NIGP Nurses in General Practice September/October 2020

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ISSUE 5 VOLUME 13 | SEPTEMBER-OCTOBER 2020

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ASTHMA AND COPD VIRTUAL REVIEWS IN THE COVID ERA

OSTEOPOROSIS

FRAGILITY FRACTURES

ECZEMA RELIEVE THE ITCH

SEXUAL HEALTHCARE

NEW GUIDANCE

ASTHMA MODULE DIAGNOSIS AND MANAGEMENT

TRUST OUR COMPLETE TRUST OUR COMPLETE RANGE TO SUPPORT ALL RANGE TO SUPPORT ALL YOUR COW’S MILK ALLERGY YOUR COW’S MILK ALLERGY INFANTS INFANTS MILD - MODERATE

MODERATE - SEVERE

MILD - MODERATE

MODERATE - SEVERE AMINO ACID-BASED FORMULA (AAF) AMINO ACID-BASED FORMULA (AAF)

EXTENSIVELY HYDROLYSED FORMULA (EHF) EXTENSIVELY HYDROLYSED FORMULA (EHF)

GMS + ACBS Approved GMS + ACBS Approved

Pepti 1 From Birth

Pepti 2 From 6 mths

1 Ireland’ s best tasting EHF2formula Pepti 1 From Birth Pepti From 6 mths

Ireland’s best tasting EHF formula1

Neocate LCP From Birth 2 Ireland’sNeocate No. 1 Amino LCPAcid-based From BirthFormula

Ireland’s No. 1 Amino Acid-based Formula2

This information is intended for Healthcare Professionals only.

Neocate LCP, Aptamil Pepti 1 and Pepti 2 are Foods for Special Medical Purposes for the dietary This information issintended forInHealthcare Professionals management of cow’ milk allergy. addition, Neocate LCP is alsoonly. indicated for the dietary management of multiple food protein allergies and for infants who require an amino acid-based formula from birth.They must Neocate LCP, Aptamil 1 and Pepti are Foods for of Special Medical Purposes for the dietary be used under medicalPepti supervision after2consideration all feeding options, including breastfeeding. management of cow’s milk allergy. In addition, Neocate LCP is also indicated for the dietary management of multiple protein allergies and for infants who require an amino acid-based formula from birth.They must Accuratefood at time of publication: September 2020 be used under medical supervision after consideration of all feeding options, including breastfeeding.

References Accurate at time of publication: September 2020 1. O’Carroll E et al. (Abstract) Presented at The Nutrition Society Advancing Nutritional Science Spring Conference, Glasgow. 2018. 2. Nutricia Data on File, 2020 References

1. O’Carroll E et al. (Abstract) Presented at The Nutrition Society Advancing Nutritional Science

Welcome

NMBI ELECTIONS 2020 Karen Canning, General Practice Nurse and NMBI board member seeks your vote What a strange year 2020 ‘International Year of the Nurse and the Midwife’ has been for us all, our families and our friends. I hope you and your families have stayed safe and well throughout.

The year has flown so far despite the lockdown, the various guidelines and the many restrictions in place.

Important milestones which would normally be celebrated have been cancelled or put on hold, eg, big birthdays, graduations and anniversaries and of course no foreign holidays. In April my ‘Richmond’ hospital class was due to celebrate our 40 year anniversary of starting general nurse training.

What I miss most (like all of you) is human contact. We are social beings.

We miss not being able to hug close family members and friends.

I miss our monthly face to face IPNA educational meetings, as well as the other groups I represent: ICGP/IPNA/ UCD steering group, ToP Clinical Advisory Forum and Cervical Check Clinical Advisory Group.

I also miss face to face NMBI committee meetings and board meetings because NMBI is a huge part of my life outside working hours. Zoom and team virtual meetings are just not the same due to lack of contact.

There is estimated to be around 2000 GPNs nationally. Because not all GPNs are IPNA members or on the PDCs lists and we have no database or division on the NMBI register it is hard to get a true figure.

NMBI role 2015-2020 Back in 2015 Breda Liston (RCN) and I (RGN), both administrators of a nursing and midwifery Facebook page, which I set up the previous year in response to NMBI proposing a 50 per cent increase in our retention fee, were

elected to the board In December our five-year term of office on the board will end.

We had no idea of the workload and the level of commitment involved but along with the other board members, have been proactive and have achieved a substantial amount in progressing positive changes within NMBI. During our time on the board, we have had extensive training and gained expertise in: ▸ Regulatory boards and regulation of professions (this includes Fitness to Practice), ▸ Standards in public office, ▸ Legal and legislative requirements, ▸ Organisational strategic planning and implementation, ▸ Governance, audit and risk management and financial procedures.

As a board member, one is required to be a member of at least two committees.

I am Vice Chair of the Fitness to Practice Committee, member of the Business, Strategy and Finance Committee and the Monitoring the Maintenance of Professional Competence (MMPC) Steering Committee. As a non HSE employed registrant I was able to contribute significantly on behalf of GPNs to the MMPC. A few years ago, in order to give more time to NMBI to which I am extremely committed, I reduced my clinical practice hours.

As the only non HSE employed registrant present (and non-union member), I regularly bring the voice of the general practice nurse to NMBI at committee and board level.

For the past number of years Roisin Doogue and I have been working with

the ICGP in devising a PGDip in general practice nursing with the aspiration of GP nursing having its own division on the NMBI register. During my first year in NMBI I discussed the possibility of a GPN Division on the Register with the then Director of Education. In more recent times I have had a few discussions with Ms Anne Marie Ryan, Director of Professional Standards and Education regarding annotation because according to the Nurses and Midwives Act 2011 there is currently no possibility of extra divisions being added.

It has been a huge yet enjoyable learning curve. Everyday is a school day in NMBI. I had the IPNA support then and I am delighted to have it again as I go for reelection next month.

As your elected representative I want to assure you that I have always and will continue to work for you if given the opportunity. I have always championed your best interests at both committee and board level.

I urgently need your help, support and YOUR VOTE to get over the line and re-elected to a second (and final) term of office to continue to represent you.

I hope that we will be leaving behind us in 2025 a regulator that we can individually and collectively be proud of.

We need your support to ensure we do not leave the job half done.

So please: ▸ Vote for me, Karen Canning, RGN seat. ▸ Vote for Breda Liston, RCN seat. ▸ Ask your colleagues to please vote for us too. ▸ Check in and out of our ‘I am a General Practice Nurse’ Facebook page for updates.

A message from Karen Canning

Thank you.

SEPTEMBER-OCTOBER 2020 1

Contents EDITOR Niamh Cahill CONSULTING EDITOR Ruth Morrow SUB-EDITOR Emer Keogh emer@greenx.ie ADVERTISEMENTS Graham Cooke graham@greenx.ie ADMINISTRATION Daiva Maciunaite daiva@greenx.ie

04

NEWS

© Copyright GreenCross Publishing Ltd. 2020

Please email publishing enquiries to Publisher and Director, Graham Cooke graham@greenx.ie The contents of Nursing in General Practice are protected by copyright.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers.

DISCLAIMER The views expressed in Nursing in General Practice are not necessarily those of the publishers, editor or editorial advisory board.

While the publishers, editor and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

Covid-19 has altered the delivery of healthcare in many ways, including sexual healthcare. GP Dr Nicola

13

Cochrane looks at what has changed and offers important guidance for healthcare

14

professionals on the topic

VIRTUAL ASTHMA AND COPD REVIEWS Advanced nurse practitioner Ruth Morrow provides a comprehensive, informative module on asthma, with multiple choice and

42

LIFE: MOTORING

true or false questions

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OSTEOPEROSIS

26

David Askin examines the area of fragility fractures in osteoporosis

Countryman

44

LIFE: CULTURE NIGP talks to Bianca Divito, an award-winning stained-glass designer and conservator, from Co Wicklow

Atopic eczema comes under focus in this educational article from Prof AnneMarie Tobin and Michelle Greenwood

CROHN’S DISEASE AND ULCERATIVE COILITIS Siún Tobin presents a clinical overview of Crohn’s disease and ulcerative colitis presentation and management strategies

36

reviews the Mini

for nurses on management

ATOPIC ECZEMA

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Morgan Flanagan Creagh

and offers succinct guidance

COPD Ruth Morrow offers guidance on how to perform virtual asthma and COPD consultations as remote healthcare continues to increase in primary care

2 SEPTEMBER-OCTOBER 2020

39

RECRUITMENT

Please email editorial enquiries to Priscilla Lynch priscilla@mindo.ie Nursing in General Practice is produced by GreenCross Publishing Ltd (est. 2007).

NEC, Regional and NIGP News

SEXUAL HEALTHCARE

44

PRODUCT NEWS

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NIGP CROSSWORD

The Pelgraz® Patient App Find out how the Pelgraz® Patient App can help your patients to confidently self inject from home

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*One dose per chemo cycle

One Dose for ANC Recovery

NEW Pelgraz ® Device Patient & App

Confidence, Convenience, Compliance Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing Pelgraz▼(pegfilgrastim) 6 mg solution for injection in pre-filled injector.

Presentation: Each pre-filled injector contains 6 mg of pegfilgrastim* in 0.6 mL solution for injection. The concentration is 10 mg/mL based on protein only**. *Produced in Escherichia coli cells by recombinant DNA technology followed by conjugation with polyethylene glycol (PEG). ** The concentration is 20 mg/mL if the PEG moiety is included. Indications: Reduction in the duration of neutropenia and the incidence of febrile neutropenia in adult patients treated with cytotoxic chemotherapy for malignancy (with the exception of chronic myeloid leukaemia and myelodysplastic syndromes). Dosage and Administration: Pelgraz therapy should be initiated and supervised by physicians experienced in oncology and/or haematology. Posology: One 6 mg dose (a single pre-filled injector) of Pelgraz is recommended for each chemotherapy cycle, given at least 24 hours after cytotoxic chemotherapy. Safety and efficacy of Pelgraz in children and adolescents has not yet been established and no recommendation on a posology can be made. No dose change is recommended in patients with renal impairment, including those with end-stage renal disease. Method of administration: Pelgraz is for subcutaneous use. The injections should be given subcutaneously into the thigh, abdomen or upper arm. See SmPC for instructions on handling of the medicinal product before administration.

Contraindications: Hypersensitivity to pegfilgrastim or any of the excipients in Pelgraz.

Warnings and precautions: To improve the traceability of biological medicinal products, the trade name of the administered product should be clearly recorded. The long-term effects of pegfilgrastim have not been established in acute myeloid leukaemia (AML); therefore, it should be used with caution in this patient population. Granulocyte-colony stimulating factor (G-CSF) can promote growth of myeloid cells in vitro and similar effects may be seen on some nonmyeloid cells in vitro. The safety and efficacy of pegfilgrastim have not been investigated in patients with myelodysplastic syndrome, chronic myelogenous leukaemia, and in patients with secondary AML; therefore, it should not be used in such patients. Particular care should be taken to distinguish the diagnosis of blast transformation of chronic myeloid leukaemia from AML. The safety and efficacy of pegfilgrastim administration in de novo AML patients aged < 55 years with cytogenetics t(15;17) have not been established. The safety and efficacy of pegfilgrastim have not been investigated in patients receiving high dose chemotherapy. This medicinal product should not be used to increase the dose of cytotoxic chemotherapy beyond established dose regimens. Pulmonary adverse reactions, in particular interstitial pneumonia, have been reported after G-CSF administration. Patients with a recent history of pulmonary infiltrates or pneumonia may be at higher risk. The onset of pulmonary signs such as cough, fever, and dyspnoea in association with radiological signs of pulmonary infiltrates, and deterioration in pulmonary function along with increased neutrophil count may be preliminary signs of Adult Respiratory Distress Syndrome (ARDS). In such circumstances pegfilgrastim should be discontinued at the discretion of the physician and the appropriate treatment given.

www.accord-healthcare.ie

Glomerulonephritis has been reported in patients receiving filgrastim and pegfilgrastim.

Generally, glomerulonephritis resolved after dose reduction or withdrawal of filgrastim and pegfilgrastim. Urinalysis monitoring is recommended. Capillary leak syndrome has been reported after G-CSF administration and is characterised by hypotension, hypoalbuminaemia, oedema and haemoconcentration. Patients who develop symptoms of capillary leak syndrome should be closely monitored and receive standard symptomatic treatment, which may include a need for intensive care. Generally asymptomatic cases of splenomegaly and cases of splenic rupture, including some fatal cases, have been reported following administration of pegfilgrastim. Spleen size should be carefully monitored (e.g. clinical examination, ultrasound).

A diagnosis of splenic rupture should be considered in patients reporting left upper abdominal pain or shoulder tip pain. Treatment with pegfilgrastim alone does not preclude thrombocytopenia and anaemia because full dose myelosuppressive chemotherapy is maintained on the prescribed schedule. Regular monitoring of platelet count and haematocrit is recommended. Special care should be taken when administering single or combination chemotherapeutic medicinal products which are known to cause severe thrombocytopenia.

Sickle cell crises have been associated with the use of pegfilgrastim in patients with sickle cell trait or sickle cell disease. Therefore, use caution when prescribing pegfilgrastim in patients with sickle cell trait or sickle cell disease, monitor appropriate clinical parameters and laboratory status and be attentive to the possible association of this medicinal product with splenic enlargement and vasoocclusive crisis. White blood cell (WBC) counts of 100 x 109 /L or greater have been observed in less than 1% of patients receiving pegfilgrastim. No adverse reactions directly attributable to this degree of leukocytosis have been reported. Such elevation in WBCs is transient, typically seen 24 to 48 hours after administration and is consistent with the pharmacodynamic effects of this medicinal product. Consistent with the clinical effects and the potential for leukocytosis, a WBC count should be performed at regular intervals during therapy.

If leukocyte counts exceed 50 x 109 /L after the expected nadir, this medicinal product should be discontinued immediately. Hypersensitivity, including anaphylactic reactions, have been reported with pegfilgrastim. Permanently discontinue pegfilgrastim in patients with clinically significant hypersensitivity. Do not administer pegfilgrastim to patients with a history of hypersensitivity to pegfilgrastim or filgrastim. If a serious allergic reaction occurs, appropriate therapy should be administered, with close patient follow-up over several days. StevensJohnson syndrome (SJS), which can be life-threatening or fatal, has been reported rarely in association with pegfilgrastim treatment. If the patient has developed SJS with the use of pegfilgrastim, treatment must not be restarted at any time. As with all therapeutic proteins, there is a potential for immunogenicity. Rates of generation of antibodies against pegfilgrastim is generally low. Binding antibodies do occur as expected with all biologics; however, they have not been associated with neutralising activity at present. Aortitis has been reported after filgrastim or pegfilgrastim administration in healthy subjects and in cancer patients. The symptoms experienced included fever, abdominal pain, malaise, back pain and increased

Oncology & Haematology

inflammatory markers (e.g. C-reactive protein and WBC count). In most cases aortitis was diagnosed by CT scan and generally resolved after withdrawal of filgrastim or pegfilgrastim. The safety and efficacy of Pelgraz for the mobilisation of blood progenitor cells in patients or healthy donors has not been adequately evaluated. Increased haematopoietic activity of the bone marrow in response to growth factor therapy has been associated with transient positive boneimaging findings. This should be considered when interpreting bone- imaging results. This medicinal product contains 50 mg sorbitol in each unit volume, which is equivalent to 30 mg per 6 mg dose. Pelgraz contains less than 1 mmol (23 mg) sodium per 6 mg dose, that is to say essentially ‘sodium-free’. The needle cover contains dry natural rubber (a derivative of latex), which may cause allergic reactions. Pregnancy and Lactation: Pegfilgrastim is not recommended during pregnancy and in women of childbearing potential not using contraception. A decision must be made whether to discontinue breastfeeding or to discontinue/ abstain from pegfilgrastim therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman. Adverse Events include: Adverse events which could be considered serious include: Common: Thrombocytopenia. Uncommon: Sickle cell crisis, capillary leak syndrome, glomerulonephritis, hypersensitivity reactions (including angioedema, dyspnoea, anaphylaxis), splenic rupture (including some fatal cases), Sweet’s syndrome (acute febrile dermatosis), pulmonary adverse reactions including interstitial pneumonia, pulmonary oedema and pulmonary fibrosis have been reported. Uncommonly cases have resulted in respiratory failure or ARDS which may be fatal. Rare: Aortitis, pulmonary haemorrhage, Stevens-Johnson syndrome. Other Very Common adverse events: Headache, nausea, bone pain. Other Common adverse events: Leukocytosis, musculoskeletal pain (myalgia, arthralgia, pain in extremity, back pain, musculoskeletal pain, neck pain), injection site pain, non-cardiac chest pain. See SmPC for details of other adverse events. Shelf Life: 3 years. Store in a refrigerator (2°C – 8°C). Pelgraz may be exposed to room temperature (not above 25°C ± 2°C) for a maximum single period of up to 72 hours. Pelgraz left at room temperature for more than 72 hours should be discarded. Do not freeze. Accidental exposure to freezing temperatures for a single period of less than 24 hours does not adversely affect the stability of Pelgraz. Keep the container in the outer carton in order to protect from light. Pack Size: One prefilled injector with one alcohol swab, in a blistered packaging. Marketing Authorisation Number: EU/1/18/1313/002. Marketing Authorisation Holder (MAH): Accord Healthcare S.L.U, World Trade Center, Moll de Barcelona, s/n, Edifici Est, 6a planta, Barcelona, 08039 Spain. Legal Category: POM. Full prescribing information including the SmPC is available on request from Accord Healthcare Ireland Ltd, Euro House, Little Island, Co. Cork, Tel: 021-4619040 or www.accord-healthcare.ie/products. Adverse reactions can be reported to Medical Information at Accord-UK Ltd. via E-mail: medinfo@accordhealthcare.com or Tel: +44(0)1271385257.

Date of Generation of API December 2019. IE-01454

Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie), or by e-mailing medsafety@hpra.ie. Adverse events should also be reported to Medical Information via email; medinfo@accord-healthcare.com or tel:0044 (0) 1271 385257

May 2020. IE-01429

NEC News IMPORTANT NOTICE

IPNA ANNUAL GENERAL MEETING to be held on Saturday 14th November 2020.

Regional News NEWS FROM IPNA BRANCHES COUNTRYWIDE Please email your branch news to Priscilla Lynch, priscilla@mindo.ie

The AGM will be facilitated virtually on this occasion and full details regarding same will be circulated to all members in advance.

MOTIONS FOR AGM 2020 RECEIVED The National Executive Committee would like to propose the motion that: The title “Irish Practice Nurses Association” (IPNA) be reviewed and replaced with a title which reflects the term General Practice Nurse and the educational objectives of the organisation. To be discussed at AGM 2020.

IPNA WEBSITE The IPNA website is currently undergoing refurbishment; we are looking forward to a more user friendly, and easy to navigate website.

In the meantime, please do not hesitate to get in touch with Caroline Daughton, IPNA administrator, if you require any information Email: admin@irishpracticenurses.ie.

IPNA MEMBERSHIP SECRETARY The NEC regret to inform members that Winnie Quigley, Membership Secretary, is stepping down.

Winnie was appointed to the position in August 2018 and despite holding the position for a relatively short duration has made significant improvements for members in relation to their membership, including ensuring an online renewal system that is user friendly, seamless and far more efficient. The NEC would like to thank Winnie for all her support and wish her the very best in the future.

4 SEPTEMBER-OCTOBER 2020

LOUTH/MEATH GRÁINNE MURPHY

The final meeting for the Louth Meath branch took place on 27th February 2020, which coincided with the first confirmed case of Covid-19 in Ireland.

Following a lively educational meeting with Paul Stoneman we were fortunate to hold the branch AGM. Our treasurer Jackie O Connell presented the branch accounts. Marie Colgan Cantwell agreed to take up the position of vice chairperson, with a view to become chairperson at a later date. We hope that having the opportunity to share the role will encourage members to take an active role in the running of the branch.

Over the months of the pandemic, MLearning became a good source of information and some valuable topics were discussed.

The branch is planning to run its first zoom meeting on 24th September. Our sponsor is Amanda Breen from Astra Zeneca. Hopefully this new initiative will run smoothly. The topic selected is “The Link between Heart Disease and Diabetes”. This theme was chosen, as many of us embark on chronic disease management in primary care with-

out much preparation. This forum for meetings will undoubtedly become the way forward and will provide some continuous professional education from the comfort and safety of our own homes.

We look forward to a time when it is safe to meet in person and enjoy a social evening together. If there are any nurses working in general practice who are paid up members of other branches and would like to access the Louth Meath zoom meetings, please get in touch and I can send you the link. Also, if you know of any general practice nurses considering joining the IPNA, and who would like to access one of our meetings to get a sense of what the organisation entails please share my details. Any lapsed members who wish to re-join are very welcome and this format may prove more suitable than travelling to meetings.

On behalf of the Louth Meath branch I would like to wish Niamh Cahill all the very best, as this is her final edition of NIGP. She has done a superb job as editor and has always been efficient and dependable. Your replacement has big shoes to fill.

News

GPs

DOCTORS HAVE ‘DUTY’ TO FOLLOW COVID-19 PUBLIC HEALTH GUIDELINES The President of the Irish Medical Council, Dr Rita Doyle, has said that doctors have a professional and ethical duty, and a responsibility to both their patients and wider society, in following and promoting Covid-19 public health guidelines.

The Guide to Professional Conduct and Ethics for Registered Medical Practitioners sets out the principles of professional practice that all registered doctors should follow for the benefit of their patients, themselves, colleagues and the wider public.

This includes having a duty to ensure compliance with all laws and regulations relating to their practice. This also includes ensuring doctors promote a culture of patient safety within the context of the wider health system.

Doctors also have responsibilities when it comes to posting on social media. The Guide to Professional Conduct and Ethics for Registered Medical Practitioners states: “You should always think about the possible impact on colleagues, patients or the public’s perception of the profession, before publishing comments on social media sites”.

Dr Doyle said: “As we enter our seventh month with Covid-19 impacting our daily lives and as we look ahead to what may be a very challenging winter for the health services, we must all, as a nation, ensure we follow the guidance from our public health experts and NPHET.” “Doctors must continue to advocate for their patients by actively promoting the public health guidance, especially the three core actions of hand washing, social distancing and the wearing of face coverings.

“We all have a role to play as citizens. Follow the guidelines and know the symptoms. If displaying any signs or symptoms of Covid-19 restrict your movements and contact your GP. We must all redouble our efforts and follow the guidance,” concluded Dr Doyle.

COVID-19

REDEPLOYMENTS SET TO CONTINUE UNTIL YEAR END

All temporary staff redeployments to support regional departments of public health and the Health Protection Surveillance Centre (HPSC) in their response to Covid-19 have been extended until the end of 2020, it has emerged.

In addition to the above, staff originally redeployed but who had later been recalled to their usual posts are to “be made available to public health for recall with immediate effect”.

The actions were detailed in a letter dated 11th August to HSE managers who have had originally provided staff for redeployment.

The letter, sent by Dr Lorraine Doherty, HSE National Clinical Director Health Protection, seeks the support of managers in implementing the measures.

At the time, it was noted that new cases remained “relatively low” compared to the peak of the pandemic, but that 183 open outbreaks were being managed.

A Public Health Pandemic Workforce Plan has been developed by the HSE, the letter advises, of which redeployments are an “essential component”.

The letter states, “It is expected that resources will be secured” to stabilise the pandemic response, suggesting that permanent support for public health

remains lacking.

Redeployments will be used to scale up and down capacity “as required”, as changing patterns of the disease occur over the coming months, according to the letter.

Sources have said that while redeployments are taking place theoretically, they do not always materialise in practice.

Redeployed staff are slow to return to public health posts, it is understood, because they are reluctant to leave their usual roles.

Furthermore, some staff redeployed once again to public health are returning for shorter periods than previously, at only 0.6 whole time equivalent (WTE), meaning redeployed staff will remain partly working in their usual role 0.4 WTE of the time.

Public health departments nationally are already chronically under-resourced and aside from redeployments, more permanent resources have yet to be secured almost six months into the pandemic.

It is understood that the redeployments to public health were primarily taken from community healthcare organisations (CHOs) and national services, such as Health and Wellbeing.

SEPTEMBER-OCTOBER 2020 5

News

MENTAL HEALTH

INCREASE IN PATIENTS WAITING FOR CIPC APPOINTMENT A HSE counselling service for people with mild to moderate psychological difficulties has seen a significant increase in the number of people waiting for an appointment since the Covid-19 pandemic emerged.

At the end of March, 18 per cent were waiting more than six months for an appointment with the Counselling in Primary Care (CIPC) Service. This increased to 38 per cent at the end of June, new figures show.

The pandemic has resulted in a change in the nature of referrals being made, with the impact of the virus evident in the reasons for referral, which include bereavement, health anxiety, financial stress, relationship difficulties and domestic violence, according to a HSE spokeswoman.

A significant factor contributing to the increased waiting time was the impact of restrictions on face to face appointments, which were paused in March.

The service remains unable to provide face to face appointments “in some areas”. Furthermore, certain staff were redeployed to assist in the response to the pandemic, resulting in a pause in service delivery in some parts of the country.

“A significant proportion of clients opted to wait for face to face counselling rather than avail of counselling by phone or video, despite the longer waiting time,” said a spokeswoman.

When face to face services were paused, structured phone counselling and online video counselling was introduced to mitigate the impact of the pause and reduce disruption to clients in counselling.

Challenges providing counselling to individuals who require interpreters and for those unable to avail of phone or video counselling due to lack

6 SEPTEMBER-OCTOBER 2020

of access to broadband, no access to a mobile device, or privacy or confidentiality issues have emerged.

A drop in new referrals to the service following the introduction of lockdown measures in March occurred, with monthly referral rates in April and May less than half that for the same period in 2019.

The referral pathway to the service is through GPs, and presentations to GP surgeries dropped significantly during the height of the pandemic in April and May. Recent figures for June indicate an increase in referrals towards pre-pandemic levels.

A HSE spokeswoman explained that “GP visits dropped significantly at the height of the COVID pandemic and this had a knock on effect on new referrals to CIPC as many people were not accessing their GP.” Up to the end of June, almost 4,500 patients had been seen by the service this year. Around 4,800 patients were discharged up to the end of June.

The service, established in 2013, is delivered by 200 full time and part time counsellors nationally.

Normally patients are seen weekly.

They are usually offered their second appointment a week after their first unless the client chooses otherwise.

A HSE spokewoman said the CIPC’s experience is “in line with international emergency experience, which indicates that as the acute medical crisis passes, the psychosocial impact of the pandemic becomes more apparent”.

“While the majority of the population will recover in the short to medium term without professional intervention a significant proportion of people are expected to experience longer lasting mental distress with increases in demand for formal psychosocial supports such as CIPC, as a result.”

MEDICATION SAFETY

EMA REVOKES MARKETING AUTHORISATION OF ULIPRISTAL ACETATE FOR UTERINE FIBROIDS

A review by European Medicines Agency (EMA) safety committee (PRAC) has confirmed that 5-mg ulipristal acetate (Esmya and generic medicines) used for the treatment of symptoms of uterine fibroids can cause liver injury, including the need for liver transplantation.

The safety committee has therefore recommended the revocation of the marketing authorisations of these medicines.

The committee considered all the available evidence in its review, including reported cases of serious liver injury.

Patient and healthcare professional representatives, including experts in gynaecology, were also consulted.

Since it was not possible to identify which patients were most at risk or measures that could reduce the risk, the PRAC concluded that the risks of these medicines outweighed their benefits and that they should not be marketed in the EU. The use of 5-mg ulipristal acetate medicines for uterine fibroids had already been suspended as a precautionary measure while awaiting the outcome of this review.

Ulipristal acetate is also authorised as a singledose medicine for emergency contraception. This recommendation does not affect the single-dose ulipristal acetate emergency contraceptive (ellaOne and other trade names) and there is no concern about liver injury with these medicines.

The journey to triple protection in T2D starts at the kidneys Choose INVOKANA – the only SGLT2i licensed to offer your T2D patients triple protection against renal events, CV events and elevated HbA1c1–4

INVOKANA® (canagliflozin) 100 mg & 300 mg film-coated tablets.

PRESCRIBING INFORMATION. REPUBLIC OF IRELAND. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. INDICATIONS: The treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise as monotherapy when metformin is considered inappropriate due to intolerance or contraindications, or in addition to other medicinal products for the treatment of diabetes. DOSAGE & ADMINISTRATION: Adults: recommended starting dose: 100 mg once daily. In patients tolerating this dose and with eGFR ≥ 60 mL/min/1.73 m2 needing tighter glycaemic control, dose can be increased to 300 mg once daily. For oral use, swallow whole. Caution increasing dose in patients ≥ 75 years old, with known cardiovascular disease or for whom initial canagliflozininduced diuresis is a risk. Correct volume depletion prior to initiation.

When add-on, consider lower dose of insulin or insulin secretagogue to reduce risk of hypoglycaemia. Children: no data available. Elderly: consider renal function and risk of volume depletion. Renal impairment: for the treatment of diabetic kidney disease (DKD) as add on to standard of care (SOC) (e.g. ACE inhibitors or ARBs), initiate with 100 mg dose. The glycaemic lowering efficacy of canagliflozin is reduced in patients with moderate renal impairment and likely absent in severe renal impairment. If eGFR falls below 60 mL/min/1.73 m2 during treatment, adjust or maintain dose at 100 mg once daily. eGFR(mL/min/1.73m2) or CrCl (mL/min)

Total daily dose of canagliflozin

≥60

Initiate with 100 mg If tolerating 100 mg and needing additional glycaemic control, increase dose to 300 mg

45 to < 60a

Initiate with 100 mg If already taking Invokana – continue 100 mg

30 to < 45a,b

Initiate with 100 mg If already taking Invokana – continue 100 mg

< 30a,b

Do not initiate If already taking Invokana – continue 100 mgc

Consider addition of other anti-hyperglycaemic agents if further glycaemic control is needed With urinary albumin/creatinine ratio > 300 mg/g c Continue until dialysis or renal transplantation Hepatic impairment: mild or moderate; no dose adjustment. Severe; not studied, not recommended.

Hepatic impairment: mild or moderate; no dose adjustment. Severe; not studied, not recommended. CONTRAINDICATIONS: Hypersensitivity to active substance or any excipient. SPECIAL WARNINGS & PRECAUTIONS: Not for use in type 1 diabetes. Renal impairment: a

b

regardless of pretreatment, patients on canagliflozin had an initial fall in eGFR that attenuated over time. eGFR < 60 mL/min/1.73 m2: higher incidence of adverse reactions associated with volume depletion particularly with 300 mg dose; more events of elevated potassium; greater increases in serum creatinine and blood urea nitrogen (BUN); limit dose to 100 mg once daily. Not studied in severe renal impairment.

Monitor renal function prior to initiation and at least annually. Volume depletion: caution in patients for whom a canagliflozin- induced drop in blood pressure is a risk (e.g. known cardiovascular disease, eGFR < 60 mL/min/1.73 m2, anti-hypertensive therapy with history of hypotension, on diuretics or elderly). Not recommended with loop diuretics or in volume depleted patients. Monitor volume status and serum electrolytes. Diabetic ketoacidosis (DKA): rare DKA cases reported, including life-threatening and fatal. Presentation may be atypical (blood glucose <14mmol/L). Risk appears higher in patients with moderate to severe decrease in renal function who require insulin. Consider DKA in event of non-specific symptoms. If DKA is suspected or diagnosed, discontinue Invokana treatment immediately. Interrupt treatment in patients who are undergoing major surgical procedures or have acute serious medical illnesses. Monitoring of (preferably blood) ketone levels is recommended in these patients. Consider risk factors for development of DKA before initiating Invokana treatment. Elevated haematocrit: careful monitoring if already elevated. Genital mycotic infections: risk in male and female patients, particularly in those with a history of GMI. Lower limb amputation: Consider risk factors before initiating. Monitor patients with a higher risk of amputation events, counsel on routine preventative foot care and adequate hydration. Consider discontinuing Invokana when events preceding amputation occur (e.g. lowerextremity skin ulcer, infection, osteomyelitis or gangrene). Necrotising fasciitis of the perineum (Fournier’s gangrene): post-marketing cases reported with SGLT2 inhibitors. Rare but serious, patients should seek medical attention if experiencing symptoms including pain, tenderness, erythema, genital/perineal swelling, fever, malaise. If Fournier’s gangrene suspected, Invokana should be discontinued, and prompt treatment instituted. Urine laboratory assessment: glucose in urine due to mechanism of action. Lactose intolerance: do not use in patients with galactose intolerance, total lactase deficiency or glucose-galactose malabsorption. Sodium: essentially “sodium-free”. INTERACTIONS: Diuretics: may increase risk of dehydration and hypotension. Insulin and insulin secretagogues: risk of hypoglycaemia; consider lower dose of insulin or insulin secretagogue. Effects of other medicines on Invokana: Enzyme inducers (e.g. St. John’s wort, rifampicin, barbiturates, phenytoin, carbamazepine, ritonavir, efavirenz) may decrease exposure of canagliflozin; monitor glycaemic control. Consider dose increase to 300 mg if administered with UGT enzyme inducer. Cholestyramine may reduce canagliflozin exposure; take canagliflozin at least 1 hour before or 4-6 hours after a bile acid sequestrant. Effects of Invokana on

LICENCE EXTENSION INVOKANA now includes evidence for the treatment of diabetic kidney disease1

other medicines: Monitor patients on digoxin, other cardiac glycosides, dabigatran. Inhibition of Breast Cancer Resistance Protein cannot be excluded; possible increased exposure of drugs transported by BCRP (e.g. rosuvastatin and some anti-cancer agents). PREGNANCY: No human data. Not recommended. LACTATION: Unknown if excreted in human milk. Should not be used during breast-feeding. SIDE EFFECTS: Very common (≥1/10): vulvovaginal candidiasis, hypoglycaemia in combination with insulin or sulphonylurea. Common (≥1/100 to <1/10): balanitis or balanoposthitis, urinary tract infection (including pyelonephritis and urosepsis), constipation, thirst, nausea, polyuria or pollakiuria, dyslipidemia, haematocrit increased. Uncommon (<1/100) but potentially serious: necrotising fasciitis of the perineum (Fournier’s gangrene) (frequency not known), anaphylactic reaction, diabetic ketoacidosis, syncope, hypotension, orthostatic hypotension, urticaria, angioedema, bone fracture, renal failure (mainly in the context of volume depletion), lower limb amputations (mainly of the toe and midfoot.

Refer to SmPC for details and other side effects. LEGAL CATEGORY: POM. PACK SIZES & MARKETING AUTHORISATION NUMBER(S): Invokana 100 mg film-coated tablets: 30 tablets; EU/1/13/884/002.

Invokana 300 mg film-coated tablets: 30 tablets; EU/1/13/884/006.

MARKETING AUTHORISATION HOLDER: Janssen-Cilag International NV, Turnhoutseweg 30, B-2340 Beerse, Belgium. ® INVOKANA is a registered trade mark of Janssen-Cilag International NV and is used under licence. © 2020 Napp Pharmaceuticals Limited.

Adverse events should be reported to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL – 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 Mundipharma Pharmaceuticals Limited on drugsafetyJNJ@mundipharma-rd.eu or by phone on 01 2063800 (1800 991830 outside office hours) FURTHER INFORMATION IS AVAILABLE FROM: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18. For medical information enquiries, please contact medicalinformation@ mundipharma.ie UK/INV-18203(3) IRE/INVK-20206a Date of Preparation July 2020 References: 1. Invokana® Summary of Product Characteristics. Mundipharma 2020. 2. Dapagliflozin Summary of Product Characteristics. AstraZeneca 2019. 3. Empagliflozin Summary of Product Characteristics. Boehringer Ingelheim 2019. 4. Ertugliflozin Summary of Product Characteristics.

MSD 2019.

CV: cardiovascular; HbA1c: haemoglobin A1c; SGLT2i: sodium-glucose cotransporter 2 inhibitor; T2D: type 2 diabetes. ®MUNDIPHARMA and the ‘mundipharma’ logo are registered trademarks of Mundipharma.

Invokana® is a registered trademark of Johnson & Johnson. IRE/INVK - 20209.

News

COVID-19

LOW NUMBER OF COVID-19 AMONG DRUG USERS LEAVES DOCTORS 'BAFFLED'

RESEARCH

SCIENTISTS USE BLOOD TEST TO PREDICT WHO IS LIKELY TO DEVELOP PSYCHOTIC DISORDERS Scientists have discovered that testing the levels of certain proteins in blood samples can predict whether a person at risk of psychosis is likely to develop a psychotic disorder years later.

The study is published in JAMA Psychiatry and was led by researchers from the RCSI University of Medicine and Health Sciences.

Based on certain criteria, such as mild or brief psychotic symptoms, some people are considered to be clinically at high risk of developing a psychotic disorder, such as schizophrenia. However, only 20 to 30 per cent of these people will actually go on to develop a psychotic disorder.

The researchers analysed blood samples taken from people at clinical high risk of psychosis. These individuals were followed up for several years to see who did and did not develop a psychotic disorder.

After assessing the proteins in blood samples and using machine learning to analyse this data, the scientists were able to find patterns of proteins in the early blood samples that could predict who did and did not develop a psychotic disorder at follow-up.

8 SEPTEMBER-OCTOBER 2020

Many of these proteins are involved in inflammation, suggesting that there are early changes in the immune system in people who go on to develop a psychotic disorder. The findings also suggest that it is possible to predict their outcomes using blood samples taken several years in advance.

The most accurate test was based on the 10 most predictive proteins. It correctly identified those who would go on to develop a psychotic disorder in 93 per cent of high-risk cases, and it correctly identified those who would not in 80 per cent of cases.

“Ideally, we would like to prevent psychotic disorders, but that requires being able to accurately identify who is most at risk,” said Professor David Cotter, the study’s senior and corresponding author and professor of molecular psychiatry at RCSI. “Our research has shown that, with help from machine learning, analysis of protein levels in blood samples can predict who is at truly at risk and could possibly benefit from preventive treatments. We now need to study these markers in other people at high risk of psychosis to confirm these findings.”

Doctors working in opioid substitution clinics (OST) have been left baffled by the low number of Covid-19 cases among people who use drugs.

According to the HPSC, which collects data on “homeless/those with addictions” there have been four outbreaks comprising 15 cases among this cohort.

The HPSC does not collect data on the number of individual Covid-19 cases in this patient group outside of outbreaks, but according to doctors the number of cases has been “surprisingly” low.

Dr Bobby Smyth, Consultant Child and Adolescent Psychiatrist with the HSE Adolescent Addiction Service, said he understands there has been a “very small number of cases amongst adult clients”.

“Hopefully, the fact that the service succeeded in continuing to provide core aspects of treatment to clients, while adhering to public health advice on strategies to minimise Covid transmission in clinic settings, contributed to this.”

Dr Garrett McGovern, a Dublin based GP specialising in substance abuse, works in several drug clinics and community based programmes in the city centre.

He said he has been “blown over” by the low number of Covid-19 cases among people who use drugs.

There has been a “very low number of cases contracting Covid-19", he said.

Due to the complex healthcare needs and conditions among people who use drugs, doctors had expected patients to contract the virus in high numbers.

But “the opposite happened”, he said, “we have seen very little Covid among this group, you could count on one hand the numbers.”

He continued: “We can’t explain it. It’s surprised us as we thought we would be inundated with cases”.

According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), because of the high prevalence of chronic medical conditions among drug users many are at particular risk for serious respiratory illness if they get infected with Covid-19.

“Risks are increased by the high level of physical and psychological comorbidity found among some people who use drugs, the fact that drug problems are often more common in marginalised communities, and the stigmatisation that people who use drugs often experience.

“The current public health crisis raises serious additional concerns for the wellbeing of people who use drugs, ensuring service continuity for those with drug problems, and the protection of those offering care and support for this population.”

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The home of Irish CPD Free, independent CPD for doctors, nurses and pharmacistsâ&#x20AC;Śall under one roof

News

DIABETES

EDUCATION

New research has identified that insufficient structure of the health service, lack of awareness and individual preferences are among barriers for adults with type 1 diabetes in getting insulin pump therapy.

The study, led by researchers from RCSI University of Medicine and Health Sciences, is published in the current edition of Acta Diabetologica.

This research builds on previous studies by RCSI researchers, which showed that people with type 1 diabetes in Ireland use insulin pump therapy at lower rates when compared internationally and there is an unequal availability of insulin pump therapy in Irish adult diabetes clinics.

Even though insulin pump therapy is recommended as a first-choice therapy for pre-schoolers and is beneficial for people with type 1 diabetes of all ages, only 10.5 per cent of people with type 1 diabetes in Ireland are using a pump to administer their insulin.

This compares significantly lower to the average uptake in Nordic, Central and Western countries, which was 15–20 per cent in 2010.

Regional disparities in insulin pump use were found, with uptake as low as 2 per cent among adults in Roscommon compared to 9.6 per cent in Kildare. One-third of Irish adult clinics, usually in rural areas, do not offer any type of insulin pump therapy support, and less than a half provides training to commence the therapy.

To identify the reasons for why uptake is lower in Ireland, the researchers conducted 21 interviews and four focus groups among people with type 1 diabetes, healthcare professionals and other key stakeholders.

The same topics were discussed in all groups and aligned with four main themes: awareness, structure, capacity and impact of an individual (a person with diabetes or healthcare professional). The main finding was that if the structure of the health service is insufficient, the quality of care is not standardized and

CEO of the ICGP Mr Fintan Foy has said he is “frustrated” that the planned transfer of responsibility for GP training from the HSE to the ICGP has yet to take place.

In a statement, Mr Foy said discussions on the matter had occurred between both parties in recent weeks, with a partial transfer of training expected by the end of 2020.

While admitting that he was pleased talks had yielded progress, he expressed frustration that the matter, which has been under discussion for several years now, has yet to be resolved.

“Discussions and negotiations have continued during the summer with all key stakeholders to move towards resolving the industrial relations issues between Programme Directors and the HSE,” said Mr Foy. “From an ICGP perspective, while we are frustrated that we are not at the point where the transfer can take place, we are very pleased with the progress that has been made and the commitment to complete same in the coming weeks.

“Once the IR issues have been resolved, the College will then move towards implementation of the transfer of training from the HSE to the College. We would hope that a partial transfer is completed by the end of this year and the full transfer is completed by June 2021.”

Clarity surrounding the employment status of programme directors and assistant programme directors affected by the proposed transfer of GP training is due by the end of 2020.

The transfer cannot conclude until a decision has been reached on the employment rights and status of directors.

The ICGP oversees GP training in Ireland, accrediting the training schemes and issuing certificates of membership, but training is currently delivered by the HSE Primary Care Division through a network of 14 training schemes nationwide.

When completed, the ICGP will be responsible for the delivery and supervision of standards of GP training.

ICGP ‘FRUSTRATED’ AT LACK OF ACTION ON TRANSFER OF GP TRAINING

RESEARCH FINDS UPTAKE OF INSULIN PUMP THERAPY IS LOW IN IRELAND

10 SEPTEMBER-OCTOBER 2020

capacity is poor, the uptake of insulin pump therapy is more reliant on the individual’s interest, leadership skills, willingness and motivation.

“These factors may make the regional differences in accessing diabetes related technology and the quality of care more evident,” said Dr Katarzyna Gajewska, the study’s lead author and HRB PhD scholar in population health and health service research at RCSI. “The results of this study may inform healthcare professionals and policy makers regarding gaps in the delivery of diabetes care. Solutions are needed to reduce the disparities in health service provision in the countries where reimbursement of diabetes technology is offered. Such steps may include the development of national guidelines, models of care, and structured approaches to provide equal access to insulin pump therapy across the country.”

It was great meeting our fab nurses at the IPNA in Galway. IUCD’s were a hot topic! We have them available ex-stock with great bulk rates! All instruments available individually – talk to Noreen on 01-9030125 if you would like to talk about your requirements!

We’re Talking About …

IUCD Packs & Instruments IUCD DELUXE Everything You Need In One Pack!

Uterine Scissors Vulsellum Forceps Rampley Sponge Holder Speculum Medium Uterine Steel Sound

IUCD Mini Pack We’ve taken out the sound & the speculum

Kidney Dish Cotton Wool Balls Dressing Towel Gallipot Sterile Field

Vulsullum forceps

Tenaculum forceps

€22 per pack.

Buy 10 Packs €18.45 each.

Case of 25 Pieces - €399.75 = €16 each.

IUCD Midi Pack We’ve taken out the sound

*You can have this pack with tenaculum or vulsullum forceps

€16 per pack.

Buy 10 Packs €14.75 each. €325 per case of 25 / €13 each Implanon Removal Pack 2 x Non woven swab 7.5x7.5cm 1 x Syringe 2.5ml & Orange Needle 1 x Halstead Artery Mosquito Forceps Curved 12.5cm 1 x Disposable Scalpels with no 15 Blade 1 x Steri-strip skin closures 6x75mm packet of 3 1 x Conforming Bandage 7.5cm x 4m 1.00000 1 x Drape fenstrated with adhesive 55 x 50cm 1 x Plastic tray with 2 gallipots 1 x Paper crepe white 60x60cm

€20 per pack.

Buy 10 Packs €17.25 each. €375 per case of 25 / €15 each

€8.49 per pack.

Buy 10 Packs €6.79 each.

Coil Removal Instruments

Have you considered the following options?

Spencer Wells Forceps

The long serrated tip is great for catching short threads.

Buy Each €4.50 incl vat Buy 25 Pieces Each €4 inc vat

Buy 50 Pieces Each €3.65 incl vat

Rampley Forceps

Great all round forceps for your gynae clinic!

Buy Each €4.50 incl vat Buy 25 Pieces Each €4 inc vat

Buy 50 Pieces Each €3.65 incl vat

Phone Noreen on 01-9030125 to order.

FREE Delivery on all orders over €100.

Prices value until 31st December 2019 – prices include vat.

Pelican Thread Retrievers

Hartmann Crocodile Forceps 20cm

Not for every patient however they handy to have for especially difficult coils.

Designed to locate lost IUD threads and can also be used to sound the uterus for the presence of the intra-uterine device.

Buy 20 Pieces €15 incl vat

Buy Each €10 incl vat

WE WOULD LOVE TO TALK TO YOU! noreen@fitzmedicalsupplies.ie www.fitzmedicalsupplies.ie 33 Slaney Road, Glasnevin Dublin 11

News

BUDGET

CANCER SOCIETY CALLS FOR €30 MILLION The Irish Cancer Society has called on the Government to invest €30 million in cancer services in the upcoming budget.

The society’s pre-Budget submission outlines the need for €20 million in ring-fenced funding for the National Cancer Strategy and €10 million to address backlogs in cancer services.

Irish Cancer Society Director of Advocacy Rachel Morrogh said: “Sadly we have had almost no money dedicated to the implementation of the National Cancer Strategy over recent years. The lack of Government funding has meant a lack of investment in innovation, new services and addressing unmet needs of cancer patients – instead cancer services have been stretched to the point of breaking. This needs to change.

“The lack of funding for cancer has led to missed performance targets, waiting lists, unfilled posts and under-developed services.

These were all problems in cancer services pre-Covid-19, and the pandemic has only made things worse. Continuing to demand that healthcare professionals and cancer services do more with less will ultimately impact negatively on patients.

“Budget 2021 is an opportunity to claw back some of the ground that has been lost due to underfunding in recent years. Over 9,000 people die from cancer every year in Ireland and we want to ensure the National Cancer Strategy meets its target of being in the top quarter for five-year survival among EU member states.

“The stark choice is that either proper funding is provided to resource the National Cancer Strategy, which would both save and improve the lives of struggling cancer patients all around the country, or the pattern of underfunding continues, and services and healthcare professionals remain overwhelmed, leading to the risk of worse outcomes for patients,” Ms Morrogh concluded.

12 SEPTEMBER-OCTOBER 2020

CERVICAL CHECK

MINISTER FOR HEALTH COMMITS TO ADDITIONAL FUNDING FOR 221+ GROUP

Minister for Health Stephen Donnelly has committed to providing additional funding to the 221+ Group beyond the current agreement.

The assurance was given by Minister Donnelly at a recent meeting with representatives of the 221+ Group, the CervicalCheck patients support group; the Marie Keating Foundation and the Irish Cancer Society.

The Department of Health signed a grant agreement in 2018 for the establishment of a CervicalCheck Patient Support Group, which runs up to end August 2021. Details of the additional funding will be announced in due course.

At the meeting, the Minister committed to appointing a second patient representative from the 221+ group to the CervicalCheck Steering committee. The membership of the Committee is drawn from across a variety of organisations, such as the Department of Health, the HSE, the Irish Cancer Society, the RCPI and the ICGP. The Minister for Health said: “I am pleased to announce that I am committed to approving funding for the 221+ Support Group beyond August 2021. This funding will support the 221+ Group going forward so that

it can continue its very important work in assisting patients and next of kin of those directly affected by the CervicalCheck issues through the provision of information, advice and support.

“I would like to acknowledge the important contribution that the 221+ Group make, ensuring that the voices of women and families affected are heard in the delivery of our National Screening Services. I am looking forward to working with the group to ensure that Ireland continues on the journey to best-in-class population health screening services for cervical cancer.

“I am fully committed to ensuring and supporting the central role that patients play in working with the public health service to develop health policy and in designing and reforming health services. It is vital that government hears and includes the voice of the service user.

"Patient representatives participate on a number of committees and working groups across the Department of Health, the HSE and health agencies and make a significant contribution to the strategic decision-making work of those committees and groups.”

Recruitment

Please email your recruitment ads to Louis, Recruitment Manager: Louis@mindo.ie

PRACTICE NURSE REQUIRED

PART-TIME PRACTICE NURSE REQUIRED

DUBLIN 9

MAYO

Friendly computerised training practice with excellent administrative

Part-time practice nurse required to join our friendly long-established

support.

GP practice in Westport, Co Mayo.

Please contact Sarah at 01 837 8158

Must be a Registered General Nurse with NMBI. Practice nurse experience desirable.

Flexible working hours. Excellent working conditions.

PRACTICE NURSES REQUIRED

Please forward your CV to practicenurse082020@gmail.com

WICKLOW Practice nurses required part-time for our two busy practices, one in Kilcoole, Co Wicklow and one in Wicklow Town.

The following skills would be ideal: Phlebotomy, diabetic care, chronic disease management, asthma care, ear syringing, smear taking, ECG, 24-hour BP monitoring.

PART-TIME PRACTICE NURSE REQUIRED

NORTH DUBLIN CITY Practice nurse required for friendly modern GP practice in North Dublin City. Initially 20 – 25 hours p/w with scope to increase hours

Flexible hours.

Please apply with CV to Practicemanager@thedoctorssurgery.ie

as role develops. Standard duties including phlebotomy, childhood vaccinations, ECGs, cervical screening, and previous experience is required.

Contact Practice Manager glen@milligan.ie.

PRACTICE NURSE REQUIRED

STEPASIDE

Practice nurse required for well organised practice in Stepaside.

• Experience preferred, but training can be provided.

PRACTICE NURSE REQUIRED

• Flexibility in hours available.

RENELAGH

• Fully computerised friendly working environment.

• Must be general nurse with The Nursing Midwifery Board of Ireland (NMBI).

Practice nurse wanted for friendly computerised practice in Ranelagh, Dublin 6.

Part-time position, flexible hours. Practice nurse experience an

Please forward CV to belarmine3@gmail.com

advantage though training will be provided. Job to start September

Or informal enquiries to Dr Deirdre Searson 01 295 0815

2020. Pay commensurate with experience.

Contact drritabrennan@gmail.com

Have a vacancy?

ADVERTISE IT HERE Contact louis@mindo.ie to find out more

SEPTEMBER-OCTOBER 2020 13

Asthma Module

Feature

ADULT ASTHMA – DIAGNOSIS AND MANAGEMENT Ruth Morrow Respiratory Nurse Specialist.

Registered Nurse Prescriber, Nurse Educator & Consultant

The aim of this module is to explore the diagnosis and management of stable asthma in the adult person. The module will focus on symptoms, diagnosis, differential diagnoses and management of stable asthma Setting the scene Asthma affects over 380,000 people in Ireland. 7.1 per cent of Irish adults have asthma (www.asthmasociety.ie accessed 7th July 2020). In 2020, one person continues to die from asthma in Ireland every six days despite advances in knowledge of the mechanisms of asthma and pharmacology.

In 2019, the Asthma Society of Ireland published a report on the economic burden of asthma in Ireland. Easing the Economic Burden of Asthma – The Impact of a Universal Asthma Self-Management Programme is the first prevalence and impact assessment of asthma since 2001. The report, for the first time, confirms the enormity of the asthma burden and contains up-to-date figures on the number of people affected by asthma in Ireland. Previous estimates using the Quarterly Household National survey and other crude data, into the large-scale impact of asthma on the Irish healthcare system, grossly under-estimated the number of people with asthma in Ireland. 2017 saw 2.4 million GP and 625,000 practice nurse asthma consultations respectively, 421,000 specialist visits, 133,000 emergency department visits and 8,000 hospital admissions. One person dies every five days from an acute asthma attack and there is one attendance at emergency departments every four minutes by a person with asthma.

The annual economic burden of asthma is a staggering €472million.

Some other statistics from the report include: ▸ 890,000 people in Ireland experience asthma at some stage of

14 SEPTEMBER-OCTOBER 2020

their life. ▸ €1,242: The annual average cost of asthma per person. ▸ 1 in 13 people in Ireland currently have asthma. ▸ 1 in 10 children currently have asthma ▸ 1 in 5 children experience asthma at some stage in their life. ▸ Compared to 14 other European countries: Ireland had the highest death rate from asthma in 2015. ▸ The average number of work days missed every year due to asthma is seven ▸ The average number of school days missed every year due to asthma is five ▸ Ireland had the second highest rate of asthma hospital discharges in Western Europe in 2016 ▸ 40,593: The number of children registered under the Asthma Cycle of Care programme ▸ 2.68 days: Average length of stay with an asthma hospital admission Asthma is a condition that can be treated effectively and most patients can obtain good control through optimal use of their medication and appropriate management plans. Optimally controlled asthma includes: ▸ little or no use of reliever inhaler ▸ have no night-time or daytime symptoms ▸ have productive physically active lives ▸ have near normal lung function ▸ avoidance of serious attacks

(GINA, 2020) A copy of the report can downloaded here https://www.asthma.ie/document-bank/easing-economic-burdenasthma-report Signs & Symptoms The symptoms of asthma include wheezing, coughing, shortness of breath and chest tightness following exposure to allergens. These symptoms are variable and usually troublesome at night or early morning. To make a diagnosis of asthma patients should have at least two of these four symptoms. Symptoms are variable and may occur or worsen in a seasonable pattern. The patient may also have eczema and hay fever. A positive family history of asthma or other atopic conditions may also be present. The patient may describe their symptoms becoming worse when exposed to certain trigger factors.

Trigger factors Trigger factors for asthma are individual to each patient and can include smoking, house dust mite, respiratory tract infections, exercise, changes in temperature, fumes, occupation agents, fog, stress, hormones, emotion and certain medications (aspirin, beta-blockers and NSAIDs). The list of possible trigger factors can be lengthy and it may take the patient some time before they can identify their trigger factors.

Asthma Phenotypes Traditionally asthma has been divided

Feature

Asthma Module Multiple Choice Questions Q1: The pathological changes which occur in the airways as a result of asthma are: a) hypertrophy of the bronchial walls b) contraction of the muscle layer c) infiltration of inflammatory mediators d) all of the above Q2: A diagnosis of asthma is made based on: a) Chest x-ray b) Chest examination c) History taking, chest examination and spirometry with reversibility testing d) Peak flow reading True/false questions Q3: The diagnosis of asthma involves carrying out spirometry only Q4: Medications that may cause the onset of asthma include beta-blockers, NSAIDs and aspirin

into allergic or non-allergic asthma. Other terms which have been used include eosinophilic or non-eosinophilic. As research has developed, asthma is now classified as T2 or nonT2 asthma and treatments have developed as a result.

Diagnosis The diagnosis of asthma is made by the patient’s symptoms and medical history with the measurement of lung function using spirometry (GINA, 2020). If the patient has a history of any of the following then asthma should be suspected: ▸ Cough which is worse at night ▸ Recurrent wheeze ▸ Recurrent difficulty breathing ▸ Recurrent chest tightness History taking & assessment: An accurate and complete history is essential and should include the following: ▸ Personal history – recurrent chest infections? asthma as a child?, smoking history including passive smoking?, allergies to medications? Is the person taking any medications for other conditions such as hypertension, diabetes etc? ▸ Family history- asthma? eczema?, allergic rhinitis? urticaria? ▸ History of current symptoms- what symptoms of asthma is the person experiencing? What triggers the symptoms? Has the person missed any days of work with these symptoms? Symptoms of allergic rhinitis?

How many acute episodes has he/she had?

Have these acute episodes necessitated hospital admission, nebulisations or the use

of oral steroids? Have they ever been prescribed inhalers before and if so what were they? ▸ In relation to asthma symptoms three questions should asked at every visit. Does the person experience wheezing, coughing, shortness of breath or chest tightness during the day? Does the person experience these symptoms at night? Does the person experience these symptoms on exercising? If the answer to any of these questions is yes then the frequency of asthma symptoms needs to be ascertained.

Spirometry is the preferred method for measuring airflow obstruction with reversibility to establish a diagnosis of asthma. An increase in FEV1 of 12 per cent or 200mls 15 minutes after inhaling a bronchodilator demonstrated airflow limitation consistent with asthma (GINA, 2020). However, not all patients with asthma will have reversibility and repeated tests are advised.

Peak flow measurements can be used if the patient is unable to perform spirometry and are very useful as a monitoring and educational tool for patients. An improvement of 60l/min or greater than 20 per cent post bronchodilator or a greater than 20 per cent in diurnal variation (with twice daily readings, more than 10 per cent) suggests a diagnosis of asthma (GINA, 2020).

FENO testing is associated with levels of blood and sputum eosinophils.

FeNO levels are higher in:

T2 Asthma, high eosinophilic asthma

Non-T2 Asthma or non-eosinophilic asthma

Previously known as allergic asthma

Previously known as non- allergic asthma

Onset

Usually in children linked to atopy but will be present in adults who have had asthma as a child

Usually in adulthood

Inflammation

High levels of eosinophils in sputum and blood

Low levels of eosinophils in sputum and blood. Inflammation tends to be neutrophilic

Response to inhaled corticosteroids (ICS)

Responds very well to ICS

Poor response to ICS and usually require high doses of ICS

Triggers

Dust, animal hair and dander, pollens

Infections, smoking, pollution, hormones, exercise Table 1: Asthma phenotypes

SEPTEMBER-OCTOBER 2020 15

Feature

Asthma Module

Figure 1

▸ Asthma that is characterized by Type 2 airway inflammation ▸ Non-asthma conditions, eg, eosinophilic bronchitis, atopy, allergic rhinitis, eczema ▸ Late response to allergen (after 24 hours) FeNO levels are lower in: ▸ Smokers ▸ Bronchoconstriction ▸ Early phases of allergic response ▸ Some asthma phenotypes, e.g. neutrophilic asthma FeNO is increased or decreased in: ▸ Viral infections ▸ Response to ICS ▸ In adult steroid-naïve patients with nonspecific respiratory symptoms, FeNO >50ppb was associated with good shortterm response to ICS ▸ No long-term studies examining the safety of withholding ICS if FENO is low ▸ FeNO cannot be recommended for deciding against treatment with ICS FENO testing can be viewed here: https://youtu. be/c8e-vmZBWy8 Measure of allergic status (IgE, RAST, skin allergy tests) can be useful in identifying risk factors. The presence of allergies, eczema and allergic rhinitis increase the probability of a diagnosis of asthma. In secondary care, histamine and metacholine challenges may also be carried out.

Challenges to the diagnosis of asthma include:

16 SEPTEMBER-OCTOBER 2020

▸ Cough variant asthma – some patients have chronic cough which occurs at night.

Evidence of lung function variability and airway hyper-responsiveness are important to determine the presence or absence of asthma ▸ Exercise induced bronchoconstriction – for some patients, physical activity may be the only trigger for asthma. An eight minute running challenge can confirm an asthma diagnosis (GINA, 2020) ▸ Asthma in the elderly can be difficult to determine as there are several complicating factors such as poor perception of symptoms, reduced expectations of mobility and activity and the possibility of other conditions such as COPD, heart failure, lung cancer, and TB to mention but a few. ▸ Occupational asthma requires a defined history of occupational exposure to sensitizing agents, an absence of asthma symptoms prior to employment and a documented relationship between symptoms and the workplace. The patient should be asked to maintain a peak flow diary while at work and while away from work to help determine the diagnosis. The opinion of an occupational respiratory physician should be sought.

Assessment of symptoms All patients should be assessed and their level of control established. In general, good clini-

Answers Q1: D The clinical features of asthma (wheeze, cough, shortness of breath and chest tightness) result from changes in the airways as a result of abnormal sensitivity called bronchial hyper-reactivity. The muscle of the bronchial walls becomes hypertrophied causing occlusion of the airway resulting in contraction of the muscle causing bronchospasm. Secondly, in the mucosal, submucosa and smooth muscle layers of the bronchi and bronchioles inflammatory cells infiltrate. Eosinophils, neutrophils, macrophages, mast cells and plasma cells are found in varying numbers. All of these cells contain chemical mediators that produce the “asthmatic response”. With the increase in secretions, plugging of the smaller airways result.

Asthma is a condition where not only bronchospasm occurs but muscle constriction, mucosal swelling and an increase in secretions in the lumen in the airways.

Q2: C Chest x-ray should only be considered for patients who present with atypical symptoms and those who fail to respond to inhaled therapy. Most people with asthma do not demonstrate any abnormality on their chest x-ray. Hyperinflation may be seen on x-ray when the patient is experiencing an acute asthma attack.

Q3: False The diagnosis of asthma involves full history taking including family history, personal medical and surgical history, current medications, assessment of trigger factors, clinical examination and spirometry/PEFR (GINA, 2020) Q4: True Patients on NSAIDs. Aspirin and betablockers may be predisposed to developing asthma. Medication history should be explored when assessing patients.

Feature

Asthma Module Multiple Choice Questions Q5: The differential diagnoses for asthma include: a) COPD b) Inhaled foreign body c) Hyperventilation d) all of the above Q6: Identification and management of allergic rhinitis is required because: a) the presence of these conditions may exacerbate asthma b) the presence of these conditions has no effect on asthma c) these conditions rarely present in people with asthma d) there is no licensed treatment for asthma and allergic rhinitis True/false questions Q7: Risk factors for asthma include family history of asthma and atopy Q8: 10% reversibility to Salbutamol is positive diagnostic test for asthma

Figure 2: Asthma Control Test

cal control of asthma leads to reduced risk of exacerbations (GINA, 2020). There are a number of well validated tools available which can assist the practice nurse in assessing asthma control such as the Asthma Control Test (www. asthmacontrol.com). The maximum score is 25 which indicates good asthma control. A score of 19 or less indicates poor asthma control. GINA (2020) recommends using the Royal College of Physicians provide 4 item tool to assess the patient’s asthma over the previous four weeks. If the patient answers “yes” to all these questions, their asthma is not controlled, “no” to all questions, their asthma is well controlled and if they answer “yes” to one or more, their asthma is partly controlled.

Management of asthma The treatment and management of asthma should incorporate the following elements: ▸ Education on the disease process ▸ Management of trigger factors ▸ Medication management – actions, delivery, side effects ▸ Asthma Action Plan ▸ Management of acute episodes of asthma The goal of asthma management is for the patient to be optimally controlled on the minimum amount of medication. GINA (2020) provides healthcare professionals with a management approach based on control (Figure 2 & 3).

This assists health professionals with the titration of medications using a step down or step up approach in attempt to achieve this goal.

The cornerstone of asthma treatment is inhaled therapy as medication is directly targeted at the airways and therefore, is more effective.

This also limits the amount of systemic absorption and reduces side effects. Patients should be commenced on the appropriate step of the treatment guidelines (GINA, 2020). Each patient is assigned to one of five treatment steps and patients may move up or down the steps depending on symptoms and the amount of reliever therapy being used (see figures 2 & 3). Inhaled glucocorticosteroids are the cornerstone of asthma treatment and are the most effective controller medications available (see table 2).However, there are additional oral medications such as leukotriene receptor antagonists which can be added on and are very useful in patients who have an allergic component to their asthma, experience cold air bronchoconstriction and have exercise induced symptoms.

These medications are also licensed for use in allergic rhinitis, a condition which 85 per cent of people with asthma also have.

The Global Initiative for Asthma Management and Prevention (GINA) (2020) recently updated their strategy which outlined significant changes to way healthcare professionals (HCPs) manage asthma in adults and adolescents. The changes recognise a real sea change in the use of short acting bronchodilators (SABA) and the introduction of combination therapy of inhaled corticosteroids (ICS) and long-acting bronchodilators (LABA) as “a needed therapy” at Step 1 and as a maintenance therapy at Step 2.

Using a combination therapy as an “as-needed” therapy will require a significant change in the mindset of HCPs given that we having been using SABAs for the last 50 years to relieve asthma symptoms.

Why this change?

Inhaled SABA (Salbutamol, Terbutaline) have been first-line treatment for asthma for 50 years. Traditionally asthma was thought to be a disease of bronchoconstriction and therefore SABA was the drug of choice. Added to this, rapid relief of symptoms, reliance on, patient satisfaction and their low cost have meant that

SEPTEMBER-OCTOBER 2020 17

Feature SABAs were widely used, overused and over-relied upon. The perception by patients that their reliever “gives me control over my asthma”, so much so that they often don’t see the need for other treatment. However, research over the past number of years has shown that regular and frequent use of SABAs decrease bronchoprotection, increase rebound hyperresponsiveness, and decrease bronchodilator response (Hancox, 2000). Patients with apparently mild asthma are at risk of serious adverse events such as near fatal asthma, acute asthma and death from asthma. Regular or frequent use of SABAs are also associated with Increased allergic response and increased eosinophilic airway inflammation (Aldridge, AJRCCM 2000). Patients who get three or more canisters of SABA per year (average 1.7 puffs/day) are associated with higher risk of attendance to the emergency department (Stanford, AAAI 2012) and patients who receive 12 or more canisters per year are associated with higher risk of death (Suissa, AJRCCM 1994).

Combination therapy “as-needed” In their review of the literature, GINA found no evidence to support a Step 1 SABA-only approach. The lack of evidence for SABA-only treatment contrasted with the strong evidence for safety, efficacy and effectiveness of the treatments recommended in Steps 2-5 of the strategy i.e. ICS and ICS/LABA. For safety, GINA no longer recommends SABA-only treatment for Step 1. This decision was based on evidence that SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk. It is now recommended that all adults and adolescents with asthma should receive symptom-driven or regular low dose combination LABA/ICScontaining controller treatment, to reduce the risk of serious exacerbations (GINA, 2019).

Patients who have symptoms more than twice a month should be prescribed ICS/LABA twice daily (Step 2-5) and patients who have symptoms less than twice a month should use ICS/ LABA on “an as-needed basis” (Step1). Daily ICS is no longer listed as a Step 1 option which was included in GINA 2014-18 as it has a high probability of poor adherence. It is now replaced by a more feasible as-needed controller option at Step 1. The rationale for this using low dose ICS/LABA as needed has been shown to reduce

18 SEPTEMBER-OCTOBER 2020

Asthma Module exacerbations. Indirect evidence from SYGMA 1 of large reduction in severe exacerbations vs SABA-only treatment in patients eligible for Step 2 therapy (Bateman,2018, O’Byrne, 2018).

Patients should be offered self-management plans with instructions on how to adjust their medications in response to worsening symptoms and/or worsening PEFR. An example of a self-management plan is available on www. asthmasociety.ie.

The non-pharmacological management of asthma includes management of trigger factors, smoking cessation, management of obesity and annual influenza vaccination.

Gastro-esophageal reflux can worsen asthma symptoms. Treatment of reflux may improve asthma symptoms. Hormones can also play a significant role in asthma control. Some patients will experience worsening of their asthma symptoms pre-menstrually or during menstruation. During pregnancy, asthma control may improve, deteriorate or stay the same as pre-pregnancy. Asthma may also develop in women who are menopausal.

Inhaled glucocorticosteroids in asthma Inhaled glucocorticosteroids are the cornerstone of asthma treatment. The aim of which is to reduce the inflammatory process in the airways. Table 2 outlines the treatment options available to patients. It is recommended that if patients use their bronchodilator more than twice a week, then they should be commenced on inhaled steroid therapy.

Adherence with medication regimes One of the biggest challenges in asthma management is adherence to medication, as many patients may be asymptomatic and therefore “don’t feel the need to use their medication daily”. Exploring the patient’s beliefs and attitudes can be useful in determining a rationale for non-adherence to their medication regime. Saving medication until it is needed, fear of becoming addicted or the health professional didn’t listen are amongst reasons given by patients in the recent INCA study (Sulaiman et al, 2014). In the current climate, cost is a significant factor even for the person who has a medical card and should not be overlooked.

Two proven ways to address non-adherence are

Answers Q5: D The differential diagnoses for asthma include COPD, cardiac disease, tumour, bronchiectasis, foreign body, interstitial lung disease, pulmonary emboli, aspiration, chronic cough syndrome, vocal cord dysfunction and hyperventilation. Referral for specialist opinion is indicated when the diagnosis of asthma is unclear and when unexpected clinical findings such as crackles, cyanosis, clubbing are found on clinical examination. Should occupational asthma be suspected the patient should be referred for further investigation and management.

Persistent shortness of breath, weight loss, persistent chest pain, non-resolving pneumonia and persistent cough all warrant specialist opinion.

Q6: A Allergic rhinitis is present in 85% people with asthma and needs be addressed and managed effectively as it can cause worsening of asthma symptoms (ARIA, 2007).

Patients should be questioned about symptoms of itchy watery eyes, rhinorrhea, sneezing, nasal obstruction, nasal pruritus and conjunctivitis. Leukotriene receptor antagonists are licensed for use in both allergic rhinitis and asthma and are a useful treatment option for these patients.

However, they are effective in only 50% of patients and should be discontinued after 6 weeks if they are ineffective. Side effects include sleep disturbance and nightmares and patients should be counselled about these.

Q7: TRUE A family history of asthma or other atopic condition such as eczema or allergic rhinitis inn first degree relatives contribute to a diagnosis of asthma.

Q8: FALSE An increase in FEV1 of 12% 15 minutes after inhaling Salbutamol 400mcg is positive for asthma (GINA, 2020).

Asthma Module

Feature

Drug Name

Formulation

Dose Frequency

Side Effects

Availability As Combination Therapy

Beclomethaone Becotide™ Beclazone™ Qvar™

Inhaler

Twice daily but can be used up to four times daily

Oral candidiasis, dysphonia, pharyngitis

No

Budesonide Pulmicort™ Novolizer budesonide™

Inhaler, respules

Twice daily but can be used up to four times daily

Yes – with Formoterol (Symbicort™)

Fluticasone Proprionate Flixotide™

Inhaler, nasal preparation

Twice daily

Yes – with Salmeterol

Inhaler

Once daily

Mometasone Asmanex™

Inhaler

Once daily

No

Clicesonise Alvesco™

Inhaler

Once daily

No

Prednisilone Prednesol™ Deltacortril Enteric™

Tablet, intravenous/ intramuscular preparation, soluble preparation

Once daily

Fluticasone fuorate Relvar™

5 step rule: how to deal with an asthma attack 1. Sit up and stay calm, do not lie down 2. Take slow steady breaths 3. Take 1 puff of reliever inhaler usually blue every minute use a spacer if available. People aged 6+:up to 10 puffs in 10 mins. Children under 6: up to 6 puffs in 10 mins 4. Call 112 or 999 if your symptoms do not improve after 10 minutes 5. Repeat step 3 if an ambulance has not arrived in 10 minutes

Yes with Vilanterol

Prolonged use can cause: Weight gain, hypertension, diabetes, changes in mood, moon face, hirsuitism, depression, adrenal suppression

No

If someone has an asthma attack Do not leave them on their own.

Extra puffs of reliever inhaler (usually blue) are safe.

Table 2: Inhaled glucocorticosteroids for asthma (GINA, 2020)

shared decision-making between the health professional and the patient and motivation interviewing. Using motivational interviewing, the health professional can assess the individual’s likelihood to adhere to their medication or to non-pharmacological interventions.

Asthma Safety Care The National Review of Asthma Deaths (NRAD) in the UK (2014) showed that asthma deaths were linked to overuse of and over reliance on Salbutamol. The Asthma Society of Ireland launched the Asthma Safety Care campaign early in 2020. According GINA, using three or more reliever inhalers a year indicates a person is at risk of an asthma exacerbation while the use of twelve or more a year is an indication someone is at risk of an asthma-related death. The Asthma Ruler can be used to assess if a patient is over reliant on their Salbutamol inhaler and be accessed on line here: https://www.pcrsuk.org/resource/asthma-slide-rule Patient education

Patients require ongoing education and support in self-managing their asthma. Regular review of their Asthma Action Plan to ensure it is up to date and reflects the patient’s lifestyle.

Education should include: ▸ Managing Acute Asthma - patients should be educated in the 5 Step Rule for managing acute asthma attacks which is available on www.asthma.ie ▸ Management of trigger factors ▸ Inhaler technique ▸ Adherence to medication ▸ Use of Asthma Action Plan ▸ Vaccinations Conclusion This e-learning module has focused on the diagnosis and management of stable asthma in the adult. The differential diagnosis of asthma, pharmacological treatment, non-pharmacological treatment and the importance of adherence with medication have been discussed. The significant changes to the management of asthma have also

been discussed. The importance of the patient being involved with decisionmaking in relation to medication has also been addressed.

Further reading ▸ Asthma Society of Ireland, 2019, Easing the Economic Burden of Asthma – The Impact of a Universal Asthma Self-Management Programme ▸ Asthma Control in General Practice Adapted from the GINA Global Strategy for Asthma Management & Prevention, 2012, Irish College of General Practitioners ▸ Global Initiative for Asthma, 2020, Pocket Guide for Asthma Management and Prevention (For Adults and Children over 5 Years) ▸ Laube BL, Janssens HM et al, 2011, What the pulmonary specialist should know about the new inhalation therapies, European Respiratory Journal, 37: 1308-1331 REFERENCES ON REQUEST

SEPTEMBER-OCTOBER 2020 19

Osteoporosis

Feature

A FRAGILITY FRACTURE SCREAMS CHRONIC DISEASE David Askin, Clinical Nurse Specialist, Bone Health, Tallaght University Hospital, examines treatment gaps in osteoporosis management Osteoporosis was on the back foot before the emergence of Covid-19. Leading bone health specialists highlighted a critical care gap in an ageing population with the urgent need to increase screening and instigate osteoporosis treatment in high-risk groups in 2016 (American Society of Bone Mineral Research (ASBMR) 2016). Jane E Brody writing for The New York Times high-

20 SEPTEMBER-OCTOBER 2020

lighted the perfect storm for broken bones in 2018. In America, osteoporosis treatment is on the decline with less screening in those that had already fractured. From a European perspective, the treatment gap was highlighted in a study in six countries with 6080 per cent of patients not receiving treatment following fracture (International Osteoporosis Foundation (IOF)

2018). Harrington aptly described osteoporosis care as "The Bermuda Triangle made up of orthopaedists, primary care physicians and osteoporosis experts into which the fracture patients disappear" (Ă&#x2026;kesson et al, 2013). Orthopaedic surgeons rely on primary care to manage osteoporosis, but need to advise them when followup is required. The osteoporosis ex-

Osteoporosis perts have no need to interact with the patient during acute fracture management. Fracture patients silently slip away until they present with another fracture. The next fracture can be debilitating causing disability, loss of independence and even death (AMSBR 2016). This tide must turn if the International Osteoporosis Foundation’s vision is to become a reality a "world without fragility fractures in which healthy mobility is a reality for all".

The World Health Organisation was first to recognise the evolving care gap, launching an awareness campaign heralding 2000-2010 as the bone and joint decade. This led to the development of a fracture risk assessment tool known as FRAX in 2007.

In the presence or absence of bone density values of the femoral neck a 10-year risk of hip and major osteoporotic fracture is estimated. This led to guidelines and international key performance indicators for osteoporosis management. There is now greater awareness of the disease and guidance on correct management. But is it enough? There remains a significant treatment gap. Acute hospitals managing fractures should provide Fracture Liaison Services (FLS) to identify those at highest risk through investigation and intervention with lifestyle recommendations and treatment where appropriate. This will assist in reducing the burden of disease.

Amongst a wealth of research published on osteoporosis, the most notable is from the National Osteoporosis Society (2014). The qualitative publication stresses the effects of living with osteoporosis. This great unseen disease dramatically effects patient’s quality-of-life. Box 1 highlights thousands of patient’s feelings associated with the disease. Data published from hip fracture registries reports significant increase in morbidity and mortality following hip fractures (NOCA 2018). Of those who were independent prior to fracture 50

Feature per cent require a walking aid. 25 per cent admitted from home require admission to a nursing home for their remaining years. Mortality rates are 10 per cent within 30 days rising to 25 per cent at one year. Therefore, we must provide better care fracture cascade exists as described in diagram 1.

Fractures are common, with prevalence set to increase in line with all other chronic diseases as people live longer. From an Irish perspective fracture rates due to osteoporosis are estimated to be one-in-three for women and one-in-five for men over age 50. The pathogenesis of fractures is complex as osteoporosis is described as a paediatric disease with geriatric consequences (Mitchell at al, 2015).

Bone accrual is paramount during childhood and adolescence for later life. For young adults at peak bone mass a cubic inch of bone can endure four times the stresses of a cubic inch of concrete. Yet bone is mischievous, changing, becoming fragile without any sign or symptom. Bone loss is asymptomatic, estimated at around 0.5 per cent-1 per cent per year for women and men. This accelerates for women following menopause, doubling the rate of bone loss for up to 10 years. This is one of many risk factors that increases fracture risk.

Increasing prevalence of falls with age also increases fracture risk. 90 per cent of these fractures tend to occur from a fall at standing height or less. This can be considered a mini bone health assessment. If fractures are sustained through this mechanism, they are deemed to be fragility fractures, which increase future fracture risk. This screams chronic disease in post-menopausal women and men over age 50. They can be a symptom of bone loss. Unknown to the patient that suffered this fracture they believe it was just an accidental fall that caused a break that will not happen again.

Selecting the correct patient for

Osteoporotic fractures are prevalent in certain bones; hip, distal radius, neck of humerus, vertebra (thoracic and lumbar).

Significant research at these sites reports a raised risk for future fracture and a clinical diagnosis of osteoporosis

Box 1

Diagram 1

Rheumatoid Arthritis

49

Steroids

180

Parental hip fracture

181

High alcohol intake

177

Late menarche

418

Family history

449

Cigarette smoking

578

Early Menopause

592

Previous fragility fracture

789 Table 1

treatment is challenging and is probably contributing to treatment gaps in osteoporosis management. This mix-up is fuelled by clinical and quantitative diagnosis of osteoporosis. Key to reducing fractures is knowing risk factors. The osteoporosis mantra for healthcare professionals is fracture begets fracture. It is a red flag for future fracture. The FLS

SEPTEMBER-OCTOBER 2020 21

Osteoporosis

Feature

Femoral neck bone mineral density is as predictive for hip fracture as high blood pressure is for stroke

Medications interfering with bone health

Secondary causes for osteoporosis

Glucocorticoids

Ankylosing spondylitis

Anti-epileptic drugs

Diabetes type 1 and 2

Proton pump inhibitors

Prolonged mobility

Medroxyprogesterone acetate

Inflammatory disease of the bowel

Androgen deprivation therapy

Malabsorption diseases (coeliac/lactose intolerance)

GnRH agonists

Thyroid disease

SSRI

COPD

Thiazolidinediones

HIV

Calcineurin inhibitors

Organ transplantation

Heparin Table 2

at Tallaght University Hospital identifies this as the most dominant risk when performing bone health assessments (table 1). For this reason, recent guidelines from IOF and ESCEO recommend treating post-menopausal women with a prior fragility fracture without further assessment.

Osteoporotic fractures are prevalent in certain bones; hip, distal radius, neck of humerus, vertebra (thoracic and lumbar). Significant research at these sites reports a raised risk for future fracture and a clinical diagnosis of osteoporosis. To a lesser extent pelvis and prox-

22 SEPTEMBER-OCTOBER 2020

imal/ distal ends of bones are validated. Bones of less consequence are irregular short bones (patella, tarsals and phalanges).

A FRAX calculation and bone densitometry is a more appropriate management in younger post-menopausal women and men under 70 (Kanis et al, 2020).

Bone loss is quantified by DXA (dual x-ray absorptiometry)/bone densitometry. It is the best clinical tool to assist in reviewing fracture risk and response to treatment. Femoral neck bone mineral density is as predictive for hip fracture as high blood pressure is for stroke (Leslie et al 2006). DXA will provide two results - a T-score and Z-score. A Tscore will apply to post-menopausal women and men over age 50. This score evaluates the patient's bone density against young adult peak bone density. A Zscore will identify bone loss in people of the same age. It is applied to pre-menopausal women, men under age 50 and children. An x-ray will report normal bone mass, low bone mass or osteoporosis. This lowest score is used from all three regions; hip, spine or forearm (which is only used if hip and spine are unreliable). The most

desirable choice in clinical practice is the femoral neck density.

Bone densitometry was once thought to be the holy grail of management with the operational definition by the World Health Organisation (WHO) T-score of -2.5 or less to diagnose osteoporosis. However, this was used in research for clinical trials and its clinical application was not sensitive enough to predict fractures.

Most DXA T-scores for patients attending the Fracture Prevention Service at Tallaght University Hospital with previous fragility fracture report low bone mass of the femoral neck than osteoporosis across hip and lumbar spine sites (table 3). Therefore, based on bone density alone patients would not meet the WHO treatment threshold as there is no osteoporosis recorded by DXA. This has created confusion when selecting the correct patients for treatment.

If fragility fractures are sustained at other major osteoporotic sites such as the pelvis, ends of long bones, radius humerus tibia and fibula, treatment should be considered for this group in the presence of low bone mass. This is a diagnosis of osteoporosis as there is a raised risk for fracture. The disease increases fracture risk through loss of micro architectural structure leading to low bone mass and increased susceptibility to fracture (NOGG 2017). A fragility fracture to a hip or vertebra (Thoracic/lumbar) is a clinical diagnosis of osteoporosis. These patients should be offered treatment.

Recent research reports that those who sustain an osteoporotic fragility fracture are at imminent risk of another in the next two years (Kanis 2020). This was addressed through re-categorisation of fracture risk to either low, high or very high risk.

Low-risk patients should be reassured with lifestyle advice. High-risk patients should be considered for first line treatment such as bisphosphonate. Very high-risk patients

Feature

Osteoporosis

Neck of Femur

Total femur

Lumbar spine

Normal bone mass

210

62

285

Low bone mass

428

126

282

Osteoporosis

160

102

158 420 Table 3

might require an anabolic agent.

To a degree this is flipping previous management strategies. Previous practice was commencing first line bisphosphonate to slow bone loss reducing fracture risk. However, in theory it would make sense to stimulate a fragile structure to increase its mass. This is now becoming a reality fuelled by the advent of biosimilar anabolic agents, as patency expires for the originator. Data reporting the effect of a first line anabolic agent followed by anti-resorptive can further reduce hip fracture risk (Kanis et al, 2020). The anti-resorptive agent maintains the benefit of the previous anabolic stimulation.

It is difficult to see how this could be effectively delivered within the current Irish health system as anabolic agents are currently prescribed through high tech prescription by hospital physicians with a special interest in osteoporosis.

Critical for this patient group is access to fracture risk assessment at the acute hospital or in primary care. This should encompass a multi-faceted health and lifestyle assessment. A focused as-

24 SEPTEMBER-OCTOBER 2020

sessment can be directed through the Fracture Risk Assessment tool (FRAX). This free online tool will calculate an absolute fracture risk of fragility fracture with or without bone mineral density measurements in adults between the ages of 40 and 90. It will give direction on who to consider for treatment or lifestyle advice. It can be accessed at http://www.shef.uk/FRAX/tool. aspx?country=48. This tool is validated within the Irish population using epidemiology of fracture and rate of death (McGowan et al, 2013).

Fracture risk is calculated by age, body mass index and well-established risk factors (see Table 1 & 2). FRAX is not perfect and users should be aware of the following limitations: ▸ Falls are not incorporated into this assessment. ▸ It cannot account for dose responses such as alcohol intake, cigarette smoking, glucocorticoid doses and the number of fractures sustained to date (two previous fracture carry higher risk than a single previous fracture). ▸ It can only be used in treatment naïve patients as the algorithm cannot accommodate patients on bone protection treatment who have lowered their fracture risk.

Considering these limitations FRAX can underestimate fracture risk and should not remove clinical judgement (NOGG 2017 Kanis et al 2020).

Going forward nurses are the answer to Ireland’s bone health call.

Nurses are highly experienced and educated with skills to competently assess patients fracture risk. The ASMBR’s warning address highlighted patients’ hesitancy to commence bone protection treatment due to rare side effects (2016). Many services around Ireland are benefiting from advanced nurse practitioner roles that will drive bone health services into the future. Entwined in this role is establishing rapport with patients, assessing their needs and formulating a management plan with patients.

Giving patients the right information and management plan will ease fears and improve compliance.

A similar model of care is developing at Tallaght University Hospital.

A nurse led FLS now charges a clinical nurse specialist in bone health who is a registered nurse prescriber to assess patients for future fracture risk and instigate treatment. Nurse prescribing is well established in Ireland since 2007 with the reported benefits documented by Watson and Gethin (2013): ▸ Improved availability to medications for patients ▸ Greater medicinal compliance ▸ Safe and appropriate decision making around the prescription of medicines ▸ Holistic nursing practice Nurse prescribing can help tackle the challenges faced when managing osteoporosis to instigate treatment in those with the highest risk.

In the coronavirus era, now more than ever, staying fracture-free is critical for anyone with osteoporosis. Healthcare systems are overstretched, with general recommendations urging people to avoid hospitals and doctor’s offices unless treatment is needed or acute illness requires assessment. The Royal Osteoporosis Society has communicated

Feature

Osteoporosis REFERENCES

Åkesson, K., Marsh D., Mitchell P. J., McLellan A. R., Stenmark J., Pierroz D. D., Kyer, C., Cooper, C. (2013) Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporosis International. (24) 2135–2152.

ASMBR(2016) Call to Action to Address the Crisis in the Treatment of Osteoporosis https://www.asbmr.org/advocacy/ sfp-initiative. Accessed online 2020.

Brody, J.,E. (2018) Perfect Storm for Broken Bones. The New York Times. Accessed online 2020, International Osteoporosis Foundation (2018) Broken bones, broken lives – the fragility fracture crisis in six European countries. International Osteoporosis Foundation. Nyon.

Johnell O et al, (2005) Predictive Value of BMD for Hip and Other Fractures. J Bone Miner Res. (20)185-94.

Kanis J. A., Harvey N. C., McCloskey E., Bruyère O., Veronese N., Lorentzon M., Cooper C., Rizzoli R., Adib G., Al-Daghri N., Campusano C., Chandran M., Dawson-Hughes B., Javaid K., Jiwa F., Johansson H., Lee J. K., Liu E., Messina D.,. Mkinsi O, D. Pinto, Prieto-Alhambra D., Saag K., Xia W., Zakraoui L., &. Reginster J. -Y. (2020) Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporosis International. (31) 1–12.

the following advice - reinforce falls prevention strategies with patients ensuring the home environment is obstacle free.

It is likely that some treatments by injection or infusion for osteoporosis treatment were cancelled, but a temporary delay in medication will not have a long-term effect on bone health (Royal Osteoporosis Society, 2020).

Denosumab should not be delayed for more than four weeks, as the benefits wear off quickly. It should be rescheduled as soon as possible so that the benefits of treatment are maintained. As denosumab is a monoclonal antibody it may cause concern for increased risk of infection. Patients should be reassured it does not suppress immunity. There are no special isolation measures required with denosumab. It does not increase your risk of complications from coronavirus (Royal Osteoporosis Society, 2020).

A video was created to facilitate self-administration of denosumab, available at amgencare. ie. This can be selected for certain patients who should have normal kidney function and may skip pre-treatment bloods if serial levels are normal with regular sources of calcium and vitamin D. Syringes must be disposed of in a sharps box (Royal Osteoporosis Society, 2020).

Regarding intravenous bisphosphonate; Zoledronic acid is a long-lasting drug. It remains active for longer than 12 months, and probably more than 24 months. Most infusion services should be back running at this time and patients should liaise if this infusion is outstanding (Royal Osteoporosis Society, 2020).

Teriparatide injections should continue as normal during the pandemic. Patients who miss a dose should not worry, it will unlikely affect their overall bone health. Restart treatment when the next injection is due or as soon as is feasible. For patients completing two years of teriparatide it is important to discuss a treatment plan with the prescribing team to maintain benefits of treatment (Royal Osteoporosis Society, 2020).

Key to prevention, detection and management of fragility fractures is risk identification.

Once risks are identified initial risk calculation

by FRAX can help stratify risk. Modify lifestyle where possible. Minimise further risk of fragility fracture with bone protection treatment in high and very high-risk groups within a long term management plan. Remember the red flag mantra; fracture begets fracture.

Leslie, William D. et al (2006) Effectiveness of Bone Density Measurement for Predicting Osteoporotic Fractures in Clinical Practice. The Journal of Clinical Endocrinology & Metabolism.

92(1):77– 81.

McGowan B, Kanis, John A, Johansson, H Silke, C Whelan, B. (2013) Development and application of FRAX in the management of osteoporosis in Ireland. Arch Osteoporos. 8 (1-2):146.

Royal Osteoporosis Society. Coronavirus and Osteoporosis. https://theros.org.uk/information-and-support/osteoporosis/ coronavirus/ (Accessed online 2020).

Watson C and Georgina G. (2013) Five years of prescribing powers. World of Irish Nursing. 20(02). 24-25.

SEPTEMBER-OCTOBER 2020 25

Feature

26 SEPTEMBER-OCTOBER 2020

Atopic Eczema

Atopic Eczema

Feature

ATOPIC ECZEMA – MORE THAN AN ITCHY RASH Prof Anne-Marie Tobin, Consultant Dermatologist, Tallaght University Hospital, Clinical Associate Professor TCD; and Michelle Greenwood, Health Promotion Manager, Irish Skin Foundation, review the management of atopic eczema Atopic eczema (AE), also known as atopic dermatitis, is a common, non-communicable, chronic, inflammatory skin condition characterised by intense itch and recurring eczematous lesions. AE is the most common inflammatory skin disorder in children and infants affecting approximately 20 per cent of children. However, for some, AE can persist or develop for the first time in adulthood with some reports suggesting up to 10 per cent of adults are affected. Clinical manifestations (appearance and location of eczematous lesions) of AE may vary with age, and three stages have been recognised, infancy, childhood, and adolescent/adult.

Presentation Depending on severity, this inflammatory skin condition is recognisable by severe dryness caused by a dysfunctional epidermal barrier, intense itching, cutaneous inflammation, and vesicle formation. AE symptoms have a chronic, or relapsing disease course. As itch is a major symptom of AE, scratching only provides temporary relief, and leads to more itching and scratching, which is often referred to as the ‘itch-scratch-cycle’. The clinical appearance of AE may be modified by scratching, which in time may produce lichenification, broken skin surface resulting in excoriations, exudate, and secondary infection.

Pathophysiology and risk factors The pathogenesis of this common inflammatory skin disease is complex, and comprises an interplay of genetics, immunologic and environmental triggers, that lead to a skin barrier disruption and abnormal immune system response.

A strong risk factor for AE is a positive family history and in excess of 30 susceptibility loci have

been identified in genome-wide association studies. The strongest known genetic risk factor in AE is associated with null (loss-of-function) mutations in filaggrin gene (FLG), which encodes a key epidermal structural protein filaggrin, which is necessary for skin barrier function.

The epidermis acts as a barrier, preventing water loss, as well as entry of foreign substances such as irritants, microbes, and allergens. The epidermal barrier is made up of structural proteins including filaggrin (FLG). FLG deficiencies or mutations in the epidermis result in a weakened skin barrier, as it is less able to retain water, and the lipids that surround and support the cells break down more quickly.

The impaired skin barrier allows loss of moisture and irritants or allergens to pass through the skin more easily. This can ultimately prompt an inflammatory cascade. The immune response, which involves T-helper cell (Th) type 2 and other T-cell subsets, results in greater activity of interleukins, (IL)-4, IL-5, and IL-13 in both acute and chronic disease, which contribute to further changes which include activation of eosinophil and mast cells, B-cell IgE production and IL-31 secretion. This series of events is thought to lead to itch and further disruption to the skin barrier due to scratching.

Triggers of AE may include, allergen exposure such as house dust mite, whereas, non-allergic factors such as Staphylococcus aureus infection, abrasive garments, temperature changes, stress, and exposure to irritants such as detergents, harsh soaps and fragrances and habitual scratching can disrupt the skin barrier function.

SEPTEMBER-OCTOBER 2020 27

Atopic Eczema

Feature Assessment and management of AE Once a diagnosis of AE is established, treatment decisions are based on disease activity and impact of the disease on the patient’s quality-of-life. According to NICE guidelines, referral to dermatology specialist consultation is recommended if: a child’s eczema is uncontrolled or unresponsive, including recurring infections and/or a negative impact on quality of life and psychosocial wellbeing.

Assessment The diagnosis of AE is made clinically and is based on clinical features, patient history, and exclusion of other dermatoses. Occasionally skin biopsy, blood tests and patch testing may be useful to rule out other skin conditions. The overall disease severity may be determined by using for-

28 SEPTEMBER-OCTOBER 2020

mal diagnostic criteria, of which several sets have been developed over time. One of the most acknowledged diagnostic criteria is the Hanifin and Rajka criteria.

A scientific refinement of the Hanifin and Rajka criteria was developed by the UK Working Party criteria. According to the UK Working Party diagnostic criteria, a diagnosis for AE requires patients must have a history of itchy skin plus a minimum of three of the following: ▸ Flexural involvement, involving skin creases such as behind the knees, bends of elbows, wrists, front of ankles, or neck ▸ History of generally dry skin in the last 12 months ▸ Visible flexural eczema ▸ Personal history of asthma or hay fever (or history of atopic disease in a first degree relative, if patient is under four years of age) ▸ Onset of signs and symptoms in the first two years of life.

The European Task Force of Atopic Dermatitis developed the Scoring of Atopic Dermatitis (SCORAD), this index combines evaluation of extent, intensity of skin lesions and symptoms such as daytime itch and sleep loss. AE that scores above 50 is categorised as severe, while values below 25 are regarded as mild.

Other disease severity scales used are the Eczema Area and Severity Score (EASI) which only assess the visible lesions extent and severity and not subjective symptoms, such as sleep disturbance and itch. In contrast the Patient-Orientated Eczema Measures (POEM) is a symptomsonly score measuring subjective symptoms and frequency from a patient’s perspective.

A really useful health-related quality of life measurement tool used in clinical practice is the Dermatology Life Quality Index (DLQI). This tool is not AE specific, however it helps clinicians to assess the impact of AE on the person’s life and assists the clinician to

measure effectiveness of treatments.

DLQI scores range from 0 (no impairment of quality-of-life) to 30 (maximum impairment). For children there is the Children’s Dermatology Life Quality Index (CDLQI) which also consists of 10 questions, with 4 possible replies, the scores also range from 0 to 30. The aim of the questionnaire is to measure how much the child’s skin condition affected them in the last week.

Management AE is a life-long skin condition, so the main aim of treatment is to improve symptoms and achieve long-term control. Although there is no cure yet, typically a multistep treatment approach is considered, according to severity of the disease, patients age, and its extent and distribution.

The key principals in AE management are restoring the skin barrier with emollient therapy, baseline trigger avoidance, anti-inflammatory treatment with topical steroids or topical calcineurin inhibitors (non-steroidal immunomodulators). When topical treatments do not provide relief of symptoms, or in severe cases of AE, phototherapy maybe considered, and lastly, systemic immunosuppressants may be prescribed.

Topical treatments Ongoing efficacious, practical application of over-the-counter emollients is the cornerstone of treatment for the condition (augmented by topical corticosteroids, or topical immunomodulatory treatments as needed), as dry skin is one of the predominant manifestations of AE. The purpose of emollients is to improve the skin barrier by restoring and maintaining skin hydration, therefore soothing the skin, and reducing pruritus. Emollients are also a crucial element of maintenance treatment and also in the prevention of flares. Adults require at least 500g/ per week and children at least 250g/per week. Pump dispensers are preferable,

Atopic Eczema in order to prevent contamination. The use of emollient wash products instead of ordinary soaps and bubble baths are also recommended. Bathing should be limited to short periods of time (eg, 5-10 minutes) with warm water, and when finished, followed by application of emollients.

In July 2020 the UK, Medicines and Healthcare Products Regulatory Agency (MHRA), in partnership with the National Fire Chiefs Council, launched a campaign to raise awareness around the potential fire risks of emollients (moisturisers) often used in the management of skin disease.

The British Association of Dermatologists (BAD) released a statement on their website in July 2020 on fire risk associated with emollient use. According to the BAD â&#x20AC;&#x153;emollients represent a safe treatment option, for most patients.

That said, it is important that patients, carers, and healthcare professionals are aware of the potential fire risks associated with these products, and how to minimise them. It is important to stress that emollients are not flammable in themselves, nor when they are on the skin. The risk comes when emollient residue dries onto fabrics such as clothing or bedding and then comes into contact with a naked flame or lit cigarette causing them to catch fire.

To reduce the fire risk, patients using these products are advised to avoid naked flames completely, including smoking cigarettes and being near people who are smoking or using naked flames. It is also advisable to wash clothing and bed linen regularly.â&#x20AC;?

Wet-wrapping treatment is a technique used in people with moderate to severe eczema by using two layers of open-weave tubular bandage applied over emollients. The bottom layer is soaked in warm water, squeezed out and then put onto the skin over the emollient wet and then followed by the top layer which is dry. This treatment is reported to introduce moisture, soothe, and protect irritated skin from damage

Feature caused by scratching and is applied for short periods of time. Caution should be taken when wet wrapping using topical steroids, as absorption is increased. Occlusive medicated dressings or dry bandages should not be used in infected AE. Topical corticosteroids are recognised as first-line anti-inflammatory treatment in acute exacerbations, and selection of agent varies depending on po-

It is important to stress that emollients are not flammable in themselves, nor when they are on the skin.

The risk comes when emollient residue dries onto fabrics such as clothing or bedding and then comes into contact with a naked flame or lit cigarette causing them to catch fire

tency, the location and severity of skin affected by AE, patient age and formulation. Topical corticosteroids are grouped into classes depending on their potency, ranging from mild, moderate, potent, and very potent. A fingertip unit (FTU) is a useful method for individuals to apply topical corticosteroid in safe quantities. An FTU refers to the amount of ointment or cream applied from the end of an adult index fingertip, to the distal crease (first joint) in the finger and is equivalent to approximately 0.5grams.

The recommended FTU of topical corticosteroid will depend on the part of the body being treated and whether the patient is an adult or child. The Irish Skin Foundation has a useful guide describing the number of FTUâ&#x20AC;&#x2122;s required

for different parts of the body in adults and children in the eczema booklet on https://irishskin.ie/eczema/.

Topical calcineurin inhibitors (TCI) are considered as a second-line option for short-term and intermittent treatment of AE. These non-steroidal, antiinflammatory agents do not cause skin atrophy, and are beneficial in treating sensitive skin areas such as the face and groin. Stinging on application is the most common side-effect, but this usually settles within a few days, also sun protection is advised, in patients treated with TCI. Some patients and/or their carers may find application of topicals timeconsuming and inconvenient, fear of side effects and some treatments can be greasy in application. Due to these factors, patient adherence to topical therapy can be suboptimal. It is important that patients and/or their carers are educated with verbal and written instructions to support the safe and successful use of these treatments in the long-term and to set realistic expectations.

Phototherapy Phototherapy is a form of artificial ultraviolet light treatment, comprised of either ultraviolet A (UVA) or ultraviolet B (UVB) wavelengths of light, delivered in hospital dermatology day care centres. Narrowband UVB is the most common type of phototherapy used to treat AE and is usually given three times a week. Another form of phototherapy that may be prescribed is PUVA. UVA must be combined with a light sensitising medication such as psoralen to be effective, which is commonly known as PUVA and this is given twice a week.

Phototherapy may be given in combination with topical steroids and emollients to prevent flare-up.

Systemic treatment Oral glucocorticosteroids may be prescribed for an acute flare of AE in unique cases and sometimes in exceptional circumstances as a short-term

SEPTEMBER-OCTOBER 2020 29

Atopic Eczema

Feature

Dupilumab received regulatory approval in September 2017 from the European Medicines Agency (EMA). It is not currently reimbursed in the Republic of Ireland but is available to people living in Northern Ireland through the NHS

bridge therapy, while initiating another systemic treatment, however long-term use is not recommended in patients with AE and are limited to short-term use.

Oral antihistamines may be prescribed for short-term and intermittent use in circumstances caused by intense pruritus during a flare.

In circumstances where AE is moderate to severe or widespread and has not responded to topical or phototherapy treatments or when quality of life is significantly impacted, systemic immunosuppressive treatments may be prescribed. Current options include, methotrexate, ciclosporin, mycophenolate mofetil, and azathioprine. The individual patient profile, lifestyle factors, associated comorbidities, side effect profile along with patient preference all

30 SEPTEMBER-OCTOBER 2020

influence choice of drug. These medications have different toxicity profiles, therefore patients are reviewed and monitored regularly to avoid any potential side effects.

Biologics Dupilumab is a monoclonal antibody that inhibits signalling of interleukin (IL)-4 and IL-13, two particular interleukins thought to play a role in AE development. Positive results in improved clinical and symptomatic outcomes have been reported in several clinical studies in the treatment for moderatesevere atopic eczema in adult patients.

Dupilumab received regulatory approval in September 2017 from the European Medicines Agency (EMA). It is not currently reimbursed in the Republic of Ireland but is available to people living

in Northern Ireland through the NHS. There are also other biologic treatments for AE which are currently undergoing research globally.

Trigger avoidance Taking a careful history to help identify any relationship between suspected triggers and AE skin symptoms is important. Identification, elimination and/or control of exacerbating triggers such as physical and chemical irritants, environmental allergies, is helpful in preventing recurrent symptoms and disease deterioration. Consideration for non-allergic triggers, may include, psychological stress, temperature extremes, and dry wintery or conditioned air.

AE associated infections

Atopic Eczema

Feature fection is localised to face and limbs and may present with, grouped vesicles and/ or pustules which may progress to superficial erosions and crusting. This infection can spread quickly and responds well to oral antivirals or systemic antiviral therapy if fever or systemic symptoms are present.

Due to a weakened skin barrier, trauma from scratching and impaired cellular immunity, AE is often complicated by bacterial, viral, and fungal infections.

Staphylococcus aureus, is the most common organism, to cause bacterial infection in AE. Distinctive signs may include honey-coloured crusts, weeping and pustules, and folliculitis in hairbearing areas. Topical or oral antimicrobials may be prescribed. Bleach baths may be recommended in patients with moderate to severe AE with frequent bacterial infections.Common viral Infections seen in individuals with AE include molluscum contagiosum, cutaneous warts and herpes simplex virus. The herpes simplex virus is reported in 3 per cent of patients and if not treated early may cause systemic complications such as Eczema herpeticum. Usually the in-

Itch AE is often referred to as the “itch that rashes” due to the pruritus that patients with AE often experience. The urge to scratch can be overwhelming but only provides temporary relief, leading to more itching and scratching (the itchscratch cycle) which may lead to excoriation and skin barrier damage. Itch interferes with sleep and negatively impacts on an individual’s quality-oflife, as well as that of the wider family, with sleep deprivation contributing to difficulties concentrating at school, and/or work. Sufficient sleep is crucial for health and well-being. In children, both acute and chronic sleep disruption has been associated with a range of ‘cognitive, mood and behavioural impairments’, as well as poor performance in school. In an ISF ‘Living with Atopic Eczema Survey’ in 2019, respondents reported interrupted/loss of sleep in 86 per cent of children and 84 per cent of adults. Additionally, 26 per cent of carers of children with AE, reported that their child missed 1-2 days of school per month due to their skin condition.

Emerging comorbidities AE is associated with allergic comorbidities such as food allergy, allergic rhinitis, and asthma, along with an increased risk of irritant and allergic contact dermatitis. However, less is known about AE’s possible association with non-allergic comorbidities, amongst which include: extra-cutaneous infections, obesity, cardiovascular disease, alopecia, gastrointestinal immunemediated disorders, and adult lymphomas (the latter has been associated with severe long-term AE.)

Quality-of-life For some, the burden of AE often extends beyond the immediate dermatological effects of this disease. AE can place a serious mental health burden on patients, particularly those living with moderate-to-severe disease, with research indicating that the more severe the AE, the more quality of life is impacted. It has been associated with anxiety, depression, and attention deficit hyper-activity disorder. Research has indicated that the health-related quality of life in children with AE is comparable to that of other chronic childhood diseases such as diabetes or asthma.

Conclusion AE is often associated as a disease of childhood, but it is important not to forget that AE can be a very distressing condition for adults as well. While severity of AE varies greatly, most are affected by mild disease. Due to a variety of treatments for AE and different individual symptoms, it is important to educate patients and their families about the disease, and self-care to ensure compliance and effective management. These include, basic skin care routines that fits in with the individual’s lifestyle, management of future flares and trigger avoidance.

Also, consideration around any potential fears with regards to side-effects of medications, such as topical steroids, should be addressed, as this may impede sufficient treatment. Education for selfmanaging AE is reported to improve the severity of the disease and also improve the quality-of-life for these individuals and their carers.

Information and resources for people with atopic eczema and their carers are available on the Irish Skin Foundation’s (ISF) website, www.irishskin.ie. The charity also operates an ‘Ask a Nurse’ Helpline on (01) 486-6280 with access to specialist dermatology nurses, who provide one-to-one guidance about a range of skin conditions.

SEPTEMBER-OCTOBER 2020 31

Crohn's Disease

Feature Siún Tobin, MPSI Senior Pharmacist, Our Lady's Hospice and Care Services.

Specialising in cancer care, palliative care, and medicines information

TREATING AND MANAGING CROHN’S DISEASE AND UC

A clinical overview of Crohn’s disease and ulcerative colitis presentation and management strategies Crohn’s disease (CD) and ulcerative colitis (UC) are collectively known as inflammatory bowel disease (IBD). An estimated 40,000 people in Ireland live with IBD, most of whom are diagnosed between the ages of 15 and 35 years. The main symptoms of IBD include: Diarrhoea; cramping pains in the abdomen; tiredness and fatigue; feeling generally unwell; loss of appetite and loss of weight; anaemia; and mouth ulcers.

These disorders have both distinct and overlapping pathologic and clinical characteristics. CD is an inflammatory condition of unknown aetiology that can affect any portion of the gastrointestinal tract from the mouth to the perianal area. UC affects the colon

32 SEPTEMBER-OCTOBER 2020

exclusively and is characterised by inflammation of the mucosal layer, whereas CD is recognised by its transmural inflammatory nature. Although the pathogenesis of IBD remains undetermined, a number of risk factors have been identified, including male sex, genetic factors, and smoking.

Crohn’s disease In people with CD, the immune system recognises the lining of the digestive tract as foreign and attacks it, causing inflammation. This inflammation causes the lining of the digestive tract to develop ulcers and bleed. The severity of CD varies greatly and depends on the site of inflammation and the extent

of inflammation.

The vast majority of patients with CD (approximately 80 per cent) have small bowel involvement, with the remaining 20 per cent having disease limited to the colon. The mouth/oesophagus are less commonly considered as affected areas in CD but reportedly 5-to-15 per cent of patients have predominant involvement of the mouth or gastroduodenal area, while fewer patients have involvement of the oesophagus.

Clinical manifestations It is common for patients to have persistent symptoms for many years prior to receiving a diagnosis of CD. The hall-

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Crohn's Disease

Feature

The vast majority of patients with CD (approximately 80 per cent) have small bowel involvement, with the remaining 20 per cent having disease limited to the colon

mark symptoms of CD include fatigue, prolonged diarrhoea with abdominal pain, weight loss and fever, with or without gross bleeding.

Bleeding: Although stools often reveal the presence of microscopic levels of blood, gross bleeding is less frequent than in UC. The greater the colonic involvement, the more likely it is that melena will occur.

Malabsorption: Bile acids are normally absorbed by specific receptors in the distal ileum. Bile salt malabsorption occurs when this area is inflamed or diseased. Unabsorbed bile salts enter the colon, resulting in a secretory or ‘bile salt’ diarrhoea and fat malabsorption.

Bile salt diarrhoea is watery and affects the reabsorption of electrolytes and water from the colon.

Other gastrointestinal involvement: Severe oral involvement may present with aphthous ulcers or pain in the mouth and gums.

Oesophageal involvement may present with odynophagia and dysphagia.

34 SEPTEMBER-OCTOBER 2020

Ulcerative colitis UC is characterised by recurring episodes of inflammation limited to the mucosal layer of the colon. Unlike CD, it commonly affects the rectum and may extend in a proximal and continuous fashion to involve other parts of the colon.

The diagnosis of UC is based on the presence of chronic diarrhoea for more than four weeks, and evidence of active inflammation on endoscopy and chronic changes on biopsy. Often, diarrhoea will contain blood. The onset of symptoms is usually gradual and symptoms are progressive over several weeks. Establishing the severity of a patient’s UC is critical in the management of their condition. It also has implications in terms of predicting the long-term impact of the colitis.

Clinical manifestations UC, being an inflammatory bowel disease, will periodically present with acute symptoms. In between times, the disease can be quite stable and does not have to impact on patient activities of daily living.

Symptoms of acute exacerbations of UC include rectal bleeding, episodes of more than 10 stools per day, abdominal pain and distension and toxic symptoms, including fever and anorexia.

Drug treatment in IBD Numerous therapies are used for the treatment of IBD. The choice of therapy will vary, depending upon the anatomic location of disease, the severity of disease, and the goal of therapy (ie, induction or maintenance of remission).

Oral 5-aminosalicylates (5-ASA) — sulfasalazine, olsalazine, mesalazine Although the precise mechanism responsible for the clinical efficacy of 5-aminosalicylic acid (5-ASA) compounds is not known, they are thought to act topically. In vitro investigations have identified many anti-inflammatory and immunosuppressive properties of 5-ASA, suggesting a multifactorial basis of therapeutic action. Since orally-ingested unconjugated 5-ASA undergoes rapid absorption in the jejunum, various formulations have been developed to prevent proximal absorption of

Crohn's Disease 5-ASA and increase bioavailability in the distal small bowel and colon. Oral 5-ASAs such as mesalazine generally act in two-to-four weeks after the initiation of therapy.

Common side-effects of sulfasalazine and 5-ASAs include nausea and headache. Sulfasalazine has been associated with male infertility and, rarely, agranulocytosis. Transient, mild, watery diarrhoea can occur in patients on all oral 5-ASA preparations. Side-effects are less common where 5-ASA is administered rectally, rather than orally.

Second-line treatment for CD Antibiotics — ciprofloxacin, metronidazole Antibiotics are generally indicated in patients with CD who do not tolerate 5-ASAs or do not improve within threeto-four weeks of starting a 5-ASA. It is unclear if the efficacy of antimicrobial therapy is due to treatment of an undetected pathogen in the gut lumen, alteration of the composition of the intestinal microbiota to favour beneficial bacteria, or treatment of micro abscesses.

Metronidazole and/or ciprofloxacin are generally used, though there is also limited evidence for the use of rifampicin and clarithromycin.

Second-line treatment for UC Topical steroids and treatment combinations Patients who cannot tolerate topical 5-ASA medications should be treated twice daily with rectal steroid preparations for the induction of remission. Steroid foam preparations such as Budenofalk (budesonide) 2mg/dose rectal foam or prednisolone 20mg/dose rectal foam are both reimbursed by the HSE PCRS and may be useful. A response is usually seen in three-to-four weeks. In patients with a clear improvement in symptoms, topical steroid treatment can be tapered gradually to a nightly regimen. In the treatment of severe UC ((≥6 stools/day, severe cramps,

Feature anaemia, tachycardia) oral glucocorticoids are indicated in combination with high-dose oral 5-ASA. Further treatments for CD Glucocorticoids — prednisolone, budesonide Oral glucocorticoids are the mainstay of treatment for patients with mildto-moderate CD who are unresponsive to the above measures, or for those presenting with more severe initial symptoms. Initially, 40-to-60mg/day of prednisolone is generally prescribed and should be gradually tapered after 10-to-14 days. 5-ASA drugs and antibiotics can be used concomitantly with prednisolone.

Immunomodulators — azathioprine, 6-mercaptopurine, methotrexate Immunomodulators are indicated only in severe or refractory IBD. Azathioprine or its active metabolite, 6-mercaptopurine (6-MP), are occasionally indicated. Treatment can be initiated with either drug at a dose of 50mg/day and titrated upwards as required, depending on the response.

The maximum licensed dose of azathioprine (Imuran) is 4mg/ kg/day. A response to these medications will usually be seen within three-to-six months of treatment. During this period, patients often require concomitant steroid therapy, with a gradual reduction in the steroid dose after one-to-two months of treatment with the immunomodulatory.

Methotrexate is an alternative for patients who do not tolerate or do not respond to azathioprine or 6-MP and may be preferable to azathioprine or 6-MP in patients with troublesome extra-colonic symptoms. To guarantee bioavailability, the drug should be initiated subcutaneously/intramuscularly using Metoject/ Nordimet products. A response should be seen within three months. Once a response to intramuscular methotrexate is achieved, the patient can be switched to oral therapy, if

more tolerable.

Biologic therapies — adalimumab, infliximab, tofacitinib Biologic therapies are best reserved for patients refractory to primary therapy or who are steroid-dependent. In Ireland, infliximab is an anti-tumour necrosis factor (anti-TNF) therapy licensed for the management of CD and UC. Additionally, adalimumab is licensed for the treatment of CD in persons from the age of six years in Ireland.

Biosimilars for adalimumab are also now available on the HSE’s High- Tech Drug Scheme.

Tofacitinib (Xeljanz), a JAK inhibitor, is indicated for the treatment of adult patients with moderately- to severely-active UC who have had an inadequate response, lost response, or were intolerant to either conventional therapy or a biologic agent. The European Medicines Agency (EMA) initiated a review of this product in May 2019 following evaluation of data that suggest an increased risk of pulmonary embolism (PE) and overall mortality in patients using both the 5mg and 10mg twice daily doses of tofacitinib as compared with patients taking TNF-inhibitors. On 31 October 2019 the EMA’s safety committee (PRAC) published its findings which concluded that tofacitinib could increase the risk of blood clots in the lungs and in deep veins in patients who are already at high risk.

As a result, the PRAC recommended that tofacitinib should be used with caution in patients at high risk of blood clots. In addition, the maintenance doses of 10mg twice daily should not be used in patients with UC who are at high risk unless there is no suitable alternative treatment.

Further, the PRAC recommended that patients older than 65 years of age should be treated with tofacitinib only when there is no alternative treatment.

References on request

SEPTEMBER-OCTOBER 2020 35

Asthma

Feature

RUTH MORROW

VIRTUAL ASTHMA AND COPD REVIEWS Ruth Morrow, advanced nurse practitioner, provides an overview of virtual consultations in the Covid-19 era Asthma and COPD are two conditions which are ideal for virtual consultations. Both conditions have been the subject of many research studies over the last 20 years to address the issues of non-attendance at both primary and secondary care level appointment. “Every asthma consultation is an opportunity to review, reinforce and extend both the patient’s knowledge and skills. It is important to recognise that education is a process and not a single event” (BTS/SIGN 2019).

Ryan et al 2013 proposed a universal structured approach to a primary care asthma review “SIMPLES”.

SIMPLES is an acronym for Smoking, Inhaler technique, Monitoring, Pharmacotherapy, Lifestyle, Education and Support. It can be adapted to the current situation where face to face in person reviews may not be possible or even necessary for the majority of those with asthma. It allows an increased patient focused approach whilst gathering the required information.

Anecdotally, healthcare professionals have noticed that patients are more relaxed and more honest during a virtual consultation as they are away from the clinical environment and have not been waiting in a packed waiting room.

This article will address the finer points for undertaking virtual asthma and COPD reviews. It will also provide the GPN with a number of resources

36 SEPTEMBER-OCTOBER 2020

which can be used throughout the virtual consultation.

Undertaking an effective asthma review: ▸ Identify how you will deliver the remote review, eg, will It be through video consultation or telephone? ▸ In preparation for the consultation, briefly gather information from the medical record and prescribing data to assess morbidity and compliance, looking at short acting bronchodilator use (SABA). You can assess the patient’s reliance on SABA using the Asthma Slide Ruler (Figure 1). This ruler can also be downloaded from: https://www.pcrsuk.org/resource/asthma-sliderule ▸ At the time of booking the appointment for the virtual asthma review, check If the patient has an Asthma Action Plan and if they are using it. If the patient doesn’t have an Asthma Action Plan, this can be completed by the practice nurse/GP in advance of the appointment and posted to the patient. Inform the patient that you will be referring to it and discussing it during the consultation (Figure 2). ▸ Start off with an introduction and establish if the patient has access to the Internet as this will be useful to signpost them to edu-

cational resources and support, both during (where appropriate) and/or after the consultation.

Ask how the patient has been since their last review. ▸ Assessing asthma control - use the Asthma Control Test (Figure 3) and/or the GINA Assessment of Asthma Control to monitor the patient’s asthma. The ACT can be sent to the patient (or text a link to https://www.asthma. com/) beforehand so it can be discussed during the consultation. An ACT score of less than 19 (scored out of 25) indicates uncontrolled or poorly controlled asthma. If the patient has a peak flow meter, you can ask them to carry out the test and you can work out their percentage. ▸ Explore key triggers that make their asthma worse, including where appropriate, smoking which is a key element. Ask if there are any occupational or seasonal triggers which impact their asthma control, and whether avoidance or reduction of these is

Asthma practicable or acceptable to the patient. ▸ Check the patient's understanding around the role of each medication in helping their asthma including dosing information and when they should be taking their medication. Explore the Asthma Action Plan and assess patient’s understanding of when they should increase medication. Ask the patient about SABA use – using Salbutamol more than twice a week indicates poor asthma control and an over reliance on Salbutamol. If the patient is over reliant on Salbutamol inform them of the risks of acute asthma attacks and fatal asthma events in the future. ▸ Ask about inhaler use and technique.

Use videos to support your discussion where access is available and signpost people. Inhaler technique videos are available on https:// www.asthma.ie/about-asthma/resources/inhalertechnique-videos. If using video for the virtual consultation, you can check the inhaler technique and also demonstrate inhaler technique. ▸ Ask the patient about flare ups, days off work or school and establish what this means for your patient in terms of impact on their lifestyle. Ensure that the patient understands the 5 step Rule. ▸ Discuss vaccinations in line with current recommendations. ▸ Assessment of control will naturally lead to a discussion with the patient about pharmacotherapy. You will need to consider stepping up or down of treatment as per GINA guidelines (2020). ▸ Signpost the patient to any additional psychosocial support where appropriate. Advise the patient to use the Asthma Society of Ireland website for further resources (www.asthma.ie). Patients can also message the Beating Breathlessness WhatsApp service on 086 0590132 or phone the Asthma Adviceline on 1800 44 54 64 for further support. ▸ Discuss any follow up and arrange review date. ▸ Summarise the discussion at the end of the review.

Undertaking an effective COPD review: ▸ Identify how you will deliver the remote review e.g. will It be through video consultation or telephone? ▸ In preparation for the consultation, briefly gather information from the medical record and prescribing data to assess morbidity and compliance. ▸ At the time of booking the appointment for the virtual COPD review, check if the patient has a COPD Communication Card and if they are using it. If the patient does not have a COPD Communication Card, this can be completed by the practice nurse/GP in advance of

Feature

Figure 1 Asthma Slide Ruler

Figure 2 Asthma Action Plan

Figure 3 Asthma Control Test

SEPTEMBER-OCTOBER 2020 37

Asthma

Feature REFERENCES

BTS/SIGN (2019) SIGN 158: British guideline on the management of asthma. On: https://www.brit-thoracic. org.uk/quality-improvement/ guidelines/asthma/ Global Initiative for Asthma, 2020, Pocket Guide for Asthma Management and Prevention (For Adults and Children over 5 Years) GOLD, 2020, Global strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease.

Ryan et al 2013 SIMPLES A Structured Primary Care Approach to Adults with Difficult Asthma. Prim Care Respir J. Sep;22(3):365-73.

the appointment and posted to the patient. Inform the patient that you will be referring to it and discussing it during the consultation ▸ Start off with an introduction and establish if the patient has access to the Internet as this will be useful to signpost them to educational resources and support, both during (where appropriate) and/or after the consultation.

Ask how the patient has been since their last review. ▸ Assessing COPD – the COPD assessment test (CAT) can be used to assess the impact COPD is having on the patient’s life. It can be downloaded from: https://www. catestonline.org/. The higher the CAT score (scored out of 40), the higher the impact COPD is having on the patient’s quality-oflife. The Medical Research Council Dyspnoea score (MRC) score can be used to assess the level oy dyspnoea the patient is experiencing (Figure 4). ▸ Ask about exacerbations in the previous 12 months and if they required admission to hospital.

Early recognition and treatment

38 SEPTEMBER-OCTOBER 2020

of exacerbations of COPD is key to avoiding hospital admission and the complications associated with hospital admission. Assess if the patient is on the right treatment according to the ABCD classification (GOLD, 2020).

Reefer to GP for further advice if necessary. ▸ Check the person's understanding around the role of each medication in helping their COPD including dosing information and when they should be taking their medication. Explore the COPD Communication Card and COPD Self-Management Plan (available for download on www.hse.ie) and assess patient’s understanding of when they should increase medication. ▸ Ask about inhaler use and technique. Use videos to support your discussion where access is available and signpost people. Inhaler technique videos are available on https://www.asthma.ie/aboutasthma/resources/inhaler-technique-videos. If using video for the virtual consultation, you can check the inhaler technique and also demonstrate inhaler tech-

nique. ▸ Ask about smoking cessation and provide brief intervention strategies if appropriate. ▸ Discuss vaccinations in line with current recommendations. ▸ Signpost the patient to any additional psychosocial support where appropriate. Advise the patient to use the Asthma society of Ireland website for further resources (www.COPD.ie). Patients can also message the Beating Breathlessness WhatsApp service on 086 0590132 or phone the COPD Adviceline on 1800 44 54 64 for further support. ▸ Discuss any follow-up and arrange review date. ▸ Summarise the discussion at the end of the review.

Virtual reviews for chronic disease management have become a regular feature in the day-to-day running of general practice. This article has addressed the components of virtual asthma and COPD reviews.

It has signposted the GPN to various resources which will assist in carrying out virtual reviews.

Figure 4 COPD Assessment Test

Sexual Healthcare

Feature

SEXUAL HEALTHCARE IN IRELAND DURING A PANDEMIC Nicola Cochrane, a GP based in Wicklow, highlights how sexual healthcare has adapted in general practice since the emergence of Covid-19 As the Covid-19 pandemic began, few of us could have envisaged the dramatic changes to our working world in general practice during 2020. Provision of sexual healthcare was not an immediate priority for most practices as the move to telemedicine and community assessment hubs evolved in March

and April this year. However, people contacting GP practices during lockdown increasingly asked about menopause, contraception, symptoms of sexually transmitted infections and unplanned pregnancies.

In Ireland GPs with a special interest in sexual and reproductive health very quickly connected with

our UK colleagues in the Faculty of Reproductive and Sexual Health and devised guidance for doctors.

It was an opportunity to adopt a robust evidence based approach to prescribing regarding review intervals, what aspects of clinical examination are essential and red flag symptoms suggestive of reproduc-

SEPTEMBER-OCTOBER 2020 39

Sexual Healthcare

Feature tive cancer or infection.

Telemedicine GP bodies, such as the ICGP, have historically been conservative regarding telemedicine. This was largely due to new companies offering online consultations to people new to their service. The introduction of telephone and video consultations in general practices as a consequence of Covid-19 was significantly different, as the patients were well known to their GP and practice nurses who had access to medical records, previous laboratory results and hospital reports. The doctor patient relationship was well established and levels of patient trust and confidence were high. Non-Covid related consultation rates climbed throughout April and we were able to maintain regular prescribed medications with the new legislation facilitating electronic prescribing where a GP created a healthmail prescription sent to a pharmacy healthmail account.

Since healthmail had already been widely adopted by GPs as a secure platform to send confidential medical information to each other and our hospital colleagues, the transition to electronic prescribing was extremely simple.

Emergency contraception Guidance on provision of emergency contraception recommends the provision of either ulipristal, levonorgestrel or copper IUD as normal via telemedicine or face to face consultation for insertion of copper IUD. Oral contraceptive pills, rings and patches We had previously been advised that women who established on a hormonal contraceptive product need only annual reviews2 for blood pressure, BMI and risk review. During Covid-19 we are advised that we can continue prescriptions for 12

40 SEPTEMBER-OCTOBER 2020

months without any review. For women where they are exceeding 12 months and require remote consultation a self reported blood pressure result with a British Heart Foundation approved blood pressure device or a result from another healthcare professional (HCP) are sufficient for further prescription of medication to be provided. For many women the progesterone only pill is an excellent bridging or ongoing choice where doubts exist about cardiovascular risk, new focal migraine or high BMI. Progesterone only formulations require no clinical examination whatsoever.3 Most people are already ready familiar with guidance on continuous 365 combined pill prescribing and this is the recommended regime4.Troubleshooting bleeding problems can be done remotely unless they describe post coital bleeding or altered bleeding patterns after a long phase of problem free pill taking where an examination is recommended and investigations with referral to gynaecology may be indicated.

LARC during Covid-19 Subdermal rod or Nexplanon users can be advised that the incidence of pregnancy is low in the 4th year of their device but where they have a high level of concern we can arrange replacement of their device using remote consultation for pre-procedure counselling or bridging with progesterone only pill.Women in year three to four can replace their device without the need for a pregnancy test, but condoms are advised for the first seven days after insertion.

Women with a device >4 years in place should have a pregnancy test and use condoms for the first seven days. Bleeding conundrums can be managed by remote consultations as per combined hormonal contraception. Deep impalpable Implanons can be left in situ this year and a new

device inserted in the other arm.The referral for removal can be arranged at a later date.

Intrauterine devices require device specific advice. Mirena (Levonorgestrel 52mg device)can be left in place for six years while advised the patient that contraception cannot be guaranteed in the sixth year and bridging or replacement can be arranged where preferred. Kyleena use cannot be extended beyond five years as it contains only 19mg levonorgestrel. Copper devices licenced for 10 years can be advised to continue for 12 years, but again contraception cannot be guaranteed in the extra years and replacement or bridging provided should be where preferred.

The five year licenced copper devices must also be replaced or women can be offered bridging contraception.

Women can be advised to perform their own thread check after insertion to minimise unnecessary attendances.

Dep Provera injections can be extended to 14 weeks rather than 12 without the need for any added precautions.

Healthcare professionals are advised to don appropriate PPE during LARC procedures, minimise time for patients in the rooms and keep equipment to a minimum necessary for the procedure.

Menopause care during Covid-19 Women presenting with new onset menopause symptoms can be supported with remote consultations and prescribed HRT where indicated following the recommended prescribing guidelines, but face to face consultations should be arranged where indicated for examination or onward referral for breast or gynaecological investigations. It is important to emphasise to our patients that their menopause care should not be impacted by Covid-19 and that although there have been difficul-

Sexual Healthcare ties in accessing specific brands of HRT that alternatives are available and electronic prescriptions can be provided to ensure they have a continuous supply of their chosen medication. Increasingly doctors have moved towards transdermal oestrogen preparations which do not add any risk of VTE.6 This has opened hormone replacement therapy to a group of women who were previously considered high-risk because of high BMI (>30), borderline blood pressure, previous venous thrombo embolism and smoking. Menopause consultations for women with reproductive cancers are vital as these women face the added challenges of young age, emotional upheaval of cancer diagnosis with complexity of prescribing where they have been treated with anti oestrogen medication such as tamoxifen (some antidepressant SSRI medication can interact with tamoxifen reducing the efficacy). Women are recommended to aim for a BMI <27,take regular exercise, avoid alcohol and smoking as these have all been identified as exacerbating factors for vasomotor symptoms. A discussion on natural remedies, such as Black Cohosh and Red Clover should be conducted as these may interact with prescribed medication particularly tamoxifen and women should be advised to avoid them7. Agnus Castus ( Chasteberry or Monkspepper) has been found to be helpful for vasomotor symptoms but we have no accurate data on doses, interactions or adverse effects8.

Sexual assault Sexual assault rates dropped dramatically during lockdown in Ireland, but sexual assault and treatment units around the country have reported rising incidence of attendees since easing of the lockdown. The closure of bars and nightclubs may

Feature have been the most significant factor, however, although we have seen a rise in incidents of domestic violence these make up only 20 per cent of people seen in sexual assault treatment units (SATUs). It is inevitable that telemedicine may inhibit people

Women presenting with new onset menopause symptoms can be supported with remote consultations and prescribed HRT where indicated following the recommended prescribing guidelines

from disclosing domestic violence or recent sexual assault and so GPs and practice nurses should maintain a high level of vigilance in women attending for emergency contraception, unplanned pregnancy and sexually transmitted infections.

blood group where indicated and an ultrasound arranged if required, but for many women a subsequent teleconsultation for Visit 2 three days later can cover all the detail on how to take medication, what to expect, when to worry or attend hospital and arrangements can be made for collection of medication. Although provision for Termination of Pregnancy was provided by the Minister of Health under emergency Covid-19 legislation many doctors are hopeful that we will be able to continue to use telemedicine for this purpose on an ongoing basis. We have no data on rates of medical termination of pregnancy during 2020.

Pregnancy and antenatal care continues unchanged and postnatal check ups are done as normal in GP practices. The challenges for parents with limited time together during delivery in hospital has added stress to their birth experience and maintaining their relationship with their GP and practice nurse is reassuring for both parents and healthcare professionals. Infant vaccines are continuing as normal at present. During lockdown, for many practices, mothers and babies were the only people attending their buildings.

REFERENCES

1. FSRH guidance for contraceptive provision after changes to Covid-19 lockdown 2. FSRH Guideline CHC 2019 3. Guillebaud, Contraception Today 4. https://www.rcgpac. org.uk/wp-content/ uploads/2017/10/ Enhanced-efficacy-withcontinuous-use-ofCOC-v-10-10.pdf 5. https://www.fsrh.org/ news/fsrh-rcog-rcgp-andbms-statement-access-tohormone-replacement/ 6. BMJÂ 2019;364:k4810 Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases 7. BMS Consensus Statement 2020 Non-hormonalbased treatments for menopausal symptoms 8. Electronic Physician (ISSN: 2008-5842) http://www.ephysician. irJanuary2017, Volume:9, Issue:1, Pages:36853689,DOI:http://dx.doi. org/10.19082/3685 Systematic Review of Premenstrual & Infertility Disorders of Vitex Agnus Castus

Termination of pregnancy Unplanned pregnancy occurring during lockdown introduced a challenge for GPs in supporting these women and guidance was rapidly delivered from ICGP, START, RCOG, and FSRH on the use of telemedicine in provision of abortion. The systems and protocols were adapted to record cycle details, first date of positive pregnancy test, previous gynaecological and medical history, allergies and medication by telephone or video consult as Visit 1.

Notification and certification were completed as usual. Women are asked to attend for examination or

SEPTEMBER-OCTOBER 2020 41

Motoring

Feature

Morgan Flanagan Creagh

MINI'S NEW COUNTRYMAN HAS ALL BASES COVERED Morgan Flanagan Creagh reviews the latest range of Countryman offerings from Mini It’s been a very long time since the Mini was actually mini and the beefedup Countryman is the biggest of the range. The big Mini has had some design updates for 2020 and a plug-in hybrid system.

It’s also available with two petrol engines and one diesel engine featuring the latest TwinPower turbo technology. It’s also better for the planet, thanks to some serious work on emissions performance. This includes particulate filters for petrol engines and SCR with AdBlue injection for diesel engines, meaning that all model variants of the new Countryman now meet the particularly rigorous Euro 6d

42 SEPTEMBER-OCTOBER 2020

Like the petrol engines, the diesel engines also have a new starter generator with optimised efficiency

emission standard.

Mini’s TwinPower Turbo Technology is used in the three-cylinder petrol engines of the new Mini Cooper Countryman and in the four-cylinder

petrol engine of the new Mini Cooper S Countryman. It now includes an exhaust manifold integrated in the cylinder head, along with turbo charging, in highly effective cooling of the exhaust gases and the turbo-charging system. At the same time, crankcase cooling can be reduced when demand is low in the partial load range by means of a new split cooling valve.

Like the petrol engines, the diesel engines also have a new starter generator with optimised efficiency. In the four-cylinder engines of the new Mini Cooper D Countryman, the turbo-charging system features exhaust gas recirculation and common rail

Feature

Motoring direct injection. The two-stage turbo-charging system previously used exclusively in the most powerful diesel engine now also optimises the response of the four-cylinder motor in the Cooper D Countryman.

Mini’s all-wheel drive system, the ALL4, is an option for all engine variants and comes as standard in the hybrid model. According to Mini, it provides a noticeable boost in terms of traction, driving stability and agility by ensuring a need-based distribution of power between the front and rear wheels in all road surface and weather conditions. In the hybrid, the ALL4 system manages a precisely-controlled interaction between the three-cylinder petrol engine transmitting its power to the front wheels, with an electric synchronous motor that acts on the rear wheels. Together, the two power units produce a system output of 162kW/220hp.

The new hybrid comes with a six-speed Steptronic transmission as standard. The Mini Cooper Countryman ALL4 and the Mini Cooper D Countryman ALL4 now feature an eight-speed Steptronic transmission as standard, as does the Mini Cooper SD Countryman ALL4.

It is also optionally available for the Mini Cooper D Countryman. For all other model variants, a seven-speed Steptronic transmission with double clutch is optionally available to replace the standard six-speed manual transmission. The most powerful petrol and diesel engines can also transmit their drive torque to a seven-speed Steptronic sports transmission with double clutch or an eight-speed Steptronic sports transmission. This enables particularly rapid speed changes and increased shifting dynamics.

The big Mini Countryman is instantly recognisable as the brand’s largest model, with its upright stature and increased ground clearance indicative of its generous interior space. The new Countryman has a versatile interior, with three fully-fledged rear seats which fold down, expanding transport capacity and storage from 450 litres up to 1,390 litres.

The redesign of the front section for this new model adds LED headlamps to the standard trim, with turning light included in the functional range, providing intensive illumination of the side areas of the road when changing direction.

The standard trim of the new Countryman also includes LED fog lights, with a light band in the upper semi-circle of each fog light serving as a parking light.

The Cooper S Countryman and Cooper PlugIn Hybrid models now come with Piano Black interior surfaces for the cockpit and door bezels as standard. These are combined with accentuation strips in the variant British Oak. A new version of the highly exclusive Mini Yours interior surfaces is optionally available.

The optional Mini Yours Interior Style Shaded Silver combines an illuminated cockpit bezel in the variant Shaded Silver, with door bezels in Dark Silver and accentuation strips in Hazy Grey.

The new range of Countryman offerings from Mini seems to have something for every taste, all backed-up by that stalwart BMW build quality and starting at €34,070.

The new MINI Countryman is available in seven model variants: MINI Cooper Countryman 136 hp, 0–100km/h in 9.7 seconds, top speed: 205km/h, fuel consumption: 5.9–5.6 litres/100km, CO2 emissions: 135-129g/km.

MINI Cooper Countryman ALL4 100kW/136hp, 0–100km/h in 10.1 seconds, top speed: 202km/h, fuel consumption: 6.1–5.9 litres/100 km, CO2 emissions: 140–134g/km.

MINI Cooper S Countryman 131kW/178hp, 0–100km/h in 7.5 seconds, top speed: 225km/h, fuel consumption: 6.5–6.3 litres/100km, CO2 emissions: 148–144g/km (136–130g/km).

MINI Cooper S Countryman ALL4 131kW/178hp, 0–100 km/h in 7.3 seconds, top speed: 222km/h, fuel consumption: 6.5–6.2 litres/100 km, CO2 emissions: 149–142g/km.

MINI Cooper Countryman Plug-In Hybrid ALL4 162 kW/220hp, 0–100km/h in 6.8 seconds, top speed: 196km/h, fuel consumption: 2.0–1.7 litres/100 km, power consumption: 14.0–13.1 kWh/100 km; CO2 emissions: 45–40g/km.

MINI Cooper D Countryman 110kW/150 hp, 0–100km/h in 9.1 seconds, top speed: 214km/h (213 km/h), fuel consumption: 4.4–4.2 litres/100km, CO2 emissions: 116–110g/km.

MINI Cooper D Countryman ALL4 110kW/150 hp, 0–100km/h in 9.0 seconds, top speed: 211km/h, fuel consumption: 4.8–4.6 litres/100km, CO2 emissions: 127–121g/km.

SEPTEMBER-OCTOBER 2020 43

Feature

Culture

Find out more about Bianca Divito

Visit: biancadivito.com etsy.com/ie/shop/ BiancaDivitoGlassArt facebook.com/ BiancaDivitoGlassArtist www.instagram.com/ biancadivitoglass

A TALK WITH BIANCA DIVITO Lead artist at Divito Studios, Bianca Divito is an award-winning stained-glass designer and conservator, hailing from Co Wicklow.

What’s the biggest perk of being in your profession?

Having the ability to truly transform environments with architectural stained glass. I’m working with an art form that is essentially more three-dimensional rather than twodimensional and which plays a huge role controlling light and influencing the atmosphere of interiors. I’m solely involved with every step of the commissioning process, from design to installation, so I’m able to maintain control and ensure that my clients are getting exactly what we had envisioned for the space.

How has your practice changed over time?

With experience comes wisdom and I’m quite selective about my work these days. I only get involved with projects I feel are worthwhile, artistically and financially. When I set up my stu-

44 SEPTEMBER-OCTOBER 2020

dio 12 years ago, I spent an awful lot of time worrying about where the next job would come from. I tried to fulfil every opportunity, sometimes losing sight of the type of work which actually made me happy. In recent years, I’ve also been collaborating with my husband Damien Keane — a landscape garden designer (keanefacebook.com/keanespaces, spaces.ie instagram.com/keanespaces). This has been both exciting and challenging and it has opened up new opportunities for me to create glass art for outdoor environs.

How important are titles in your work?

Not at all important. Different people see different things and I love it when people draw their own conclusions. I have tried to title pieces before but it has felt contrived for me to do this, so I usually steer clear.

Culture What are you currently working on?

Since the birth of my second daughter Lila and since I’ve been back in the studio, I have experienced an explosion of creativity. I’m literally bursting with ideas and I’m currently developing new ranges of garden art glass, modern lighting features and memorial art for installation into headstones. I’m also really excited to be thrashing-out ideas for a collaborative piece with my cousin Anna Divito, a New York-based illustrator in the children’s publishing market (annadivito.com).

My current commissions on the bench include the design and fabrication of a glass entrance for a period home in the Wicklow hills, a freestanding art glass feature for a South Dublin garden, two glass memorial inserts for headstones in Limerick and Wicklow, and two fish-themed, handpainted and etched memorial panels, destined for the US. What’s good about living in Ireland?

Feature The people. I just love it here. It’s a cliché, but there’s always craic to be had. As a nation, we have an extraordinary ability to converse, to chit-chat about the ordinary. After living in many different places during my education and travels, I can safely say that there is no place I’d rather live, raise a family and practice my art than in Ireland right now.

What motivates you?

I’m a proud people-pleaser; I love how happy my commissioned works make people feel. It’s egotistical alright, but that’s what drives me. This is especially so for the memorial glass art pieces I’m creating for clients right now. I find the whole process of working closely with bereaved clients really rewarding and I’m honoured to do so.

Creating these bespoke glass features offers so much comfort to relatives and it leaves a lasting legacy for generations to come too.

SEPTEMBER-OCTOBER 2020 45

Product News

CLONMEL HEALTHCARE LAUNCH GASTRORESISTANT TABLETS

CONSILIENT HEALTH LAUNCH ALTAVITA 50,000 IU SOFT CAPSULE

Clonmel Healthcare has launched Posaconazole Clonmel 100mg gastro-resistant tablets.

Posaconazole Clonmel is indicated for use in the treatment of fungal infections in adults, including the treatment of invasive aspergillosis in patients with disease that is refractory to amphotericin B or itraconazole or in patients who are intolerant of these medicinal products.

It is also used for fusariosis in patients with disease that is refractory to amphotericin B or in patients who are intolerant of amphotericin B; chromoblastomycosis and mycetoma in patients with disease that is refractory to itraconazole or in patients who are intolerant of itraconazole; and coccidioidomycosis in patients with disease that is refractory to amphotericin B, itraconazole or fluconazole or in patients who are intolerant of these medicinal products.

Refractoriness is defined as progression of infection or failure to improve after a minimum of seven days of prior therapeutic doses of effective antifungal therapy.

Posaconazole Clonmel is also indicated for prophylaxis of invasive fungal infections in the following patients: Patients receiving remissioninduction chemotherapy for acute myelogenous leukemia (AML) or myelodysplastic syndromes (MDS) expected to result in prolonged neutropenia and who are at high risk of developing invasive fungal infections; and hematopoietic stem cell transplant (HSCT) recipients who are undergoing high-dose immunosuppressive therapy for graft versus host disease and who are at high risk of developing invasive fungal infections.

Consilient Health is pleased to announce the launch of Altavita D3 50,000 iu (Colecalciferol) capsules for the treatment of vitamin D deficiency.

The recommended dose is one Altavita D3 50,000 iu weekly for six to eight weeks for patients with vitamin D deficiency (plasma 25(OH)D < 25nmol/l).

Consilient Health continue to supply all presentations of Altavita D3 designed for your patientâ&#x20AC;&#x2122;s routine. These presentations include the 1,000 iu (daily prevention), 7,000 iu (weekly prevention) and 25,000 iu (monthly prevention).

The Altavita range is reimbursed under the General Medical and Drug Community Scheme.

46 SEPTEMBER-OCTOBER 2020

Product News

NEW EYE DROPS LAUNCHED TO HELP CALM EYE IRRITATION Clonmel Healthcare has announced the launch of Eye Drops - from the makers of Anti-Hist. The Eye Drops are moisturizing, refreshing and contain sodium hyaluronate, which is associated with the qualities of chamomile, witch-hazel and cornflower. They help to refresh, soothe and calm eye irritation, dryness and burning due to environmental elements (wind, sun, smoke) and can also help to alleviate the effects of hay fever (allergic rhinitis). Eye Drops - from the makers of AntiHist are available in a pack size of 10 preservative free re-sealable mini containers of 0.5ml.

CLONMEL HEALTHCARE BECOMES THE DISTRIBUTOR OF DISTACLOR IN IRELAND Clonmel Healthcare has been appointed distributor for the brand Distaclor in Ireland by Flynn Pharma.

In the past few months, Clonmel Healthcare has worked closely with Flynn Pharma to ensure the smooth transition of Distaclor, particularly relating to customer care and distribution.

The full Distaclor range includes Distaclor LA 375 mg Prolonged Release Tablets; Distaclor LA Forte 500 mg Prolonged Release Tablets; Distaclor 125mg/5ml granules for oral suspension; and Distaclor 250mg/5ml granules for oral suspension.

SEPTEMBER-OCTOBER 2020 47

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Latest module

Crohn’s disease — presentation, diagnosis and management was devised

by Theresa Lowry-Lehnen, Clinical Nurse Practitioner and Associate Lecturer at Institute of Technology Carlow, Assistant PRO Irish Student Health Association.

Crohn’s disease is an inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract. True or False?

Check your answer against the latest module on nursecpd.ie.Successful completion of this module will earn you 2 CPD credits Free CPD – accessible on android, iPhone and tablet

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