedication and achievement. They raise the profile of this profession within Ireland and are positioned to broaden this field.

The ceremony, which will be held in the Clayton Hotel (formerly the Burlington), Dublin on Saturday, May 20th 2017 and will provide a showcase platform for the community Pharmacy sector and a great networking opportunity, with over 600 of the industry’s most influential professionals. This occasion will once again highlight that community Pharmacy is rising to the challenges of Ireland’s health service, to celebrate the success of staff and projects but also

Part of the Clinigen Group

28

an opportunity to mix and build networks with industry peers.

Application for the Awards will open in January 2017 on the dedicated Award website www.irishpharmacyawards.ie .

This website will have full details of all the awards and includes lots of advice and tips about completing your entry and details of past winners.

Awards The Irish Pharmacy

2017

Award Categories

RB Nurofen for Children Baby Health Pharmacy of the Year 2017

QuintilesIMS Superintendent Pharmacist of the Year 2017

IDIS Young Pharmacist of the Year 2017

Business Development (Chain) Award

Pharmacist of the Year 2017

Professional Contribution Award

McLernons Innovation & Service Development (Independent) Award

Johnson & Johnson Community Pharmacy Team of the Year

MSD Innovation & Service Development (Chain) Award

RSM Community Pharmacy Technician of the Year 2017

Unilever OTC Retailer of the Year 2017

Health Promotion Award

Business Development (Independent) Award

People’s Pharmacist

Counter Assistant of Year 2017

IPN Pharmacy Representative of the Year

Bank of Ireland Long Term Care Award

Hugh’s House making a real difference for families in Ireland The IPN chosen charity for 2017 is Hugh’s House which was established by Ade Stack and Marty Curley.

When their baby son Hugh was ill in hospital, Ade Stack and Marty Curley were thankful they lived in Dublin. They witnessed the struggles of other families travelling from all over the country to visit their sick children, some of whom were unable to cope financially with the expense of accommodation and meals. They were devastated when they saw children, especially babies who rarely had visitors because their families lived too far away.

Beautiful baby Hugh passed away in hospital in August 2013, aged eight months, leaving his parents heartbroken. While Temple Street has limited space for parents to stay, it doesn’t allow brothers or

sisters to stay and the Rotunda and Holles Street have no parent accommodation.

weeks and spend 3 months in hospital but go on to have normal and happy lives.

Marty and Ade saw how much Hugh loved his brothers Theo and Fred visiting and after he passed away, they purchased and renovated a house on Belvedere Place named Hugh’s House to provide accommodation for seven families at a time. In partnership with Aer Lingus they also created a beautiful garden to act as a sanctuary. “We saw marriages break up like slow car crashes with the stress,” says Ade. “There were people sleeping on the floor beside their sick children for months with no privacy and nowhere to have a chat.”

There is no charge, all meals are provided and a team of volunteers clean and work in the house.

Each beautiful family room has been fitted out and decorated by a family who lost a beloved child, making them very special. Now, an adjacent second house has been acquired, that will provide dinners and provide respite to families who arrive when a child is dying, for example, but have nowhere to congregate or talk. Hugh’s House also provides a communal laundry service for all families to stop them having to bring washing home, it’s the little things that count.

The families are referred through the hospitals and their average stay in the house is three months.

Premature babies are born at 23

For more information on Hugh’s house please go to www.hughshouse.ie or add us on Facebook. You can also donate to us at www.gofundme.com/hughshouse

Ade notes: “We do this not because Hugh died, but because he lived. He was so inspiring as he kept going no matter what was thrown at him.”

29

Aspirin 250mg, Paracetamol 250mg, Caffeine 65mg film-coated Tablets

UNIQUE TRIPLE ACTION COMBINATION

Starts relieving Migraine Pain & Symptoms in 30 minutes1

CONTAINS PARACETAMOL. ALWAYS READ THE LABEL / LEAFLET Product Information: Please consult the summary of product characteristics for full Product Information.

Excedrin 250 mg/250 mg/65 mg film coated tablets (acetylsalicyclic acid, paracetamol, caffeine). Indications: Acute treatment of headache and of migraine attacks with or without aura. Dosage: Maximum 6 tablets in 24 hours. Drink a full glass of water with each dose. Must not be used for a longer period or at a higher dosage without first consulting a doctor. Not for use in those under 18 years.

Exercise caution in the elderly. Headache: 1 tablet; if needed an additional tablet can be taken. In case of more intense pain, 2 tablets. If needed, an additional 2 tablets can be taken. Allow 4 to 6 hours between doses. For episodic use, up to 4 days. Migraine: 2 tablets when symptoms appear. If needed, an additional 2 tablets can be taken, with 4 to 6 hours between doses. For episodic use, up to 3 days.

Contraindications: Hypersensitivity to ingredients. Patients in whom attacks of asthma, urticaria, or acute rhinitis are precipitated by aspirin or other NSAIDs, e.g. diclofenac or ibuprofen. Active gastric or intestinal ulcer, gastrointestinal bleeding or perforation and in patients with a history of peptic ulceration. Haemophilia or other haemorrhagic disorders. Severe cardiac, hepatic or renal failure. Intake of >15 mg methotrexate per week. Third trimester of pregnancy. Warnings and precautions: Not to be taken with other products containing aspirin or paracetamol. Not to be used if vomiting occurs with >20% or bedrest is needed with >50% of migraine attacks. Seek medical advice if no migraine relief from first 2-tablet dose. Not to be used on >10 days per month for >3 months. Discontinue use in actual or suspected medication overuse headache; gastrointestinal bleeds or ulceration. Risk of bleeding could be enhanced by alcohol, NSAIDs and corticosteroids. Caution in undiagnosed migraineurs, or those with atypical symptoms, exclude other neurological conditions; patients with dehydration, gout, impaired renal or hepatic function, uncontrolled hypertension, diabetes mellitus, severe glucose 6-phosphate dehydrogenase deficiency, alcohol dependence, hyperthyroidism, arrhythmia, bronchial asthma, seasonal allergic rhinitis, nasal polyps, chronic obstructive pulmonary disease, chronic infection of the respiratory tract, patients showing allergic reactions to other substances (e.g. cutaneous reactions, urticaria). May mask signs and symptoms of infection, increase bleeding tendency during/after surgery.

Not to be taken with anticoagulant or other medicines that inhibit platelet aggregation unless under doctor supervision. Monitor in patients with defects of haemostasis. Caution in case of metrorrhagia or menorrhagia. May interfere with thyroid function tests. Caution in those taking liver enzyme inducers or potentially hepatotoxic medicines, or alcohol. Limit intake of caffeine-containing products.

Pregnancy and lactation: Contraindicated in third trimester. Caution in 1st and 2nd trimester. Not recommended during breastfeeding. Side effects: Common: Nervousness, dizziness, nausea, abdominal discomfort. Uncommon: Insomnia, tremor, paraesthesia, headache, tinnitus, arrhythmia, dry mouth, diarrhoea, vomiting, fatigue, feeling jittery. Rare: Pharyngitis, decreased appetite, anxiety, euphoric mood, tension, dysgeusia, disturbance in attention, amnesia, coordination abnormal, hyperaesthesia, sinus headache, eye pain, visual disturbance, flushing, peripheral vascular disorder, epistaxis, hypoventilation, rhinorrhoea, eructation, flatulence, dysphagia, paraesthesia oral, salivary hypersecretion, hyperhidrosis, pruritus, urticaria, musculoskeletal stiffness, neck and back pain, muscle spasms, asthenia, chest discomfort. Not known: Hypersensitivity, anaphylactic reaction, Stevens Johnson syndrome, toxic epidermal necrolysis, restlessness, migraine, somnolence, palpitations, hypotension, dyspnoea, asthma, abdominal pain, dyspepsia, GI haemorrhage, GI ulcer, hepatic failure, hepatic enzyme increased, erythema, rash, angioedema, malaise, feeling abnormal. See SPC for full details. Legal category: Pharmacy only. MA number: 0030/059/001. MA holder: Novartis Consumer Health UK Limited, Park View, Riverside Way, Watchmoor Park, Camberley, GU15 3YL, U.K. Text revised: October 2016. Further information available on request.

Reference 1: Lipton R et al. Efficacy and safety of acetaminophen, aspirin, and caffeine in alleviating migraine headache pain: three double blind, randomized, placebo-controlled trials. Arch Neurol.

1998;55:210-217.

CHGBI/CHXCDRN/0005/16

Date of Preparation: November 2016.

CPD 74: MIGRAINE…. NOT JUST A HEADACHE Biography - Eamonn Brady MPSI is the owner of Whelehans Pharmacy in Mullingar.

He graduated from the Robert Gordon University in Aberdeen in 2000 with a First Class Honours MPharm degree in pharmacy.

He worked for Boots in the UK before moving back to Ireland in 2002. He bought Whelehans Pharmacy in Mullingar in 2005. He undertakes clinical training for nurses and other healthcare professional in the midlands and undertakes talks on health and pharmacy related subjects. Contact Eamonn at 04493 34591 if you wish him to undertake training or a health talk.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice.

2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

3. PLAN - If I have identified a knowledge gap

- will this article satisfy those needs - or will more reading be required?

4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result?

Have I identified further learning needs?

What is migraine?

Migraine is more than just a headache. It is a complex, attacking neurological condition. With attacks lasting anything from a couple of hours to perhaps three days, it is easy to see why it can have such a debilitating effect on those living with the condition.

Migraine affects 12-15% of people worldwide (around 1bn), with similar % figures reported (up to 500,000) for those living with the condition in Ireland. In as many as 60% of cases the condition is inherited.

Prior to puberty, boys experience migraine as often as girls. Once into adulthood, migraine becomes three times more common in women than in men. This is due in large part to the hormonal changes in women from puberty to menopause.

This is more graphically illustrated in the diagram below where you can see the highest prevalence in women around age 40, then tailing off in the post menopausal years.

With such high numbers affected in Ireland, it stands to reason that there are also economic and work related impacts to be considered.

92% of Irish migraineurs report that attacks affect their performance at work, with 39% of those, being severely affected. As a consequence, the unemployment rate for those with severe migraine is 2 – 4 times higher than the prevailing overall rate.

Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Migraine…. not just a headache Migraine is a real condition, just like asthma, diabetes or epilepsy. Although not life threatening, it has been found to have a greater impact of quality of life than conditions such as heart disease and diabetes. The World Health Organisation classifies migraine as the 12th leading cause of disability worldwide among women and the 19th overall.

Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie

5 days per annum, the resultant cost to the economy is at least ¤250 million.

Causes Whilst the precise cause of migraine is unknown, it is generally accepted that it relates to the abnormal functioning of nerve cells that affect the brain’s ability to process information such as pain, light, sounds and other sensory stimulants.

As the condition is very individual, how each migraineur arrives at this point is then determined by a varied number of “trigger factors”, but generally once here, a pattern emerges and an attack ensues. These factors can be physical, environmental or genetic and in the majority of cases it will be a particular individual combination that will precipitate an attack. In the illustration, the various stages of an attack are mapped out. However, someone may experience all or only some of these during an attack.

It follows then, that identifying triggers is one of the keys to successful management of the condition.

Common symptoms and types The word “migraine” derives from a Greek word “hemikrani” (half- skull) which literally means “pain on one side of the head”. This accurately describes and differentiates migraine from other types of headache as typically it presents on one side of the head.

An attack may consist of some or all of the following symptoms: Migraine without Aura (around 80% of all attacks) • Moderate to Severe pain, throbbing one sided headache, aggravated by movement

• Nausea and/or vomiting Migraine accounts forfor the IPN lossv1ofcopy.pdf over � million Perrigo ad 1 22/12/2016 16:56 • Hyper sensitivity to external stimuli (i.e. noise, working days in Ireland each year, with 37% of smells, light) working Irish migraineurs missing more than

60 Second Summary Migraine is more than just a headache. It is a complex, attacking neurological condition. Migraine is three times more common in women than men with highest prevalence in women around age 40, then tailing off in the post-menopausal years.

Migraine without Aura (around 80% of all attacks) includes; Moderate to Severe pain, Nausea, Hyper sensitivity to external stimuli (i.e. noise, smells, light), Stiffness in neck and shoulders and pale appearance.

Migraine with Aura Aura, around 20% experience visual disturbances prior to the headache lasting up to one hour, these include Blurred vision, Confusion, Slurred speech, Loss of co-ordination.

Analgesia: for Acute Migraine Analgesics such as aspirin, paracetamol or NSAIDs may be used to target area specific pain. Triptans are highly effective for migraine (Eg. Sumatriptan.

Zolmitriptan), reducing the symptoms within 30 to 90 minutes in 70-80% of patients. Triptans target those neural serotonin receptors specifically involved in migraine attacks and can be used in the treatment of migraine with or without aura.

Prohylaxis: for Chronic Migraine Prophylaxis for migraine may be considered if a patient must use analgesics for 8 or more days of the month. Prophylactic medication should be tried and monitored for 4 to 6 months at a reasonable dose to determine if it working effectively. Amitriptyline, topiramate and flunarizine are the three most commonly prescribed migraine prophylactic drugs with amitriptyline being the most commonly prescribed. Other prophylactics such as sodium valproate, pregabalin, gabapentin and pizotofen are considered second line (often only used if the first three are not tolerated or ineffective).

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CPD 74: MIGRAINE…. NOT JUST A HEADACHE thought can be a potential danger for someone susceptible to migraine

• Stiffness in neck and shoulders • Pale appearance

• Bright or Flickering lights (could be cinema, shop displays or sunlight through trees whilst driving)

Migraine with Aura (in addition to above symptoms)

correct diagnosis of migraine and eliminate other potential causes (tension or cluster headache in particular; see more at end of this article about non-migraine headaches).

Some time spent with patients at an early stage reviewing their current medication regime would can prove hugely beneficial in identifying and / or preventing “medicine overuse headache”

• Aura, around 20% experience visual disturbances prior to the headache lasting up to one hour (most commonly, blind spots, flashing light effect or zig zag patterns; may also include physical sensations such as unilateral pins and needles in fingers, arm and then face)

• Certain types of lighting (fluorescent, strobe)

• Weather (variety of factors…i.e. bright sun glare, muggy close days, humidity)

In acute treatments, the goal is to stop or at least alleviate the effects of an attack once it has begun

• Blurred vision

• TV/Computer screens and monitors

Analgesics

• Confusion

• Loud and persistent noise

• Slurred speech

• Travel areas of pressure change, i.e. altitude

• Loss of co-ordination

Dietary Triggers

Used to target area specific pain and especially if taken as early as possible once an attack begins, analgesics can be a hugely effective pain killers.

• Strong smells (especially perfume, paint etc)

Research indicates about 20% of migraine attacks are brought on by dietary factors.

Whilst people believe this to be the case, actual scientific evidence proving a link is virtually nonexistent. In many cases, there may be other factors that precede consuming a “suspect” food, that could contribute more to the onset of an attack, i.e. lack of sleep, skipping meals.

Other types: Basilar Migraine Usually affecting teenage girls, this is a rare form of migraine that presents additional symptoms such as loss of balance, fainting, difficulty speaking and double vision. There can be loss of consciousness during an attack.

The most commonly cited link is foods which are high in the amino acids tyramine and/ or phenylethylamine such as: -

Hemiplegic Migraine (Sporadic or Familial) Usually beginning in childhood, this severe form of migraine causes temporary unilateral paralysis. May also feature extended aura period that could last for weeks. Generally related to a strong family history of the condition. It is a rare form of migraine; diagnosis usually requires a full neurological exam as the symptoms may be indicative of other underlying conditions.

In addition to headache, this very rare form of migraine shows additional symptoms such as dilation of the pupils. Inability to move the eye in any direction, as well as drooping of the eyelid occurs. It occurs primarily in young people and is caused by weakness in muscles which move the eye.

• nitrites (common in processed meats)

Generally used for more severe migraine attacks, evidence shows Ibuprofen to be highly effective. Soluble forms may act quicker than tablet form for those where stomach issues are part of their migraine episode.

• sulphites

• additives (MSG) • aspartame (Diet drinks) • caffeine (coffee, tea, etc.; although caffeine can be used to prevent migraine, really down to personal tolerance)

Once females move into puberty and then adulthood, hormones play an increasing role in migraine prevalence. Oestrogen fluctuations due to menstruation or through the use of oral contraceptive pills or HRT can sometimes trigger migraine. Conversely, migraine susceptibility can decrease during pregnancy when oestrogen levels are high

Let’s look at some of the most common: Environmental factors Perrigo addoing for IPN v1 copy.pdf 1 Just moving around normal day to day stuff, which wouldn’t cost you a second

Combinations

NSAID’s

Symptoms are usually nausea and stomach related rather than headache. Occurs predominantly in children, usually evolves into typical migraine with age.

Again, these can be different for everyone and indeed, may differ for an individual each time depending on their situation; trying to track down specifics can be difficult.

As effective as aspirin, but without the antiinflammatory effects

• alcohol (beer and red wine particularly)

Hormonal Triggers

A myriad of trigger factors, whilst in themselves not the cause of migraine, can build, bringing an individual to the point where a migraine attack is imminent.

Paracetamol

• chocolate

• cheese (fermented, aged or hard mouldy types),

Abdominal Migraine

Triggers

Traditional first line of defence, has anti inflammatory properties that can help alleviate many of the physical symptoms of migraine

Drugs that contain aspirin or paracetamol along with another agent such as codeine or caffeine.

Codeine and other opiates are best avoided due to addiction, side-effect risk and risk of triggering “over-use headaches”

(eg. Preservative in dried fruit and red and white wine)

Ophthalmoplegic Migraine

Aspirin

In the main, migraine attacks lessen post menopause (although can increase in the years preceding it). Identifying triggers can be the single most important step an individual can take in helping themselves to manage their condition. It may not be necessary to avoid situations completely but instead build levels of awareness so that appropriate preventative steps and actions can be taken.

Treatment16:56 22/12/2016 The key to successful treatment is to establish

Triptans Triptans are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70-80% of patients. Triptans target those neural serotonin receptors specifically involved in migraine attacks and can be used in the treatment of migraine with or without aura. All of them are available in tablet form with some brands also available as fast melt tabs, nasal spray or SC injection.

The table shows those triptans available in Ireland along with information from trials regarding effectiveness over the course of an episode. In all cases, these are only for treatment where migraine has been diagnosed and not for the treatment of hemiplegic, basilar or ophthalmoplegic migraine.

Currently all are POM, although, following calls from pharmacists and IPU etc, sumatriptan has been listed to move to OTC (available OTC in UK) by HPRA at some point in the future.

Preventative medication for migraine Prophylactic medication may be considered if the patient has taken adequate lifestyle steps to prevent migraine such as using a diary to determine triggers and avoidance of these triggers but the migraine continues. It would

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Dosage

Drug

Brand

% chance of experiencing

Maximum Dose in 24-Hour Period

Pain Relief at 2 Hours

Complete Sustained Recurrence response, Freedom from Pain no adverse event at 2 Hours

Almotriptan

12.5mg

Almogran

25 mg

56%

25%

13%

33%

Frovatriptan

2.5mg

Frovex

7.5 mg

Not available

Not available

Not available

Not available

Sumatriptan

50 &100mg Ftabs

200 mg

61%

32%

15%

31%

10&20mg Nasal Spray

Imigran

40mg 12mg

6mg SC Zolmitriptan

2.5mg Tabs & FTabs

Zomig

10mg

63%

29%

14%

31%

Eletriptan

20 & 40mg tabs

Relpax

80mg

69%

39%

21%

26%

Naratriptan

2.5mg tabs

Naramerg

5mg

49%

18%

11%

20%

Table adapted for Irish market, source Data from a meta-analysis of head-to-head trials, in C. Asseburg, P. Peura, T. Oksanen, J.a Turunen, T. Purmonen and J. Martikainen (2012). Costeffectiveness of oral triptans for acute migraine: Mixed treatment comparison. No head to head info available for Frovatriptan

be reasonable for a prescriber to consider prophylaxis for migraine if a patient must use analgesics for 8 or more days of the month.

Prophylactic medication should be tried for 4 to 6 months at a reasonable dose to determine if it working effectively. Prophylactic medication has potential side effects that can limit dose or use. Amitriptyline, topiramate and flunarizine are the three most commonly prescribed migraine prophylactic drugs with amitriptyline being the most commonly prescribed. Other prophylactics such as sodium valproate, pregabalin, gabapentin and pizotofen are considered second line (often only used if the first three are not tolerated or ineffective).

Amitriptyline A traditional tri-cyclic anti-depressant but not used much for depression due to side effects such as drowsiness, constipation, dry mouth, vivid dreams or nightmares and risks in people with glaucoma. It is dangerous in overdose.

Low dose may be effective in preventing migraine; the dose for migraine varies between 10mg to 150mg but the lower the better and it should only be titrated up slowly. Use at 6 months at maximum tolerated dose before considering changing.

Topiramate Topiramate is traditionally an epilepsy drug that is sometimes used in low dose form to prevent migraine. It must be used in caution in those with liver or kidney problems and must be avoided in pregnancy. Possible side effects include nausea, vomiting, constipation, diarrhoea, decreased appetite, drowsiness Perrigo ad for IPN v1 copy.pdf 1 and sleeping problems. Highest daily dose of

700mg but for migraine, recommended dose is 25mg to 200mg twice daily. Starting dose is 25mg at night for 2-8 weeks and increase gradually.

Propranolol (Inderal®) This is an old-style beta blocker traditionally used for angina and blood pressure but is rarely used for these indications nowadays due to safer never versions of beta blockers with less side effects. However, in low doses, it is used for migraine prophylaxis in some. It should be used in caution in people with asthma, COPD, some heart problems and diabetes. Side effects can include cold hands and feet, pins and needles, tiredness and sleeping problems.

Flunarizine (Sibelium®) Flunarizine can take months to see a significant reduction in symptoms. Patients should be regularly reviewed to assess their response to this preventive treatment, and if a sustained attack-free period is established, interrupted flunarizine treatment should be considered.

Flunarizine Maintenance Treatment If the patient is responding satisfactorily to flunarizine and a maintenance treatment is needed, the same daily dose should be used, but this time interrupted by two successive drug-free days every week, e.g. Saturday and Sunday. Even if the preventative maintenance treatment is successful and well tolerated, it should be interrupted after 6 months and it should be re-initiated only if the patient relapses Treatment is started at 10 mg daily (at night) for 16:56 adult patients aged 18 to 64 years and at 5 mg

22/12/2016

daily (at night) for elderly patients aged 65 years and older. It is good practice to start at 5mg for all patients before titrating up. Side effects include increased weight, increased appetite, depression, insomnia, constipation, stomach discomfort and nausea Gabapentin Like topirimate, gabapentin is traditionally an epilepsy drug. It may be used if topirimate, flunarizine or propranolol are not effective or tolerated. However, in recent years, studies have indicated that gabapentin may not be as effective for preventing migraine as first thought. Side effects can include dizziness, drowsiness, appetite increase, weight gain and suicidal thoughts.

Sodium Valproate is another epilepsy drug occasionally used for migraine prevention if other prevention options fail or are not tolerated. Other preventative medicines include Pizotifen (Sanomigran®) and Pregabalin (Lyrica®) Riboflavin (Vitamin B2) There has been some indication that Vitamin B2 supplementation may help prevent migraine; however, this has not been proven Is it really migraine?….

Distinguishing between Non-migraine headache One of the most important steps in the successful management of migraine is in diagnosing that it is actually migraine which is the cause of the headache. Migraine is quite distinct from other headache types in how it presents and in how an episode evolves, attacks and subsides. Let’s look at the three most common “primary” types of non-migraine headache (secondary being headaches caused by other medical conditions) Tension Headache The most common type of headache is tension headaches and is usually caused by stress, poor posture or inadequate lighting. Often beginning in the afternoon or early evening of a stressful day and presenting as a “band like” or “pressing” sensation at the front of the head, they can last from one to six hours.

With tension headache, pain tends to be

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disturbance, people will usually experience a more typical “breakthrough” migraine attack on top of the enduring “background” headache.

Medication Overuse Headache

bilateral (both sides of head), constant and with no other symptoms as opposed to migraine which is usually confined to one side of the head, together with other identifiable symptoms.

For most, treatment with an analgesic (paracetamol, aspirin or ibuprofen) will usually take care of it. Engaging in self-management activities such as regular exercise, regular eye breaks from the computer at work, sensible eating habits and learning stress management techniques can all lead to a reduction in tension headaches.

Chronic Daily Headache Different from tension headache, which is episodic in nature, Chronic Daily Headache (CDH) refers to any headache that occurs on at least 15 days per month with each at least four hours’ duration. Currently affecting 4-5% of the population (and growing) variants of CDH can significantly affect an individual’s ability to function at work, at home and socially.

There are three distinct types: Chronic Tension Headache Typically affects those with a history of ordinary tension headache and whilst similar, it occurs on at least 15 days per month.

Whereas tension headache is usually related to individual situations, chronic tension headache tends to be provoked by more enduring ongoing personal situations, i.e. job issues, family and relationship problems, grief, depression Chronic (Transformed) Migraine

This is caused by the overuse of medication, taken primarily to alleviate headache. In the main this relates to analgesics (paracetamol, codeine, aspirin or ibuprofen) although can also occur with migraine attacking drugs (triptans). Those most commonly affected are those with a history of tension headaches or migraines that have become more frequent or severe over time. They take medication to gain relief from the pain, only to find the headache returning once the drugs have worn off. Sufferers then take more medication to alleviate continued pain, pain eases, drugs wear off, pain returns etc. (a vicious circle!). It becomes easy then to fall into a cycle of taking medication for a headache that is itself caused by medication. Once in this spiral, the only way is to break the cycle completely is through withdrawal. Typical withdrawal side effects can be worsening headaches, nausea and anxiety for a couple of weeks. Withdrawal is best achieved through consultation with a medical professional; the GP may be the patient’s first point of call but the pharmacist has a major role in recognising signs of.medication overuse headaches (eg. Regular headaches, Frequent purchases of analgesics) and is well placed to help the person identify and help the person tackle the problem.

Cluster Headache Affecting around 1% of people, this is a rare but very severe headache found six times more commonly in men and usually begins in late 20’s or early 30’s. Typically, attacks begin in the middle of the night. Primary symptom is a severe stabbing pain affecting one side of the head. The side affected can vary between attacks but only in very rare cases would it affect both sides of the head at the same time.

The duration of an attack can be between 15 minutes and up to 3 hours. Attacks come in clusters (hence the name) and can occur several times a day over a period of weeks or even months. After each cluster, though attacks can disappear for months or years.

A cluster attack can be distinguished from a migraine attack in that with cluster headache the person is agitated during an attack or unable to sit or lie at peace or find relief though sleep.

Diagnosed if you have migraine on 15 or more days a month over a period of at least six months. Over time, people with this diagnosis During an attack, other symptoms may may experience an additional daily or almost occur such as red or watery eyes, runny daily headache. As the frequency of these nose, nasal congestion, facial sweating. In headaches increases, there is a corresponding addition, a sufferer’s eyes may be affected decrease in actual headache pain along with with constriction of the pupil or drooping or other migraine symptoms. The down side swelling of the eyelid. Cluster headache has of this perceived relief is that the headaches been described by some medics as “the most become less responsive to treatment. With painful event that can happen a person” which emphasises the severity of the condition. other effects, suchadasfor depression and sleep1 22/12/2016 Perrigo IPN v1 copy.pdf 16:56

Whilst the cause is unknown, suspected trigger factors include alcohol, tobacco, irregular sleeping patterns, and stress and decreased blood oxygen levels. The most common treatment for cluster headache is the inhalation of pure oxygen and is only successful if the mask fits perfectly without leaking. Your GP should be able to help with further information.

The three “primary” types of headache I’ve described are the most common nonmigraine headaches. There are other types of headache, i.e. those relating to sinus problems, over exertion especially exercise.

These are known as secondary headaches.

The pharmacist’s role • Familiarise yourself with diagnostic criteria which is available on www.migraine.ie to enable you distinguish recognise migraine and distinguish between migraine and other headache types (eg) cluster headaches, tension headache • Inquire what treatments and medication the patient has used already to treat the headaches • Familiarise yourself with the step-wise analgesic ladder recommended for headaches and migraine starting with paracetamol, aspirin and ibuprofen • With the HPRA hopefully going to re-classify some triptan therapies as P medicines, pharmacists should familiarise with these therapies • Pharmacist should be able to identify when to refer to a GP References 1. NICE Clinical Guideline 150. Headaches costing report. September 2012 2. The Irish Nurses & Midwives Organisation http://www.inmo.ie/Home/Index/7066/8626 3. World Health Organization. The Global Burden of Disease: 2004 update, Part 3, p28–37. http://www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/ 4. WHO (2001) The World Health Report 2001: Mental health, new understanding new hope.

World Health Organization, Geneva, Switzerland www.who.int/whr/2001/en/whr01_en.pdf 5. World Health Organization. Lifting the Burden.

Atlas of headache disorders and resources in the world 2011. WHO, Geneva; 2011.

6. Steiner TJ. Lifting the burden: the global campaign against headache. The Lancet Neurology. 2004; 14:204–205. doi: 10.1016/ S1474-4422(04)00703-3.

7. Steiner TJ. Lifting The burden: the global campaign to reduce the burden of headache worldwide. J Headache Pain. 2005; 14:373– 377. doi: 10.1007/s10194-005-0241-7

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Solpadeine Soluble Tablets (P) contain Paracetamol, Codeine Phosphate Hemihydrate and Caffeine. For the treatment of acute moderate pain not relieved by other analgesics such as paracetamol or ibuprofen alone; for symptoms of headache, including migraine, toothache, backache, common cold, influenza, menstrual pain, muscoskeletal pain. Adults and children 12 years and over: 2 tablets in water three to four times in 24 hours as required; not more frequently than once every four hours. Maximum 8 tablets in 24 hours. Children under 12 years: Not recommended. Do not take for more than 3 days without consulting a doctor. Do not take any other paracetamol or codeine containing products concurrently.

Avoid excessive caffeine intake. Can cause addiction. Use for 3 days only. In case of overdose, seek immediate medical advice, even if the patient feels well. Contraindications: Lactation, acute asthma, known hypersensitivity to ingredients, known CYP2D6 ultra-rapid metabolisers, patients under 18 years who undergo tonsillectomy or adenoidectomy for obstructive sleep apnoea syndrome, rare hereditary fructose intolerance. Precautions: Caution in renal or hepatic impairment, non-cirrhotic alcoholic liver disease, obstructive bowel disorders, previous cholecystectomy, acute abdominal conditions, pregnancy, hypertension, oedema. Interaction with coumarins (including warfarin), domperidone, metoclopramide, colestyramine, monoamine-oxidase inhibitors. Side effects: anaphylaxis, bronchospasm, dependency or worsening of headache following prolonged use, dizziness, GI disturbances, hepatic dysfunction, thrombocytopenia. PA 1186/11/1. MAH: Chefaro Ireland Limited, 1st Floor, Block A, The Crescent Building, Northwood Business Park, Dublin 9. RRP (excl. VAT): 12s €4.99, 24s €7.99, 60s (GMS) €12.15. SPC: www.medicines.ie/medicine/6826/SPC/Solpadeine+Soluble+Tablets.

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Is the Era of Independent Pharmacy Over?

At a recent breakfast seminar, hosted by Ulster Bank. Representatives gathered to discuss the future of Pharmacy and the expansion opportunities for the sector. “The days of independent pharmacies operating as dispensary-led businesses surviving on the high-street are limited over,” declared Ulster Bank Business Development Manager Conor Walsh “Many Pharmacies are exploring a wider retail offering and those who can do this successfully are thriving” during a business breakfast arranged by his financial institution.

United States. Another example, closer to home, was Lloyds’ acquisition of 277 Sainsburys’ pharmacies for £125 million; a deal which received competition approval last July. This merger helps Lloyds – who now have over 1,500 stores in the UK – close the gap on its main rival Boots – who have over 2,500 UK outlets.

Far from being immune from these international trends, statistics suggest that the Irish Pharmacy market will move much further towards the international model in the not so distance future.

Oonagh O’Hagan, MD Meagher’s Pharmacy Group, Stuart Fitzgerald Director, Fitzgerald Power Ltd and Ulster Bank Business Development Manager Conor Walsh

The theme of the event, which took place in George’s Quay on November 14th, was ‘Expansion in Pharmacy’, and Walsh had been observing a huge increase in demand for financing this year, as pharmacies expanded organically and consolidated. “This year alone, our organisation have seen 60 transactions in the Pharmacy sector, and expect another 15,” he said. “In the two years previous to that, we only saw 50 transactions combined. The biggest opportunity in the market is undoubtedly acquisitions but it’s not the only opportunity.”

Nevertheless, despite the recent increase in activity, Ireland is still something of an outlier in the industrialised world when it comes to Pharmacy ownership.

36

Only 26% of the market is owned by operators with six stores or more (conversely, 61% of pharmacies in the UK, and 63% in the US, are in group ownership). As such, many opportunities to expand and consolidate exist.

Room to expand This room to expand is one of the reasons Stuart Fitzgerald, Director at Fitzgerald Power, believes that Irish Pharmacists are in an ideal position to benefit from international trends towards amalgamation. “There are huge opportunities in this market, which will consolidate in the next three to six years,” he noted during his presentation. Judging by the packed house for the event, where speakers included

Meagher’s Pharmacies owner and MD Oonagh O’Hagan, Stuart was far from alone in this opinion.

According to Stuart, there are many factors driving consolidation in the Pharmacy market internationally at the moment. “There is strong liquidity in international chains,” he said, “which have a preference for acquisition strategy and a strong desire to keep pace with their rivals.”

One example he provided was the upcoming $9.4 billion merger between Walgreens and Rite Aid, which will result in Walgreens overtaking CVS (which has recently taken over in store pharmacies in Target) as the largest pharmacy chain in the

For instance, Pharmaceutical Society of Ireland (PSI) statistics imply a noticeable increase in expansion by acquisition in Ireland in the last two years. In 2014, there were 42 changes of ownership in the Irish Pharmacy sector; a figure that had increased to 95 by 2015.

By November, there had already been 118 changes of ownership in 2016, and there are several more in the pipeline.

“By the end of the year, we expect there to have been 135 changes of ownership,” Stuart said. “The market is really starting to pick up and figures support the fact that transaction volumes are increasing year on year.”

Further driving forces for Stuart include the availability of cheap debt (European interest rates have been at an all-time low since January 2009) and the fact that banks are currently very supportive of the pharmacy sector in general. Financial institutions such as Ulster Bank now see Irish pharmacies

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Children under 10 years: One 5 mg suppository to be administered under medical supervision only. Contraindications: Intestinal obstruction, ileus, acute abdominal conditions including appendicitis, acute inflammatory bowel diseases, severe abdominal pain associated with nausea and vomiting, severe dehydration, and hypersensitivity to bisacodyl or any other ingredient. Dulcolax Suppositories should not be used when anal fissures or ulcerative proctitis with mucosal damage are present. Warnings and precautions: Not to be used on a continuous daily basis for more than five days without investigating the cause of constipation. Prolonged excessive use may lead to electrolyte imbalance and hypokalaemia. Electrolyte imbalance may lead to increased sensitivity to cardiac glycosides. Intestinal loss of fluids can promote dehydration; symptoms may include thirst and oliguria. In patients suffering from fluid loss where dehydration may be harmful (e.g. renal insufficiency, elderly patients) Dulcolax should be discontinued and only be restarted under medical supervision. Laxatives do not help with weight loss. Pregnancy & lactation: Not to be used in pregnancy, especially the first trimester, and during breast feeding, unless the expected benefit is thought to outweigh any possible risk to the foetus. Side effects: Rare: anaphylactic reactions, angioedema, hypersensitivity, dehydration, syncope, colitis. Uncommon: dizziness, vomiting, haematochezia (blood in stool), abdominal discomfort and anorectal discomfort. Common: abdominal pain, abdominal cramps, nausea and diarrhoea. RRP (excl. VAT): Suppositories 10 mg, pack of 12, £4.03, suppositories for Children 5 mg, pack of 5, £1.78. Legal category: P. Product licence numbers: PL 00015/0243, PL 00015/0242.

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Children under 4 years: not recommended. Contraindications: Intestinal obstruction, ileus, acute abdominal conditions including appendicitis, acute inflammatory bowel diseases, severe abdominal pain associated with nausea and vomiting, severe dehydration, and hypersensitivity to bisacodyl or any other ingredient.

Warnings and Precautions: Not to be taken on a continuous daily basis for more than five days without investigating the cause of constipation. Prolonged excessive use may lead to electrolyte imbalance and hypokalaemia. Electrolyte imbalance may lead to increased sensitivity to cardiac glycosides. Intestinal loss of fluids can promote dehydration. Symptoms may include thirst and oliguria. In patients suffering from fluid loss where dehydration may be harmful (e.g. renal insufficiency, elderly patients) Dulcolax should be discontinued and only be restarted under medical supervision. Contains a small amount of lactose and sucrose - patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Laxatives do not help with weight loss. Pregnancy & lactation: Not to be taken in pregnancy, especially the first trimester, and during breast feeding, unless the expected benefit is thought to outweigh any possible risk to the foetus. Adverse Effects: Rare: anaphylactic reactions, angioedema, hypersensitivity, dehydration, syncope, colitis. Uncommon: dizziness, vomiting, haematochezia (blood in stool), abdominal discomfort and anorectal discomfort. Common: abdominal pain, abdominal cramps, nausea and diarrhoea. RRP (excl. VAT): 10 tablets £1.34, 20 tablets £2.24, 40 tablets £4.06, 60 tablets £5.49, PL 00015/0240, Legal Category: GSL. 100 tablets £5.89, PL 00015/0241, Legal Category: P. Date of revision: December 2015. Further Information available from: Boehringer Ingelheim Ltd, Ellesfield Avenue, Bracknell, Berkshire, RG12 8YS, UK. Dulcolax® Pico Liquid - Product Information: Presentation: Dulcolax® Pico Liquid containing sodium picosulfate 5mg / 5ml. Indication: Short term management of constipation. Dosage: Adults and children over 10 years: one to two 5ml spoonfuls at night. Not to be taken by children under 10 years without medical advice. Children 4-10 years: Half to one 5ml spoonful at night. Children under 4 years: 0.25 mg per kilogram body weight per day. Once regularity has been restarted, dosage should be reduced and can usually be stopped. Contraindications: Intestinal obstruction, ileus, severe painful and/or feverish acute abdominal conditions (e.g. appendicitis) potentially associated with nausea and vomiting, acute inflammatory bowel diseases, severe dehydration and hypersensitivity to sodium picosulfate or any other ingredient. Warnings and precautions: Not to be taken on a continuous daily basis for more than five days without investigating the cause of constipation. Prolonged excessive use may lead to electrolyte imbalance and hypokalaemia. Dulcolax Pico Liquid contains 5.9 % ethanol (alcohol); may be harmful for those suffering from alcoholism and should be taken into account in pregnant or breast-feeding women, children and high-risk groups such as patients with liver disease or epilepsy. Interactions: After excessive doses, the concomitant use with diuretics or adreno-corticosteroids may increase the risk of electrolyte imbalance. Electrolyte imbalance may lead to increased sensitivity to cardiac glycosides.

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Date of revision: July 2014. Further information available from: Boehringer Ingelheim Ltd, Ellesfield Avenue, Bracknell, Berkshire, RG12 8YS. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.mhra.gov.uk Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 0800 328 1627 (freephone).

Report as pretty safe investments, despite challenges such as reductions in HSE fees, the introduction of reference pricing as well as continued increases in operating costs. A key reason for their confidence is our ageing population, with the number of people in Ireland over 75 is set to double by 2026. As our demographics transform, demand for goods and services provided by Pharmacists will only increase. Between 2009 and 2014, banks were slower to lend. At the time, as Stuart noted, the market was artificially slow because of the recession with vendors less willing to sell, prospective purchasers thin on the ground and transactions dominated by Lloyds.

One sector that wasn’t hurt by the recession was Greenfield openings. “The recession actually helped them,” Stuart noted. “If you were a landlord of a vacant commercial unit in the recession, it suited you to have a Pharmacist pay a modest rent and keep the place heated. As the property market improves, it is going to be less straightforward.” Greenfield expansion continues to healthy, however, with 28 net new openings in 2015, and 20 net new openings in 2016 as of the Ulster Bank business breakfast.

Another recent trend that has hit Ireland is the emergence of symbol groups such as CarePlus, Allcare, Totalhealth and Life Pharmacy. The later, for instance, has experienced significant growth, expanding from only eight members in 2015, to over 60 by the end of 2016. These groups do not own or operate pharmacies, but act as suppliers to independent pharmacies which trade under a common banner. “All symbol groups delivering efficiencies for pharmacies,” Stuart said, “helping them get to their next stage of growth. Whether they can all compete on national level remains to be seen.”

Oonagh O’Hagan and the Art of Acquisition One Pharmacist who is not particularly enamoured with the idea of symbol groups is Oonagh O’Hagan. “Sometimes I feel that Pharmacists think they have to embark on this journey because they are going to be left behind,” she said during

38

the business breakfasts’ panel discussion. “They feel like they don’t have the time to do their buying or their marketing. But it is my belief that Pharmacists can lose their identity in joining a symbol group. Pharmacy for me is about building relationships.

It’s about providing an exemplary customer experience. It’s about building trust with our customers and particularly those based on empathy, and I feel you can lose a lot of that perception with a symbol group.”

Without a symbol group, Oonagh has successfully expanded her business in recent years, since purchasing her first Pharmacy in Baggot Street in 2001. Currently she runs eight stores in Dublin and is in the process of opening her first store outside of the capital. She explained how her desire to expand had initially been fuelled by her frustrations in trying to compete with a multinational chain.

“Our business at the time was 80% dispensary and 20% retail,” she said. “Customers would come in at lunch time with my main competitors’ bags full of products, and buy their medicines from us. We sold the same products, but there was a perception of value with our competitor, especially around 3 for 2’s and they are brilliant at marketing this.

Customers thought of them as a supermarket and us as a dispensary and as a healthcare provider” Oonagh knew that in order to compete in retail, she would have no choice but to expand. “In order to provide that same value to our customers, we needed scale to buy better.

I knew that if I had a number of shops I could buy a wider variety of products at better margins, and then pass the savings onto to my customers.”

Since acquiring her second store in 2003, Meagher’s Pharmacies have gone from strength to strength, now employing almost 100 people. Oonagh has never acquired new outlets just for the sake of it, however, and considers many key factors before making the purchase. Her premier consideration is always location. “When I moved to Barrow Street,” she said, “some people thought I was mad. But I knew in two years’ time, Google, Accenture and Pfizer were going to be in that area. So I had to get

in before the rents would actually go really crazy.”

For her, a perfect Pharmacy to acquire would be ones that are under performing against a set of KPI’s she drives her own business to achieve. Questions she asks herself, therefore, include: “Is there something I can bring to the store that can improve its profitability? For instance, what is the generic substitution percentage, or do they have high overheads in particular areas? What are the demographics? Are there customers in the area who are underserviced? Who is living in that area and what do they need or want to buy?” One example she gave regarded her decision to acquire an outlet in Ranelagh; an urban village where a lot of young mothers live. The Pharmacy that existed there previously hardly catered to mothers at all. “There was a very poor offering for young mothers in the pharmacy,” she said.

“They were just not servicing the customers they needed to serve.” As such, she saw a great opportunity just waiting to be exploited.

Moreover, Oonagh stresses the importance of hiring well when expanding your Pharmacy business. “One of the qualities successful Pharmacists must have is empathy,” she said. “But how are you going to replicate that empathy when you expand to two, three or four stores?

The answer is you can’t, unless you have the right people on the ground who have the same values you have and who will treat your customers exactly as you would, or in some cases even better!” Before 2008, Oonagh admits that she used to hire people based on their qualifications and academic achievements. Far more important for her now, however, is that her employees fit who Meaghers are and match their core values.

“I used to recruit based on aptitude,” she said. “I have learnt over the years that people with first class honours, whilst truly brilliant academically, can sometimes struggle with truly empathetic relationship building with diverse customer groups. We don’t recruit on aptitude anymore – we recruit on attitude.” She prefers that people join Meaghers who are customer

centric and have a sense of community rather than to gain expertise and training. “This has resulted in us having a very low turnover of staff, “she added, “and this has made a huge difference to our business”.

In 2015, Oonagh launched the successful online Pharmacy www.Meaghers.ie, though she admits that regulations and other customer considerations limit what they can do in that medium. “90% of what we sell online is beauty products,” she said. “When it comes to healthcare, most people want to speak to you directly. Until we get a way of providing online consultations, I honestly think we’ll always sell more healthcare products in the Pharmacy. Ireland is also highly regulated, though we don’t know what the future holds and it is possible that one day, revised legislation could allow us sell prescriptions online.”

The Future While declaring the era of traditional dispensary-led pharmacies on the high street to be coming to an end, Conor Walsh believes the future of the overall Pharmacy market in Ireland to be a bright one .

“Ulster Bank is positive to pharmacies and we will want to continue to support them however there are much wider and more strategic considerations that pharmacies should be be thinking about – competition, branding and becoming a ‘destination’ retail outlet.”

“Pharmacies are a robust cashflow business,” he said, “and an ageing population and the growing prevalence of lifestyle diseases gives them further opportunity to grow.” The future, however, will be one with much more group ownership, where retail and OTC goods will play a much more prevalent part than prescription medicines.

An online presence and social media utilisation will be essential tools to pharmacies as the industry continues to develop.

“It is a sector that never fails to fascinate,” Conor Walsh noted.

And as it evolves, it should be a robust one for some time to come.

Advertorial Nourella – helps turn back the signs of skin ageing Nourella® is an Active Skin Support System that has been clinically proven to reverse the signs of Accelerated Skin Ageing by more than 20 years, according to a recently published, peer reviewed, clinical study.

Today’s way of life presents many challenges for the skin and its structure, which can serve to accelerate the ageing process.

Everyone will experience skin ageing – it is normal.

As part of this natural process, the skin loses the ability to rebuild and maintain its youthful appearance.

This is demonstrated as a steady decline in average skin thickness and elasticity, resulting in thinner, less elastic and less supple skin.

There are both extrinsic and intrinsic factors that influence the health and ageing of skin.

Extrinsic skin ageing – the influence on skin caused by the environment, such as exposure to sunlight (photo-ageing), environmental pollutants, diet and stress – is a major contributor to skin age degradation, leading to lines, wrinkles, sagging skin and age spots. As skin ages, its ability to replace cells with newer, younger skin cells is reduced.

Intrinsic skin ageing – the influence on skin caused by time and genetics – is due to slower cell turnover leading to the breakdown of collagen, elasticity and moisture retention. This causes dryness, wrinkles and dull and rough skin.

The skin rebuilding process that is going on inside and outside, slows down and can result in accelerated skin ageing.

The good news is that the skin’s extrinsic and intrinsic rebuilding processes can be supported.

Existing Treatments Ranging from surgical procedures and facial injections, to chemical skin peels and chemical/acidbased creams and lotions, not only are there obvious personal risks associated with some of these invasive procedures, but unfortunately, most treatments only provide short-term visual improvements, as the skin will typically build a tolerance to the chemicals and acids used. This leads to a continued need for ‘improved formulations’ in the marketplace.

Alternatively, instead of accepting this discouraging reality, there is something that can be done about it.

The Nourella® Effect Nourella Active Skin Support System is a unique combination of cream and supplement tablet which stimulates, rebuilds and rejuvenates the skin and has been scientifically researched and developed to provide natural skin protection and improve skin structure, quality and appearance and comprises of: ®

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active elements that have been engineered to be water-soluble though a proprietary, complex binding process. By way of its sophisticated, proprietary, carrier system, RetileX-A penetrates the epidermis and enters the dermis layer of the skin exactly like Retinoic Acid (Trentinoin). Once in the dermis, RetileX-A becomes hydrolysed and metabolised to provide the powerful antiageing effect of Retinoic Acid, but without the associated side effects.

Nourella® Active Skin Support Supplement with proprietary Vercilex®, has developed to support normal collagen structure and help maintain a normal skin function – to maintain healthy, youthful skin. Nourella® is scientifically formulated to stimulate the intrinsic rebuilding process of the skin.

The specific proteoglycans in Vercilex®, which have been carefully extracted using Pharma Medico’s proprietary enzymatic extraction process, are the ones that are present in human dermal connective tissue. A certain component of the proteoglycans found in Vercilex is proven to interact with the growth factors involved in skin cell cycling, as well as the formation of elastin and collagen. This supports the rebuilding of the skin’s overall cellular structure, which is directly responsible for an objectively youthful skin condition.

Nourella® Active Skin Support System has been clinically proven to reverse the signs of Accelerated Skin Ageing by more than 20 years, protecting against collagen and elastin degradation, free radicals and future photo damage whilst supporting the skin’s ability to retain moisture and maintain integrity.

Feature

Managing Menopause in Pharmacy How Pharmacists can help women at this stage of life Women experience menopause in response to decreasing concentrations of oestrogens being produced in their bodies over time. A woman’s menstrual cycle will also come to a permanent halt at this time. It is most common for women of middle age (i.e. 50 years or older) to experience the onset of menopause1. Menopause can be thought of as occurring in three stages: pre-menopause, in which a woman may notice changes in her normal cycle and symptoms (see below). The next is menopause, in which menstruation has definitely ceased due to a terminal drop or shift in the concentrations of hormones such as progesterone and oestrogens2. The last stage is post-menopause, in which the body has adjusted to its new hormonal profile and symptoms have stopped or have become normalised2. Women who have had a full hysterectomy (i.e. one that included the removal of the ovaries) are also considered to be menopausal.

Oestrogen Levels and Their Role in the Menopause Oestrogens (e.g. oestradiol, or E2) typically function to promote ‘feminine’ physical traits and normal physiological processes.

These are produced in many areas of the body, the most notable source being the ovaries and/or reproductive system.

Recent scientific advancement has also found that oestrogens are also produced and are functional in some areas of the brain. Initially, it was thought that they mainly acted as antioxidants, thus protecting nervous tissue from damage and death3. However, the results of subsequent studies suggest that they are also protective against conditions such as mood disorders (e.g. depression), particularly in women4. The same body of research has also found that drops or variations in oestrogen levels may predict changes in normal emotional states. These reductions can be acute or chronic, suggesting that menopausal or post-menopausal women may be at greater risk of depression or other mental health problems4.

Medical Treatment for Oestrogen Deficiency As a result, medical treatment for menopausal women typically consists of courses of ‘replacement’ oestrogen (or progesterone and oestrogen) therapy, or HRT5. This treatment may be recommended in some cases based on the likelihood of certain health problems as the patient progresses through the menopause5. For example, changing oestrogen levels may determine the risks of bone density loss and damage (i.e. osteoporosis)5. Female steroid

40

hormones are also associated with the regulation and/or promotion of immune system functions7. This may explain the increased chance of developing respiratory disorders during or after the menopause, as observed in a recent study partially conducted at NUI Maynooth8.

Obviously, the combinations of progesterone and/or oestrogen replacements prescribed differ from patient to patient, depending on their needs. On the other hand, some women may be able to progress through their menopause without medical treatment, although they may require some lifestyle changes and increased attention to their health status to do so5.

Menopausal Symptoms The menopause and premenopause may also be

associated with many other symptoms and signs, which tend to differ from person to person. They may include the classic indicator known as hot flushes, in which the woman experiences what appear to be sudden, transient increases in body temperature. This symptom has been observed to be strongly associated with the progress of menopause1. The exact reason for hot flushes is still not completely understood. However, current research suggests that they are associated with well-known menopause-related changes in ovarian hormones, including the levels of follicle-stimulating hormone (FSH) and inhibin-B, as well as increasing irregularities in the concentrations of E21.

A recent study, conducted collaboratively between a team at UCC’s Department of Obstetrics

& Gynaecology and others at institutions in the UK, US and Bangladesh, may throw more light on this symptom. They found that anti-Müllerian hormone (AMH) levels were also significantly associated with the incidence of hot flushes in over 100 women of different ethnicities and backgrounds over two weeks, as were FSH levels1. However, they did not confirm the prior findings related to inhibin B or E21. They also found that other factors, including education levels and body mass, were also associated with the incidence and frequency of this symptom1. This study suggests that AMH and FSH levels are also strong influencers of menopausal progress and symptoms1. It also implies the importance of health and lifestyle advice and information for women who are currently experiencing the menopause.

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Substituting two daily meals of an energy-restricted diet with meal replacements contributes to weight-loss.

Substituting one daily meal of an energy-restricted diet with a meal replacement contributes to the maintenance of weight after weight-loss.

Subject to availability. Selected stores only. *92% of 47 people agreed

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Feature Pharmacists and Their Role in Menopause Treatment Pharmacists are in a unique and fortuitous position to deliver this advice, which may make the menopause a less stressful and adverse period in a woman’s life.

A woman may need to talk to their GP or gynaecologist for an accurate diagnosis and treatment plan as she faces this new stage in her life. However, further advice from her Pharmacist may also be necessary and helpful. He or she is also likely to be prepared to offer advice on the medications prescribed, as well as other supplements, vitamins or lifestyle changes that may be beneficial for menopausal women. Currently, there are no formal guidelines that direct how a Pharmacist advises a woman experiencing the menopause. However, a Co. Mayo-based community Pharmacist maintains that experience and training is enough to inform this for professionals in this position10.

Accordingly, Pharmacists may realise quickly that every woman may have different needs, depending on the treatment they need (or perhaps want), what they already know about the menopause and perceptions of risks associated with hormone replacement or other therapy10.

Other Pharmacists observe that many women are likely to source information about the menopause from their older female relatives10.

Pharmacists are aware that their role in discussing the menopause is one of impartial information-giving, so as to give these customers the best service and an independent choice of treatments and other products10.

Customers going through the menopause may be more likely to ask for Pharmacist assistance if their symptoms are severe or unexpected10. In these cases, the Pharmacist can offer information, as above, on products that may address these symptoms10.

However, if these symptoms persist or get worse over time, the Pharmacist often refers the customer to her GP10.

Menopause Treatment – Further Research and Insights Some Pharmacists may find that their customers are unwilling to start a course of HRT, if this has been prescribed or recommended by said doctor10. This may be connected with a number of large-scale clinical trials, including one conducted by the Women’s

Health Initiative, which showed correlations between HRT use and greater risks of congestive heart disease (CHD) and breast cancer5. However, newer, better-designed studies indicate a positive effect of HRT use on CHD and the risk of death due to any cause, but only when HRT is initiated soon after the onset of menopause5. A recent systematic analysis of 14 studies found that treatment with combined E2, levonorgestrel, norethisterone and medroxyprogesterone was associated with increased breast cancer risks, but that treatment with E2 alone or combined with progesterone and dydrogesterone was not9. On the other hand, the prolonged use of any of these treatments was associated with an increased risk9.

Conventional treatment for the symptoms of menopause may result in benefits for some customers. It may help with mental health issues connected with the onset of menopause, as outlined above. In addition, a recent study (based on data from many hospital databases including one in Dublin) suggests that correcting menopause-related irregularities in immunomodulation may reduce the risk of other conditions such as multiple melanoma developing in women experiencing this life-stage7. Women have been encouraged by the media and the health industry to increase their calcium intake as they reach the final stage of menopause.

However, recent research has found that this form of supplementation alone does not improve or maintain bone density, or even prevent the increased breakdown of bone related to decreasing steroid hormone activity6. Recent research indicates that calcium requires other co-factors – which are not confined to the classic vitamin D, but also include newly-discovered molecules such as short-chain oligosaccharides – to efficiently conserve bone matter in postmenopausal women6.

she should refer the customer to a doctor if these symptoms seem particularly severe or unusual10.

In addition, keeping up to date with interesting developments in menopause research can be useful. For example, if you are discussing supplements for menopause-related problems such as brittle bones, remember that calcium supplementation alone is not enough to maintain bone density6. However, ultimately, the Pharmacist cannot influence the patient’s choice of treatment, save through offering as much education as they can on each relevant option10.

Slevin MM, Allsopp PJ, Magee PJ, et al. Supplementation with calcium and short-chain fructo-oligosaccharides affects markers of bone turnover but not bone mineral density in postmenopausal women. The Journal of nutrition. 2014;144(3):297304.

7.

Costas L, Lambert BH, Birmann BM, et al. A Pooled Analysis of Reproductive Factors, Exogenous Hormone Use, and Risk of Multiple Myeloma among Women in the International Multiple Myeloma Consortium. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2016;25(1): 217-221.

8.

Triebner K, Johannessen A, Puggini L, et al. Menopause as a predictor of new-onset asthma: A longitudinal Northern European population study. The Journal of allergy and clinical immunology.

2016;137(1):50-57.e56.

9.

Yang Z, Hu Y, Zhang J, Xu L, Zeng R, Kang D. Estradiol therapy and breast cancer risk in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology. 2016:1-6.

Sources: 1.

Dhanoya T, Sievert LL, Muttukrishna S, et al. Hot flushes and reproductive hormone levels during the menopausal transition.

Maturitas. 2016;89:43-51.

2.

Shan Y. Phyto-oestrogens and the great soya debate.

Primary Health Care.

2005;15(3):23-25.

3.

Behl C, Widmann M, Trapp T, Holsboer F. 17-beta estradiol protects neurons from oxidative stressinduced cell death in vitro.

Biochemical and biophysical research communications.

1995;216(2):473-482.

Final Points Menopause is a natural part of life. However, women approaching this stage may benefit from assistance and advice that can be found at their pharmacy. It is not unusual for women to ask help with their symptoms during menopause10. In this case, the Pharmacist can draw on their training and experience when discussing these options. He or

6.

4.

Douma SL, Husband C, O’Donnell ME, Barwin BN, Woodend AK. Estrogenrelated mood disorders: reproductive life cycle factors.

ANS. Advances in nursing science. 2005;28(4):364-375.

5.

Lobo RA. Hormonereplacement therapy: current thinking. Nature reviews.

Endocrinology. 2016.

10. The results of interviews with Pharmacists based in Co. Mayo or Galway, who declined to be quoted directly.

43

Feature

Vitamins and dietary supplement market set to continue to expand into 2021 The Irish economy continues to improve, which is leading to an increase in disposable income. Because of this, consumers can afford to take better care of themselves again by taking vitamins and dietary supplements.

The market for vitamins and dietary supplements are predicted to increase at a value CAGR of 1% at constant 2016 prices over the forecast period to reach ¤63 million in 2021*.

This year alone, vitamins and dietary supplements have grown by 1% in current value terms, with sales valued at ¤59 million. Emphasis on the importance of getting nutrition from food instead of supplements also continues to grow.

Value growth has also been slightly stronger in 2016 than in the previous year.

There has been a growing emphasis on eating natural foods where possible, while many foods such as bread are also still fortified.

However, for many, obtaining the adequate level of vitamins and minerals through their food is not always possible - so supplements remain popular, particularly coming toward the winter months.

The category is mature with growth expected to be limited thus. There will likely be some innovation and this will help to maintain growth.

However, consumers are anticipated to seek their nutritional needs without the aid of dietary supplements where possible and they will instead seek natural and fortified foods, eg superfoods, to maintain their healthy lifestyle.

The most dynamic category in 2016, with current value growth of 8%, is Co-enzyme Q10. However, it should be noted that this is from a relatively small base of ¤2 million. These products have become more widely available in recent years which has assisted in the strong growth levels.

44

There also continues to be a strong demand for products that are designed for muscular health and fatigue, due to consumers leading busier lifestyles and Ireland’s aging population. Public service initiatives also tend to promote eating a healthy balanced diet as opposed to using vitamins and dietary supplements.

However, many health care professionals will instead recommend to their patients that they may need to use dietary supplements to support specific health problems, such as for females who are low on iron.

There are several different formats of vitamins and dietary supplements with jellies and gummies targeted towards children. Oral sprays are becoming more popular for adults with the product entering the blood stream through the mouth.

The traditional tablet format remains the most popular amongst consumers, and paediatric vitamins accounts for a 93% value share of paediatric vitamins and dietary supplements as most children do not require dietary supplements if they are following a balanced diet.

Dietary supplements have grown by 1% in current value terms in 2016. Growth continues to increase as consumers have more disposable income to spend on these products.

There has been an increase in the availability of combination products that are gaining the interest of consumers particularly for pre and post pregnancy and for aging consumers.

Paediatric vitamins should see a significant boost to sales towards the end of 2016 during the back to school

period when there will be an increase in the advertising of brands such as Gummy Vites on television. Vitamins has grown by 1% in current value terms in 2016.

Oral sprays are becoming more popular for adults with the product entering the blood stream through the mouth.

However, the traditional tablet format remains the most popular amongst consumers.

Vitamins Most consumers believe there is no difference between branded and private label vitamins and therefore many are trading down to private label alternatives. This has inhibited the growth of the category in value terms.

Chemists and pharmacies such as Boots and even smaller chains such as Cara Pharmacy have their own

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Feature news brief 16TH ANNUAL IAPC EDUCATION AND RESEARCH SEMINAR 2017 The Annual Irish Association for Palliative Care (IAPC) Education and Research Seminar is the premier meeting for those engaged in, and interested in palliative care research in Ireland.

The Seminar promotes the undertaking of research in palliative care and related areas, and is a vibrant learning and sharing day.

Recognising that best practice in palliative care is enabled through education and research, the Seminar provides a unique platform for palliative care practitioners and researchers to present their research to their peers and interested parties.

private label alternatives to the regular brands that consumers are used to seeing. Consumers are seeking to address their vitamin needs through natural whole foods where possible.

There is also a growing number of consumers who are interested in taking vitamin B and vitamin D which are the most dynamic categories in 2016 growing by 6% and 7% in current value terms respectively. Vitamin D has been heavily promoted in the media in 2016, with consumers being encouraged to take the supplement during the winter time due to the lack of sunlight.

Multivitamins has grown by 1% in current value terms in 2016 and remains the largest vitamins category in value terms. However, its maturity means that growth tends to be slower.

More consumers are also getting their vitamins from other sources eg Pregnacare supplements which contain both vitamins and minerals and are classified assupplements. Targeted products based on age and gender continue to be seen for most multivitamins brands.

There is a demand for vitamins kits such as JuicePlus+,

which offer consumers a monthly supply of vitamins and minerals. The products are distributed through direct selling and offer capsule format products to adults and also gummies products for children.

Dietary Supplements Dietary supplements have grown by 1% in current value terms in 2016. Growth continues to increase as consumers have more disposable income to spend on these products.

There has been an increase in the availability of combination products that are gaining the interest of consumers particularly for pre and post pregnancy and for aging consumers. Fish oils/omega fatty acids remains the most popular category within dietary supplements with sales of ¤8 million in 2016.

However, the category continues to slide with a decline of 2% in current value terms in 2016. While consumers know that these products are good for them, there is a negative connotation with the smell of fish oil products and consumers are showing a growing preference for other supplements instead.

Cod liver oil and krill oil continue to be popular products for older consumers.

Combination dietary supplements has recorded current value growth of 6% in 2016. There continues to be a demand for convenience amongst consumers and combination products are attractive as consumers only need to take one capsule to get their nutritional needs as opposed to several different products.

The targeted approach of these products has assisted with sales growth with strong demand for products for pregnant women and consumers over the age of 55. Tonics is a relatively small category in Ireland with value sales of ¤1 million.

However, its sales have also fallen over the review period with a further decline of 1% in current value terms recorded in 2016. Energy tonics and beauty from within tonics are the most popular types that are available Ireland.

However, they have had little investment and there are low awareness levels or interest amongst consumers. *Information accredited to Euromonitor.

The Seminar promotes the undertaking of research in palliative care and related areas through the submission of abstrats for Platform and Poster presentation.

It serves not only as a point of discussion for evidence-based research through oral and poster presentations, it is also a springboard for researchers aspiring to bring their work to international fora and to publication. The Seminar also provides a pathway to greater dissemination for those wishing to publish and present at other national and international gatherings.

The Seminar Aims to: Provide an opportunity for Palliative Care researchers to present oral or poster presentations to a range of professionals who work in diverse clinical and academic settings.

Enable health care professionals in Palliative Care and related areas to network and share ideas and to debate issues around palliative care research and education in Ireland.

Provides a platform to greater dissemmination for those wishing to publish and present at other national and international gatherings.

47

Treatment goals in depression have evolved1,2

2010 Functional recovery: Symptoms are essentially absent, patient returns to pre-morbid functional status2

1990s Remission: Some symptoms may persist1,2

1970s Response: Many symptoms remain1,2

.....and so it’s time to rethink our approach References 1. McIntyre RS et al. Depress Anxiety. 2013;30(6):515–527.

2. Greer TL et al. CNS Drugs. 2010;24(4):167–284.

Date of preparation: October 2016 UK/VOR/1610/0392

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Feature

From euphoria to despair The two faces of Bipolar Disorder Bipolar Disorder is a serious mental disorder that affects approximately 1-2% of Irish people. Bipolar Disorder is not restricted to any particular sex, race, or socio-economic class - doctors, lawyers, teachers and taxi drivers may all be sufferers. Despite its seriousness, the illness is treatable, and with proper treatment and care the prognosis can be quite good.

Left untreated or undiagnosed however, the outcome is far poorer; there is a 15-17% mortality rate overall for the illness (up to 20 times that of the general population), with at least 25-50% of sufferers attempting suicide at some stage in their lives.

What is Bipolar Disorder?

Bipolar Disorder is primarily a genetic disorder that affects mood and mood regulation. Common symptoms are: depression, anxiety, suicidality and motor retardation through to excitability, elation, mania and psychosis. The phases of the illness i.e. depression to elation may manifest themselves weeks, months or even years apart.

There are two main subtypes of the illness: Bipolar I and Bipolar II. While both have similar traits, Bipolar I is more serious – the true diagnosis of - Manic Depression and is marked by at least one episode of mania, a term used to describe extreme mood elevation, running into psychosis.

Bipolar II has similar symptoms, but the elevated mood seen by this subtype is classified as ‘hypomania’, a much less severe or disruptive form.

As Patricia Casey, Professor of Psychiatry at UCD and consultant psychiatrist, Mater Hospital, Dublin explains: “Bipolar I is where the person has full-blown mania. They’re very over-active, very over-talkative or very aggressive. They also get delusions; they may be deluded that they’re God or the queen, or a celebrity, or they may have suspicions that someone’s trying to harm them, or is talking about them or watching them. So there are psychotic symptoms present.

In Bipolar II you get what’s called hypomania, which is a milder form of mania. Delusions aren’t present and people aren’t quite so overactive. They may still be overactive and their thoughts

may still be racing but it’s much less than with bipolar I, the fullblown syndrome when psychotic symptoms are present.”

What are the causes?

As stated, bipolar disorder is a genetic illness; sufferers will likely have a relative who either suffers from the illness or another major depressive disorder. Further, between 15-30% of children of one bipolar parent are likely to develop the illness themselves.

Professor Casey says: “We know that genetic factors play a part, but quite how big a part, we don’t know. if there’s a family history of depression, that may increase the risk of bipolar disorder in first-degree relatives, so there seems to be some kind of genetic link . But if a close family member has bipolar disorder, there’s absolutely no certainty that their children will get it, so it’s not a one-to-one link. There is a general predisposition and there’s an increased risk, but exactly what genes are involved, we don’t know.

Often the illness presents itself with a depressive episode, but you can’t actually make the diagnosis

until the person has had a manic episode. So a person may present themselves with several episodes of depression first. The manic or depressive episode may come out of the blue, or it might be triggered by substance abuse, for example with cannabis, amphetamines or some such substance, or by a traumatic event.

It’s only in recent years that we’ve discovered that there may be a link between childhood sexual abuse and Bipolar Disorder. How strong the linkage is, we don’t know, but from recent research, there certainly would appear to be a link.”

What are the treatments?

The treatment of choice for Bipolar Disorder is Lithium Carbonate, a commonly-occurring salt that was shown in the 1950s to have a sedative, or mood-stabilizing effect on patients. Anticonvulsants, antipsychotics and anti-depressants are also used to varying degrees of success. ECT (ElectroConvulsive Therapy) is also used to a lesser extent for manic or severely depressed patients.

Psychotherapy also plays a role in the form of Cognitive Therapy,

Cognitive Behavioural Therapy (CBT) and counselling, though only in a supportive role.

What about prognosis?

Most sufferers of Bipolar Disorder, with proper treatment and care, go on to live relatively normal and successful lives. Hospitalizations are an unfortunate reality and are said to increase in likelihood with each admission, but can be minimised by adhering to professional advice.

As Professor Casey says: “Treated, people can achieve complete stabilisation and can get on with their lives normally; untreated, the period between episodes reduces and the episodes last longer, and if treatment is then instigated they become more difficult to treat than if they had been treated earlier. So the prognosis isn’t good for those who are untreated – the episodes just keep recurring. There is also the risk of suicide for those who are untreated and possible health problems arising from risk-taking during the manic phase.”

How can family & friends help?

Family and friends can help by

49

Feature offering non-judgemental support, by being educated on the illness itself and by seeking professional advice if needed. Bipolar Disorder can be debilitating, so sometimes just having someone there offering emotional support can help: “If someone believes that a member of the family has a mental health problem, they should firstly encourage them to get help. They should also encourage the family member to adhere to treatment.

If someone with bipolar disorder stops medication, they will relapse, as sure as night follows day. When that happens it becomes more difficult to treat next time around.

They should also encourage their loved one to link up with organisations like AWARE, which was set up specifically for people suffering with bipolar disorder, and provides up to the minute information about research, how to cope and practical things that can be done.”

The role of the Pharmacist Pharmacists can help by being educated on the illness and by offering impartial and supportive advice on treatment. Though the Pharmacist may not have control over which medications are prescribed, they can discuss common issues such as sideeffects, interactions, dosages etc.

The Pharmacist can be a valuable intermediary between the patient and psychiatric services; often the advice and feedback offered by the Pharmacist can empower the patient over treatment. Patients may only have the opportunity to discuss medication with their doctor every few weeks or months, whereas the community Pharmacist is always there for support. Such support is key in managing the illness and fosters a positive relationship between the pharmacy and psychiatric services.

Symptoms “In a nutshell, with bipolar you can get the two extremes: when you’re unwell you get the highs, which are unpleasant, and the lows, which are also unpleasant,” says Dr Stephen Murphy, of The Park Clinic Medical Centre, Cabinteely.

“The lows are like a depressive illness. The mania end, is where people become psychotic and they have thoughts which possibly taken one at a time might seem reasonable, but there is no logic to them. They’re not realistic ideas, and the patients often become frustrated and irritated because people won’t follow what they’re

50

trying to do. Sometimes they spend a lot of money, they can become sexually disinhibited, make rash decisions about where they live or their jobs or who they’ll be friendly with.”

“They will often pursue risky sports or adventures. They’re also disinhibited with regard to their alcohol intake, and may experiment with illegal drugs.

Occasionally they may also get some of the more commonly known psychotic systems, like hallucinations, both auditory and visual. And of course, one of the difficulties is that if they’re on medication, they may decide that don’t need that medication anymore.”

“And then there’s the selfimportance, the seemingly limitless energy, and the lack of sleep. If you’re listening to a patient and you say to yourself ‘oh I must pay attention’, that’s usually a hint that you’re talking to someone who’s manic, because there’s no logic to their speech pattern.”

Commonly prescribed drugs for Bipolar Disorder: Mood stabilizers/ anti-convulsants • Lithium • Carbamazepine (Tegretol) • Lamotrigine (Lamictal) • Valproate (Depakote, Epilim) • Valproic acid (Depakine) Antipsychotics • Olanzapine (Zyprexa) • Quetiapine (Seroquel) • Risperidone (Risperdal) • Symbyax (combines Olanzapine with antidepressant Fluoxetine) • Asenapine (Sycrest) • Ariprazole (Abilify) Anti-depressants (not recommended due to the risk of inducing mania/hypomania, though may be used in conjunction with a mood stabilizer).

Izabela Rozpedowska is a Master of Pharmacy and studied at Poznan University of Medical Sciences, Poland. Izabela is Pharmacy Manager at Blanchardstown Village Pharmacy, Dublin.

“The most important thing with bipolar disorder is that the patient has a good relationship with their doctor. Also, the more information they have about their illness the

better; if family and friends are also educated, that helps too. With the medication, it’s important to take it as the doctor advises, to take it at the same time, and not to stop when you start to feel well.

“One thing that we would advise patients is to make their lives organised - to go to bed at the same time, wake at the same time, to try to eat meals at the same time and to have regular routines for daily activities. That would be very helpful for patients. Physical exercise also helps, as well as having good support from family and friends.

“In terms of medication, Lithium is very effective and is one of the oldest drugs for bipolar. It needs to be monitored carefully by the doctor because if it’s not within certain limits it can result in toxicity and even death. Because of that, it’s important to have levels checked every few months.

“Medication is very particular to each individual patient. The doctor will determine the extent of the illness, how it affects you, and prescribe accordingly. Usually treatment for bipolar disorder wouldn’t involve mono-therapy – you need medication to treat the manic phase as well as the depression, so the patient would usually be on two or three medications.

“The anticonvulsant medications can be very good in controlling the illness, and in particular Lamictal, which is often the drug of choice.

It’s easier to choose an anti-manic medication than it is an antidepressant - you need to be very careful when choosing an antidepressant because sometimes they can induce a manic attack.

“If there is a problem with a medication, for example if there is an interaction between drugs or unwanted side-effects, we can contact the doctor and inform them, and maybe if we feel another drug would be better we could suggest a change and usually the doctor would take the advice. If the patient knows their medications and has good knowledge about the condition that’s really helpful for the doctor, for the patient, for their family and for the Pharmacist as well.

“It happens quite often that I see patients being over-prescribed - not so much that the dosage is too high, but that too many medications are being prescribed together. There could be a good reason for this, but at times we see that prescriptions have too many drugs listed, with too many possible interactions.

“The role of the Pharmacist is to support the patient, to make sure they get their medication at the right time, to advise them on possible interactions or side-effects and to contact doctors to make recommendations where necessary.

“A large number of patients attending the pharmacy are coming in due to mental health issues – up to 80%. Bipolar disorder would be a small percentage of this. Ideally we should have closer ties to psychiatric services, but we don’t always have the time, unless it’s maybe querying a prescription. It would be good if all pharmacies held consultations, but we don’t really have the resources to do that.”

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Pharmacy’s role in managing chronic pain Everyone has been physically hurt at some point in their lives, but some people live with chronic pain every single day.

A recent research study conducted in conjunction with the “mypainsfeelslike” by Chronic Pain Ireland has shown that 89% of people with chronic pain avoid discussing it with family and friends, so as not to bore them or seem annoying. Some 26% admitted to regularly avoiding talking about their pain with loved ones.

The research found that a lack of belief around the severity of their pain and a lack of understanding of its impact are daily issues faced by people living with chronic pain. Meanwhile, according to a European survey in 2016, 30% of people living with chronic pain feel that no one believes how much pain they are experiencing, while 25% felt that colleagues, employers and doctors were unsympathetic to their pain or did not think it was a problem.

“The stigma of chronic pain is one of the most difficult aspects of living with it,” says John Lindsay, Chairperson of Chronic Pain Ireland.

“We aim to support people to talk about their pain through support groups, pain management programmes and so they can better understand their illness, communicate effectively with their doctor and have an appropriate pain management plan in place.”

Research has shown that painmanagement collaboration with Pharmacists cuts GPs’ workloads, takes pressure off hospital services and reduces the financial burden on the economy. Better targeted interventions, including medicines use reviews (MURs), have the capability of making significant contributions to chronic pain management.

The role of the pharmacist Community Pharmacy-based services play a key role in extending access to effective pain relief.

Pharmacists can help patients to improve their patients well-being by encouraging them to manage their pain by taking into account how it affects their life. Stress, anxiety, over-exertion and poor sleep can all impact on pain levels.

Pharmacists can explain how these stressors can often worsen pain and offer advice to patients regarding support organisations, including Chronic Pain Ireland, Chronic pain is a debilitating condition and one of the risks when dealing with chronic pain

52

management is that the patient may become addicted to pain relief medication. Pharmacists must be sensitive to the risk that patients may become dependent - or even addicted to pain relief medication.

The role of the Pharmacy team has a very significant impact on those living with chronic pain, below are some of the key issues raised by patients participating in research done with Chronic Pain Ireland.

1. Not Being Believed. Pain is invisible and it is not unusual for the patient’s physician and family members to doubt the patient. Being believed by any healthcare professional including the Pharmacist benefits the patient greatly 2. Side Effects. Most people with CP are on a cocktail of medications and some experience severe side effects.

The Pharmacist suggesting alternative medications for the patient to mention to their physician would be of great assistance. The Pharmacist has the detailed knowledge of interaction between various medications and advising the patient accordingly can greatly help.

3. Adherence/Compliance/ Addiction. There is a serious issue with compliance/ adherence in Ireland with less than 30% adhering to their prescribed medications. The Pharmacist has a key role to play in this area and through a series of questions should be able to ascertain if the patient is being compliant. Stress the importance of adherence and particularly the importance of giving medications time to have an impact. There are unfounded and unproven concerns in relation to addiction to Opioids. If one is living with chronic pain, the pain itself acts as an antagonist and one will not become addicted to their medications if taken as prescribed. The vast majority of people do not understand the difference between addiction and dependency and the Pharmacist can help in this area 4. Alternative Treatments/ Medications. For various reasons, some psychological, many patients have difficulty taking medications. Assurance from the Pharmacist or suggesting alternatives can be greatly helpful.

WHO analgesic ladder The WHO analgesic ladder was developed for use in cancer pain, a stepwise approach is probably equally applicable to the management of chronic pain due to other causes.

Figure 1. WHO analgesic ladder for cancer pain The WHO pain ladder is a framework for providing symptomatic pain relief. The three-step approach is inexpensive and 70–90% effective1–4 By mouth

The oral route is preferred for all steps of the pain ladder1,2

By the clock

Cancer pain is continuous - analgesics should be given at regular intervals (every three to six hours), not on demand1

Adjuvants

To help calm fears and anxiety, adjuvant drugs may be added at any step of the ladder Step 3 Step 2

Step 1 Non-opioid (eg aspirin, paracetamol or NSAID) +/- adjuvant

Weak opioid for mild to moderate pain (eg codine) +/- non-opioid +/- adjuvant

Pain persisting or increasing The principle of this process is that a simple approach and knowledge such led to the pain relief in the majority of patients. Complete relief from pain is unlikely, but better pain management with your patients will lead to reduction in their pain, better mobility and quality of life.

Non-opioid analgesics, such as NSAIDs or paracetamol which helps to reduce inflammation around certain conditions such as migraines and headaches.

A particular problem for people with chronic pain conditions is that the medication itself can cause problems as the person often needs to take it for a significant period of time. NSAIDs should be avoided in people with stomach ulcers, heart problems, and high blood pressure. For acute problems, NSAIDs should only be taken for a number of weeks, but they can be taken for a longer period of time provided there is appropriate medical supervision.

Opioids reduce nociceptive transmission through inhibition at opioid receptors in the brainstem, spinal cord and perhaps peripheral nerves.

Strong opioid for moderate to severe pain (eg morphine) +/- non-opioid +/- adjuvant

Pain persisting or increasing

Pain controlled

Opioids for mild-to-moderate pain are used in combination with a non-opioid analgesic, such as paracetamol, at the second step of the ladder. There are numerous combination step analgesics available, however combinations may increase side-effects yet may not significantly increase pain relief.

If regular maximum doses of opioids for mild-to-moderate pain do not achieve adequate relief, then they should be replaced with an opioid for moderate-to-severe pain, such as morphine.

There is some debate of whether the effectiveness of step two on the who ladder adds value for the patient. The value lies in the accessibility of these drugs rather than the superiority of their effect on pain.

Chronic pain is a complex, multifaceted condition and Pharmacists must treat this with additional support and vigilance. Patients living with this condition, will also be dealing with the psychological impact of the condition.

This must be considered, perhaps in the form of support, counselling or medication.

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Supplements are big business and worldwide expenditure now outstrips pharmaceutical spend. Pharmacies have the perfect opportunity to provide customers with the correct information that not only helps people to be supremely healthy, but creates loyalty and repeat business.

When it comes to correct mineral and trace element supplementation, the way that they are presented that is key. There is no doubt from Government figures that food production is nutritionally deficient in micronutrients â&#x20AC;&#x201C; minerals, trace elements and vitamins. Medical science tells us we need them. Mineral cravings could provide part of the explanation as to why people over-eat.

The fact is that not all supplements are created equal.

If we understand how the body absorbs and utilises nutrients then it is easy to see why taking the wrong type and balance of minerals and trace elements fails to provide the expected health benefits. More importantly, we learn why Cellnutrition Quinton supplements are the best and how they help people to be healthy and get the most from food and other supplements too.

Minerals and trace elements are central to how the body absorbs and utilises other nutrients.

They are the first nutrients to be absorbed across the oral mucosa and the first to be absorbed at the top of the small intestine. They prime the gut to absorb the rest of the nutrients, be they macronutrients in food â&#x20AC;&#x201C; proteins, carbohydrates and fats, or other micronutrients such as vitamins and other supplements. They are also crucial for hydration.

For minerals and trace elements to be absorbed, they must be presented to the body in a bioavailable form. Inorganic minerals and trace elements that are used in the majority of multi-mineral tablets have low bioavailability. The elements are made bioavailable in nature through the action of plants on land and phytoplankton in the sea. We know that soil and plants are deficient.

Phytoplankton are found in certain areas of the oceans in large vortices that are visible

54

H. Dewayne. Mediacal Director Mineral nutrition in your life and health.

Keats Pub. New Canaan 1989

Minerals interaction Importance of balanced input

from space. They are crucial to life on the planet because their photosynthetic action not only makes inorganic elements bioavailable but collectively produces about 60% of the earthâ&#x20AC;&#x2122;s oxygen. Cellnutrition Quinton contains purely bioavailable minerals and trace elements because the marine plasma is seawater collected from these plankton blooms.

We know from scientific studies by physiologists, that the proportions of all the elements in the body are vital too. All the minerals and trace elements are co-dependent on each other. Some relationships are inhibitory, whilst others have a synergistic action. It is

impossible to supplement one or a few elements without upsetting the balance and function of others as the diagram below shows. This is why synthetic supplements based on just a few inorganic mineral sources cannot provide all the benefits their ingredients suggest.

Cellnutrition Quinton provides maximum benefits because all the minerals and trace elements are fully bioavailable and contains all the naturallyoccurring minerals and trace elements in the correct proportions which approximates to the ideal body composition.

Only a liquid supplement can provide this.

Taking Cellnutrition Quinton on a daily basis supports all cellular functions in every cell, which brings far-reaching health benefits. Due to the role that minerals and trace elements play in nutrition, it will also make other nutrients more bioavailable too. This includes not only food, but vitamins and products aimed at improving health including those for sport.

By advising pharmacy customers to take daily Cellnutrition Quinton they will achieve the health gains they are looking for and keep coming back, not just for their Cellnutrition Quinton, but for advice and other products too.

Business and Management

CPD

Reflection

Evaluation

Planning

Action

This information may be used and collected each month as an ongoing comprehensive programme for management in Pharmacy. The modules are suitable for use by anyone working in community pharmacy wanting to improve their effectiveness as a successful leader and manager for their continuing professional development.

Why CPD? Continuing profession educational development (CPD) is a legal requirement for pharmacists. Journal-based educational programmes are an important means of keeping up to date with professional developments and from a significant element of your CPD

Stress to Success Future-proof your business and professional career In this third of a series of leadership CPD articles, Rachel Dungan, ‘The Pharmacist Coach’ and founder of 4Front builds on your exploration of Values Based Decision Making (Oct 2016) and Personal Leadership (Nov 2016) to explore barriers and enablers of optimum performance and WHY ‘self-care’ and ‘communication skills’ are crucial leadership skills for pharmacists.

In this article you will explore the question “What factors enable and disable you to make and communicate decisions in ways that support you to achieve the results you want?”

Specifically we will examine the effect of stress on your relationship with yourself and others and explore its profound impacts on the pharmacy workplace.

EXPLANATION OF TERMS The true purpose of “communication”, it is helpful to look to its Indo-European derivative “Ko” meaning to share and “Mei” meaning change.

Optimal business and healthcare communication is therefore a “Ko Mei” process – a coming together in order to effect change.

Burnout is “progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the conditions of their work.”

Workplace Stress is “The adverse reaction people have to excessive pressures or other types of demand placed on them at work.”

(HSE UK, 2016).

Stressors can be viewed as either

positive (eustsress), which is the motivating type of stress that can help you feel challenged and productive or negative (distress).

Distress is not an illness – it is a state. However, if it becomes too excessive and prolonged, mental and physical illness may develop.

Resilience is the ability to balance the demands and pressures placed on you (i.e. the job requirements) with your skills and knowledge (i.e. your capabilities) Self-care is “providing adequate attention to one’s own physical and psychological wellness” (Beauchamp & Childress, 2001).

Being a successful pharmacist, not only requires the application of scientific knowledge and skills, but it also requires awareness of your own needs and the needs of others, communication skills and an ability to recognise and learn from both positive and negative experiences.

optimising and administering selfcare, your ability to exert a positive impact is enhanced.

Beyond being an aspirational goal, engaging in self-care has been described as an “ethical imperative” (Norcross & Barnett, 2008). Patient-facing healthcare professionals face a high risk for diminished personal well-being, including burnout, moral distress, and compassion fatigue, which can ultimately negatively impact professional competence.

The risks to personal wellbeing if not balanced by a proactive selfcare practice.

From a business perspective, role-modelling and facilitating self-care aids employee retention, performance, and team engagement. Proactively optimising focus and energy is both a key business growth and

risk management strategy. Risk is reduced by early recognition and response to stress in your own teams, as early intervention has been shown to have a significant effect improving safety and reducing errors.

“Employee engagement improves quality of work and health. For example, higher scoring business units report 48% fewer safety incidents; 41% fewer patient safety incidents; and 41% fewer quality incidents” (HBR 2013.07) https://hbr.org/2013/07/employeeengagement-does-more In the context of self-care, let’s explore Why We Do What We Do and how best to influence this by minimising risk factors that inhibit thriving environments and optimising conditions for peak performance. As a result, you and your team can make more

In terms of health outcomes, research shows that the quality of the relationship between pharmacist and patient is at least as important as the medicines dispensed.

In a business and professional context, Judith Glaser says “To get to the next level of greatness depends on our culture, which depends on the quality of our relationships, which depends on the quality of our conversations. Everything happens through conversations!”

Since YOU are the only constant in every interaction you have with customers, with your team, within your pharmacy business, it stands to reason that by actively

55

Business and Management

CPD

conscious decisions about which thoughts, emotions, behaviours and habits to continue to practice and which ones require upgrading to achieve even better results.

These insights can be applied

SURVIVAL-BASED STRESS RESPONSE – Long-term risk

THRIVE-BASED RESPONSE – Long-term success

Fight-Flight-Freeze-Appease Response

Rest-Digest Response

Sympathetic Drive

Parasympathetic Drive

Biochemistry driven by cortisol, adrenaline and noradrenaline

Biochemistry driven by dopamine, serotonin and oxytocin

Amygdala activated (“amygdala hijack”)

Striatum, insular cortex, nucleus accumbens activated

- as a profession

Pre-Frontal Cortex (“executive centre”) downregulated

Amygdala downregulated

- with patients

FOCUS OF ATTENTION

FOCUS OF ATTENTION

Recent understandings from neuroscience have revealed that behavioural changes, environmental changes and thoughts can all effect change in the neural pathways causing changes to physical structure and functional organisation of the brain, as a consequence of experience. This in turn affects how we respond to experiences.

This phenomenon is known as neuroplasticity, means that we ALL have the capacity to change, by creating an environment that aligns with the change.

“Away from”

“Towards”

“I” Focus

“We” focus

“I”llness

“We”llness

Isolation

Connection

Avoid what you don’t want

Achieve what you do want

Distrust

Trust

Minimise risk

Optimise Opportunity

Detect threats

Open to Options and Possibility

Problem Orientation

Solution Orientation

Blame and Excuses

Personal Responsibility

Attack or Defend

Curiosity and Collaboration

Reactive

Proactive

Maintain Status Quo

Expanding growth zone

Unconscious default habits drive behaviour

Conscious alignment of thought and behaviour habits enable goal attainment

- individually - as a team - as a business

Take a moment to read the table (right) which highlights how the stress response and the thrive response affect your willingness and ability to create long-term change. These same factors affect your patients and colleagues too!

THE BIOLOGY OF THE STRESS RESPONSE The stress response is a series of reactions triggered when you perceive a threat. When a real or imagined threat is perceived, the hypothalamic-pituitaryadrenal (HPA) axis is stimulated, triggering the release of cortisol and adrenaline. The amygdala is activated, which triggers the brains response to fear, resulting in this emotional experience being imprinted in long term memory.

The activity in the pre-frontal cortex is suppressed, impairing short-term memory, concentration and rational thinking. The stress response causes more reactive, defensive thinking and makes you less able to process new information, making you more likely to remain stuck in habitual default behaviours.

When chronically triggered, you are more likely to become uncommunicative, isolate yourself and easily lose sight of the big picture. Physical exhaustion from a body constantly ready to flee or fight leaves you ill-prepared to work.

56

It is vital to remember that until you allay the threat response, it is almost impossible for a person to process much else.

Moreover, perceived threats to mental, emotional or physical safety make people extremely resistant to change.

For pharmacy managers, remember they are balancing pressure from owners to produce

results with professional duty to maintain quality standards and pressure from their own teams to represent them in the pharmacy.

Pharmacists have strong clinical skills but little or no training for navigating the psychological pressures of management. They also tend to be the most hardworking and conscientious staff - those least likely to admit they’re experiencing stress and most likely

to try to put their job before their wellbeing.

For patients, remember their threat response has often been triggered before they even enter the pharmacy due to “diagnostic shock”, stigma, criticism, feelings of uncertainty, a perceived lack of control, any sense of unfairness or an experience where the healthcare professional has not demonstrated they have the patient’s best interests at heart.

In an environment where the ability to create and sustain long-term change is a major competitive advantage, the threat response tells you to keep things as they are, that there is safety in the familiar and that change is just another threat to deal with. If change implementation is a recurring resistance point, first and foremost, put strategies in place to minimise the threat response for both staff and customers.

Business and Management

CPD

THE THRIVE RESPONSE enables optimum performance 1. Social connection – Oxytocin (the “trust hormone”) release is stimulated when you have someone to confide in that has your best interests at heart, you have practical support and someone with whom you can discuss problems and share solutions. So what?

When oxytocin levels are low, inter-personal trust is low.

This places a hidden “tax” on every communication, every interaction, every strategy, every decision, bringing speed down and sending costs up. My experience is that significant distrust doubles the cost of doing business and triples the time it takes to get things done.

Stephen Covey 2014.

2. A sense of control – feeling you are in control of your work and health is one of the best predictors of longevity, for you and your patients. As humans we hate uncertainty and we do everything we can to avoid the feeling. In every pharmacy there is one powerful place of control, and that is the experience you create for each of your patients and staff. This means, for example, the access they have to you, the type of conversation they have with you and the health resources and services they can access through you.

To have a sense of control, focus on being truly engaged with your patients and staff and making a difference to them.

3. Dissipation – includes ongoing self-care practices designed to counter-balance the stress response. Activities must be enjoyable and may include aerobic exercise, dancing, bouncing on a trampoline, yoga, martial arts, meditation, diaphragmatic breathing, massage and positive affirmations.

4. Affirmations – Our thinking patterns have a powerful impact on our biochemistry.

Calling to mind something positive such as a happy memory or achievement increases serotonin production.

Conversely, ruminating on sad events decreases serotonin production. Being consciously aware of what is filling your mind and the effect it has on you and others can have a dramatic impact.

These strategies activate the pre-frontal cortex, which is involved in your ability to focus and plan, make informed decisions,

express your personality, align your thoughts and actions with your internal goals and moderate social behaviour. It also hosts your moral compass, helping you to have good judgement, and work towards defined goals. It supports creativity, flexible problem solving and working memory to enable you to be productive and effective.

Dungan believes that as digitalisation gathers speed, traditional dispensing and administration roles will increasingly be automated, requiring pharmacists to focus their energies on where humans can realistically outperform machines. Pharmacists will be hired for things robots cannot do such as patient consultations.

“The longest journey begins with the first step” – Chinese Proverb.

So what first step do you commit to taking immediately to enable you to make, communicate and act upon decisions in ways that support you to achieve the results you want?”

“To understand the individual context of a patient’s life – how they perceive the relevance and impact of their medical condition and the medicine you are dispensing to their fears, their hopes, their dreams. That’s a very human skill. There we are dealing with interpersonal communication, empathy, compassion. These profoundly human skills, along with others such as creativity, problem solving and caring, are the ones pharmacists will get hired for in the future”, she says.

For a complimentary one-to-one conversation, to learn more about leveraging your stress to success, schedule an appointment with Rachel by phone 086 6025584 or Rachel@racheldungan.com Interview: Anecdotally there is a worrying trend in pharmacy. That is that the brightest and the best, (the potential pharmacy leaders of the future) are becoming so disillusioned with the mis-match between their EXPECTATIONS of life as a practising pharmacist and their experience of its reality that they are leaving in their droves.

In Ireland, Pharmabuddy ran a poll in July 2016, in which 70% of 221 respondents suggested that they have considered leaving the profession. Similarly, in Australia, the AJP ran a poll with 1000-plus responses – where 82% suggested that they are reconsidering their future in pharmacy.

IPN asked Pharmacist Coach Rachel Dungan for her advice.

• Before you quit, spend time thinking about how have you been helping people with their health. How you have been making a difference?

• Are you getting caught up in the processes of pharmacy administration and dispensing, or are you engaging with your patients, building the quality of your relationship with them, stepping into an expanded health conversation and really making a difference to their health?

• And as you think about the future of pharmacy (or any other profession for that matter), consider whether far away hills really are greener. Carefully weigh up the pros and cons of staying in pharmacy and the pros and cons of leaving.

Shiri ben Arzi PCC, co-founder of the Medical Coaching Institute, advocates that pharmacists are ideally placed to partner with patients to empower them be more proactive about medication adherence, in the context of their health and wellbeing goals. That is why we adapted our Medical Coaching Model to the context of Effective Adherence Skills Training (E.A.S.T) for pharmacists and other healthcare professionals.

Dungan points out that advances in IT will continue to lead to the automation of administrative and dispensing tasks, and as this happens, pharmacists need to be able to adapt to change.

not the time”. But ask yourself, if not now, when?

Dungan says “The LEAD mastermind programme is designed to partner with pharmacists on this journey. Not only do participants gain insights and skills that develop their leadership, communication and decision making skills, but they also gain insights into their own needs and motivation, their own behavioural style and its impact on others and explore new ways to meet these needs at a higher level”.

In this process, you may find new ways of attaining what you are searching for within pharmacy. If this is the case, give yourself even just 15 minutes per day being that pharmacist. Then see how you feel. We often run away from that which we have worked so hard to attain because we don’t know how to create something new within it.

Remember, this is your one life. You are unique. There has never been (nor will there ever be) another human being just like you, with your unique gifts, talents, challenges, perspectives, education, experience. Ask yourself – How can I be the best I can be?

And then immediately embark on the journey to become that person.

You, your family, your friends and your profession can only benefit from you committing to this personal leadership journey.

“We are seeing a lot of pharmacists investing in their own personal and professional development. Gone are the days when pharmacists are doing training for the sake of training. They are being far more strategic, looking for opportunities that will benefit them professionally AND personally”.

Dungan says forward thinking pharmacists are enhancing their careers by developing their both their clinical and non-clinical skills such as leadership, self-management and communication skills.

According to Dungan, making big decisions demands going on your own journey of self-discovery You may have reached a point of self-reflection due to a crisis (personal, health, family, job) or through proactive reflection. Either way, it is crucial to create the space to listen to your inner voice.

Rachel Dungan, The Pharmacist Coach

This journey of self-discovery requires anchor points. There will always be distractions. There will always be excuses why “now is

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Event Gallery Haven Pharmacy 2016 Awards celebrated following another successful year for the pharmacy co-op There was great excitement at the 3rd annual Haven Pharmacy Awards which were held at a glittering black tie awards ceremony on 12th November at the Mount Wolseley Hotel in Carlow with over 400 guests attending including Haven Pharmacy staff and commercial partners.

The Haven Pharmacy Awards 2016 Winners

Entertainment on the night was provided by David Meade, mind reader & mentalist and the MC for the night was TV personality, Brian Ormond.

This year there were quite a few new faces attending the event for the first time as 7 pharmacies joined the Haven group during 2017 bringing the total number of Haven Pharmacies to 52.

There were 8 awards this year: Best use of Social Media, Haven in the Community Award, Haven Rising Star, Haven Newcomer of the Year, Haven Community Pharmacist of the Year, Haven Ambassador of the Year, Haven Customer Service Team of the Year and Haven Pharmacy of the Year Commenting on the night, Owen Daly, Chairman of Haven Pharmacy said: ‘This event has become the highlight of our year and affords us a chance to celebrate another successful year for Haven Pharmacy. It is also a great opportunity to catch up with old friends, make some new ones and welcome our new members into the Haven family.

Haven Pharmacy of the Year - sponsored by Clonmel Healthcare Sales Director, Barry Fitzpatrick presents the award to Frank Holly and his team from Haven Pharmacy Hollys, Liosban, Co. Galway

2016 has been another successful year for Haven Pharmacy. We continue to grow our co-operative and we recently celebrated the rebranding of our fiftieth Haven Pharmacy. Indeed since midSeptember we have welcomed four new Haven pharmacies into the co-operative, with two launches in Bandon along with Tramore and Roscrea.

On behalf of the board of Haven Pharmacy I would like to thank our sponsors who have made tonight possible. I would also like to thank the awards committee for all their hard work in making tonight such a fantastic occasion.

Congratulations to our award winners and thank you to everyone who has worked so hard to make Haven the fantastic organisation it is today.

Tonight, while we congratulate the winners of the much coveted Haven awards it is important to acknowledge the hard work and dedication of everyone within the Haven organisation. Your enthusiasm has been the key factor in making Haven Pharmacy the success it is today’

Haven Customer Service Team of the Year - sponsored by L’Oreal Active Cosmetics Commerical Director Brian Fagan presents the award to Paul Fahey and his team from Haven Pharmacy Faheys, Tullamore, Co. Offaly

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On the night, an amount of ¤5000 was raised for Our Lady’s Children’s Hospital, Crumlin.

Haven Ambassador of the Year - sponsored by GlaxoSmithKline National Account Manager Matthew Beattie presents the award to Helena Rusk from Haven Pharmacy Kennellys, Tralee, Co. Kerry

Haven Newcomer of the Year – sponsored by Perrigo Pharmacy National Account Manager Shane Tyrell presents the award to Dan Ryan and his team frim Haven Pharmacy Frawleys, Roscrea, Co. Tipperary

Haven Community Pharmacist of the Year – sponsored by Reckitt Benckiser National Account Manager Grainne Meagher presents the award to Hazel Kelly from Haven Pharmacy Hickeys, Rush, Co. Dublin

Haven Rising Star – sponsored by Teva Paul Moran presents the award to Sophie Hart from Haven Pharmacy Doherty’s, Beaumont, Dublin 9

Best use of Social Media – sponsored by Uniphar Key Account Manager Alan Mulvey presents the award to Liam Butler and his team from Haven Pharmacy Butler’s, Birr, Co. Offaly

Haven in the Community Award Year – sponsored by United Drug Head of Business Development Ed Gibbons presents the award to Kathy Maher and her team from Haven Pharmacy Duleek, Duleek, Co. Meath

A special thank you to all our sponsors of the night: Clonmel Healthcare, Glaxosmithkline Ireland, L’Oreal Active Cosmetics, Perrigo, Reckitt Benckiser Ireland Ltd, Teva Pharmaceuticals, Uniphar Retail Services, United Drug, Bradley Brand, Fleming Medical Ireland, HMR Ireland, Meda, Naturalife, Ocean Healthcare Ltd., Office Depot, Parle & Hickey, PCO Manufacturing, Pharma Support, PKF, Premium Shop Fitting Ltd, Sam McLernons.

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Appointments Juan Fravega works as ‘Client Solutions Consultant’ for his new company PharmaSupport. The company will offer support to independent Pharmacy owners and small groups. Juan has over 20 years’ experience in the retail industry, both in Ireland and abroad.

His experience includes property development, operations management, marketing and purchasing; much of which was gained in the community Pharmacy sector working for Uniphar Retail Services, the Allcare and Haven groups. Juan will see the official launch of PharmaSupport in March and he is looking forward to supporting, empowering and helping businesses to maintain the positive results they will see.

Stacks Pharmacy is delighted to announce the appointment of Victoria Jones to the role of Deputy Superintendent to the Stacks Pharmacy Group. Victoria is a graduate of UCD and RCSI and has been part of the Stacks Pharmacy team for over 6 years. Victoria’s first position following graduation was setting up a new wholesale company with three other pharmacists and was the managing partner for this successful venture. In 2010, Victoria returned to her first love of community pharmacy and joined the dynamic team of Stacks Pharmacy. She is excited to begin her new role within the company and is looking forward to tackling the challenges the industry currently faces.

Totalhealth Pharmacy is delighted to welcome Paula Gallagher to their team as Business Development Manager.

Paula has a wealth of pharmacy experience having worked in retail and dispensary areas in stores as well as having Store, Business Development & Marketing Managerial roles within Pharmacy and other sectors. Paula also previously managed REI Top 30 Store of the Year Finalists.

Paula is responsible for Business Development, Membership Liaison, Marketing and Brand Support for the Group.

Brought to pharmacies by leading distributor, Graham Anthony Distribution

The richest thermal water for Eczema and other skin irritations Xemose, from the thermal water brand from the Alps, is a line of new generation emollient care for extreme and long-lasting cutaneous comfort. It is particularly suitable for people who suffer from eczema, psoriasis, skin irritations and very dry skin.

The Xemose products have a triple barrier action for long lasting relief; Cerasterol 2F restructures and soothes, TRL2-Regul is an anti-inflammatory while the Uriage Thermal Water soothes, moisturises and relives pruritus. This range comes in different formats and is suitable for all atopy skin conditions, ichtyosis, psoriasis and eczema, cracked scaly skin, rough flaky, burning sensation and dry to very dry skin. This range acts fast and lengthens the time between flare ups of severe dryness.

Uriage is the leading dermo-cosmetic brand on the international market and is now available exclusively in pharmacies nationwide. It is the only Thermal water which is isotonic and can be used in the mucous membranes, it is the Richest Thermal Water, with the highest concentration of minerals and trace elements and 52 x richer than other thermal waters.

Unit 18b Rosemount Business Park Ballycoolin Road Blanchardstown Dublin 11 Dublin, Ireland P: 01 822 2711 E: sales@gadistribution.ie www.gadistribution.ie

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12/15/2016 11:54:18 PM

Over 85 Years of Service to Pharmacy!

Echinaforce range A.Vogel has launched the latest product in its highly popular Echinaforce range – a soothing hot drink to treat the symptoms of cold and flu including blocked noses, aching limbs, chills, headaches and fever.

The hot drink is the first of its kind in Ireland and combines the well-researched immune boosting benefits of fresh Echinacea extract with black elderberry (Sambucus nigra), rich in vitamin C and antioxidants. The drink is easy to make and has a pleasant flavour, similar to blackcurrant juice, without the unpleasant aftertaste of medicated hot drinks or any risk of painkiller overdose.

CatwalkHQ Self-Tanning Mousse

Body Essentials

CatwalkHQ SelfTanning Mousse contains extracts which are high in anti-oxidants, vitamins, minerals and are superfoods for the skin. The unique combination of amino acids hyaluronic acid and super extracts make the CatwalkHQ tanning experience one to remember!

Body Essentials provides a range of expertly blended products using natural ingredients to care for the feet and skin, enhance wellbeing and promote a healthy immune system.

A unique blend of therapeutic aromatherapy oils, for the prevention and treatment of mild to moderate skin and nail conditions. www.orthorest.com

Eucerin Dry Skin Intensive Lip Balm Eucerin Dry Skin Intensive Lip Balm instantly soothes and moisturises dry, chapped lips, making it an essential item this winter!

Contains liquorice extract which will help soothe the redness and soreness often experienced during the colder winter months.

RRP ¤7.00

P20

Irish Skincare Sensation

Sona Milk Thistle Forte

P20 provides the ultimate coverage, both in and out of the water, on and off the slopes for up to 10 hours a day. The experts at P20 advise adults and children alike to protect their skin all year round. The P20 range includes SPF15, SPF20, SPF30 and SPF50+ and prices range from RRP ¤19.99 - ¤34.99

Award winning range of natural skincare products.

A favourite with beauty bloggers and celebrities its word of mouth recommendations for amazing results.

Available from Kinvara skincare on 091 637878, or Wholefoods, recently been appointed as the sole distributor for pharmacies in Ireland.

Sona Milk Thistle Forte has confirmed unique liver-protecting properties. Milk Thistle seed extract is a tried and tested remedy that has been used in European medicine for over 2,000 years to treat liver and biliary tract diseases.

Uriage • Uriage Xemose Lipid-Replenishing Anti-Irritation Cream is a nourishing, protective cream that will instantly sooth any itching sensations that cause scratching due to eczema and will bring long lasting comfort. It instantly penetrates and reduces peaks of severe dryness.

Uriage is the richest Thermal Water, with the highest concentration of minerals and trace elements. RRP €19.50 • Uriage Xemose Gentle Cleansing Syndet is a very gentle cleansing cream-gel specially formulated for the daily cleansing of very dry, eczema or atopy-prone skin types. Its extra-gentle cleansing base eliminates impurities from the skin without harshness. RRP €18.50 Uriage is the richest Thermal Water, with the highest concentration of minerals and trace elements. Thermal Spring Water is the key ingredient unique to the Uriage dermatological skincare range and it is the basic ingredient in all of the Uriage product lines. uriage.ie

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RRP 30’s ¤9.50, 60’s ¤14.50

PharmaConex.com

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• Manage your account & bookings online • Team on call 24/7 • Locum Heroes - Rewarding Locum Triumphs For further information just call, email, or go to the ‘Training’ section on the PharmaConex website

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*Study conducted with women who were taking Cleanmarine® MenoMin for 3 consecutive months.

National Advertising & PR Campaign Jan 2017 Featuring Brand Ambassador Lorraine Keane Point of Sale & Staff Training Available DUBLIN:

Suite 330, The Capel Building, Mary’s Abbey, Dublin 7.

T:+353 1 4853522 SHANNON: 4230 Atlantic Avenue, Westpark Business Campus, Shannon, Co. Clare.

T: +353 61530202 Emergency Number: +353 87 201 5947- E: info@pharmaconex.com

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P: 0404 62444 E: nl@naturalife.ie

22/09/2016 5:31 p.m.

EUCERINÂŽ 100 YEARS OF INNOVATIVE SKIN SCIENCE

Eucerin is a dermatologist-recommended skin care brand based on honest skin science. Through working with dermatologists and using advanced technological expertise, Eucerin ensures reliable and highly effective product innovations to the highest dermatological standards.

*

By choosing active ingredients by the strength of their clinical proof, Eucerin is synonymous with excellent product quality and the combination of effectiveness and superior skin tolerability. * Licensing product information relating to Eucerin Intensive 10% w/w Urea Treatment Cream and Eucerin Intensive Lotion 10% w/w Cutaneous Emulsion.

Marketing authorisation holder: Beiersdorf UK Ltd, Birmingham B37 7YS, UK. Active ingredients: Urea EP 10% w/w. Directions: Apply twice daily to the affected areas of the skin. Indications: For the treatment of Ichthyosis, Xeroderma, Hyperkeratosis and Atopic Eczema/Dermatitis and other dry skin conditions. Precautions: Do not use if sensitive to any of the ingredients in cream or lotion. Do not use on broken, inflamed skin. Do not apply to large areas of skin on patients with renal insufficiency. This cream or lotion could increase the penetration of some substances, such as medicines known as corticosteroids, dithranol or fluorouracil. Avoid contact with the eyes or other sensitive areas. Keep out of reach of children. For external use only. Legal category: P PA 1159/1/1 (Cream) P PA1159/1/2 (Lotion).

To report any adverse reaction, please contact BDF Consumer Relations on 0044 845 6448556.

Eucerin is a registered trademark. Revised September 2015.

www.eucerin.ie

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Clinical Profiles

Bagsværd, Denmark, 12 November 2016 - Results from a study comparing the pharmacodynamics of Tresiba® (insulin degludec) with insulin glargine U300 in people with type 1 diabetes were presented today at the 16th Annual Diabetes Technology Meeting in Bethesda, US. Treatment with Tresiba® (0.4 U/kg) resulted in lower day-to-day and within-day variability* in glucose-lowering effect, compared with insulin glargine U300 (0.4 U/kg).1 The study showed that the day-today variability was approximately four times lower with Tresiba® than with insulin glargine U300. Withinday variability was approximately 40% lower with Tresiba®, with the glucose-lowering effect being more evenly distributed across 24 hours compared to insulin glargine U300.1 In addition, insulin glargine U300 showed a 30% lower potency assessed by the total glucose-lowering effect compared to Tresiba®.1 “While large-scale head-to-head trials are needed to compare the efficacy and safety of new insulins, pharmacodynamic studies are important, as they enable us to better understand their pharmacological properties. The more stable the glucose lowering profile of insulin, the easier it is to titrate and can help reduce the risk of hypoglycaemia and hyperglycaemia in patients with diabetes,” says Dr Tim Heise, lead scientist at the Profil Institute in Germany.

About the NN1250-4227 study This was a phase 1, single-centre, double-blind, two-period, crossover trial, where people with type 1 diabetes were randomly assigned to receive Tresiba® or insulin glargine U300 at a dose of 0.4 U/kg/day. A total of 57 people completed the study. Both treatments were administered once daily for 12 days, followed by a 7-21 day period in which the participants received no study treatment, before being crossed over to receive the other treatment for a further 12 days. In order to assess the pharmacodynamic variability in the glucose-lowering effect of Tresiba® and insulin glargine U300, each participant

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underwent six 24-hour glucose clamps (three during each 12-day study period) performed at steady state (where glucose levels are stabilised in the participants).1

Populations of Patients With Chronic Hepatitis C, Including Those With Compensated Cirrhosis, Renal Impairment or on Opioid Agonist Therapy

About Tresiba®

03rd November, 2016

Tresiba is a once-daily basal insulin that provides a duration of action beyond 42 hours.2,3 It is important for people with type 1 and type 2 diabetes to establish a routine for insulin treatment. On occasions when administration at the same time of day is not possible, Tresiba® allows for flexibility in day-to-day dosing time when needed.2,4,5 Tresiba® received its first regulatory approval in September 2012 and has since been approved in more than 80 countries globally. It was most recently approved by the FDA in the United States on 26 September 2015.

MSD has announced that the European Commission has approved ZEPATIER™ (elbasvir and grazoprevir) with or without ribavirin (RBV) for the treatment of chronic hepatitis C virus (HCV) genotype (GT) 1 or GT4 infection in adults.[1] ZEPATIER is MSD’s once-daily, fixed-dose combination tablet containing the NS5A inhibitor elbasvir (50mg) and the NS3/4A protease inhibitor grazoprevir (100mg). The recent approval allows marketing of ZEPATIER tablets in the 28 countries that are members of the European Union, as well as European Economic Area members, Iceland, Liechtenstein and Norway.

®

*within-day variability was assessed in a post-hoc analysis and calculated as the relative fluctuation, in order to account for the difference in potency between Tresiba® and insulin glargine U300.

NOVOSEVEN® RESOLVED 96.5% OF BLEEDS WHEN INITIATED WITHIN ONE HOUR AFTER BLEED ONSET IN PEOPLE WITH HAEMOPHILIA A OR B WITH INHIBITORS Bagsværd, Denmark, 3 December 2016 - Novo Nordisk today announced that NovoSeven® (rFVIIa), a portable room temperature stable recombinant activated factor VIIa, resolved 96.5% of bleeds when initiated within one hour after onset of bleeding, demonstrating efficacy of early treatment in people with haemophilia A or B with inhibitors.1 Efficacy also remained high for bleeds treated after 4 hours.1 A subanalysis of the SMART-7(TM) study, evaluating the efficacy of NovoSeven® in a real-world setting, was presented today at the 58th American Society of Haematology (ASH) annual meeting.

EUROPEAN COMMISSION GRANTS MARKETING AUTHORISATION FOR MSD’S ZEPATIER™ (ELBASVIR AND GRAZOPREVIR) FOR THE TREATMENT OF CHRONIC HEPATITIS C INFECTION • In Phase 3 Clinical Trials, ZEPATIER Achieved High Cure (SVR) Rates Across Diverse

Thousands of chronic HCV patients worldwide participated in the ZEPATIER clinical development programme, which was designed to include patients with known treatment challenges, such as those with compensated cirrhosis and those who have previously failed treatment with peginterferon plus RBV, with or without an HCV protease inhibitor.

In the trials, sustained virologic response (SVR) 12 weeks after the completion of therapy (SVR12, considered virologic cure based on undetectable HCV RNA levels) was achieved in 96 percent (301/312) of chronic HCV GT1b-infected patients treated with ZEPATIER for 12 weeks. In chronic HCV GT1a-infected patients, 93 percent (483/519) and 95 percent (55/58) achieved cure following treatment with ZEPATIER for 12 weeks or ZEPATIER plus RBV for 16 weeks, respectively.

“The approval of ZEPATIER in the EU, following approvals in the United States and Canada earlier this year, is an important step in offering a new and effective treatment for this devastating disease,” said Dr Colm Galligan, Medical Director, MSD in Ireland.

“MSD has a legacy of more than 30 years in working to combat chronic hepatitis C infection. We are committed to addressing this silent killer disease and providing treatment options for the greatest number of patients, in an effort to reduce the disease burden worldwide.”

Elbasvir/grazoprevir is an investigational, once-daily, fixed-dose combination therapy containing elbasvir and grazoprevir.

The combination was granted breakthrough therapy designation by the FDA, for the treatment of patients with chronic HCV GT1 infection with end stage renal disease on haemodialysis, and breakthrough therapy designation for elbasvir/grazoprevir for the treatment of patients with chronic HCV GT4 infection.[2]

THE SANOFI CLINICAL IS FAR TOO LONG TO FIT IN HERE

TRESIBA® DEMONSTRATED LOWER DAY-TO-DAY AND WITHIN-DAY VARIABILITY IN GLUCOSE-LOWERING EFFECT COMPARED WITH INSULIN GLARGINE U300

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Send your appointments announcements to Irish Pharmacy News Our appointments page offers you a chance to officially welcome your new colleague to your pharmacy and to let your peers know about positive happenings within your business. Simply send in 100-200 words providing some background career details on the person and a separate high-resolution headshot (preferably a JPEG) to accompany the piece.

Send your details and photograph to editorial@ipnirishpharmacynews.ie or call (01) 602 4715 for more details.

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