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ISSUE 5 VOLUME 14 | SEPTEMBER-OCTOBER 2021

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HERPES ZOSTER

Diagnosis, management and prevention A DETAILED OVERVIEW OF

CHOLESTEROL

PCOS The latest knowledge and treatment approaches

SJÖGREN’S SYNDROME

CPD module on how to recognise and care for these patients

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References References

1. O’Carroll 1. O’Carroll E et al. (Abstract) Presented E etatal. The Nutrition (Abstract) Society Advancing Presented Nutritional Scienceat The Nutrition Society Advancing Nutrition Spring Spring Conference, Glasgow. Conference, 2018. 2. Nutricia Data Glasgow. on File, 2020 2018. 2. Nutricia Data on File, 2020


Welcome

GOODBYE TO SUMMER Dear Readers, Welcome to the September/October issue edition of Nursing in General Practice. I hope you all managed to get some time to switch off from work over the past few months and enjoyed the summer sunshine. In this issue, we have articles on cholesterol, Crohn’s disease, polycystic ovarian syndrome (PCOS), herpes zoster (shingles), and Sjögren’s syndrome. Blood testing for cholesterol is probably one of the most common blood tests general practice nurses (GPNs) are asked to perform by patients. I often question the rationale for regular screening for elevated lipids particularly when lifestyle changes have not been undertaken despite being encouraged to. I would also question the usefulness of checking lipids in people who are established on statin therapy. If therapy is being adhered to, these levels should be normal and one would wonder about the necessity of repeated frequent testing and the cost to the health service. In this issue, pharmacist Eamonn Brady takes us through controlling cholesterol and discusses treatment options including the newer injectable therapies. GPNs frequently care for people who have Crohn’s disease, a debilitating illness which can have a huge impact on an individual’s quality-of-life. Crohn’s is a chronic condition, with many experiencing it as an ongoing and life-long disease, often with periods of remission

as well flare-ups which can be challenging to deal with. A lot of these patients in our care are on immunosuppressant therapy, biological therapy or anti-TNF drugs which bring their own challenges in terms of education, observation and monitoring. The article in this issue provides us with an overview of Crohn’s disease and its management. PCOS is a common endocrine, metabolic, and menstrual disorder in women. Multifactorial in nature with a complex interaction of genetic and environmental factors, PCOS is exacerbated by obesity and has significant metabolic, reproductive, and psychological features, including an increased risk of type 2 diabetes mellitus, subfertility, and depression and anxiety symptoms. GPNs frequently encounter young women who require a lot of support around this condition and its wider implications. This article by Theresa LowryLehnen explores the diagnosis and management of PCOS. Sjögren’s syndrome, a chronic autoimmune condition often under-diagnosed, can have debilitating effects on quality of life that is sometimes linked to other auto-immune conditions such as rheumatoid arthritis. Tennis player Venus Williams was diagnosed with Sjögren’s syndrome a number of years ago and still plays on the women’s tennis circuit, but has cut back on the number of tournaments she takes part in. She frequently alludes to the fatigue that ac-

companies this condition. This article, which supports a module on www.nursecpd.ie that can be undertaken as part of continuing professional development, addresses the diagnosis and treatment of this complex condition which very often co-exists with other chronic conditions. The majority of patients will attend a rheumatologist for diagnosis and management with the GPN having a key role in ongoing monitoring and support. Some patients living with these conditions may find it beneficial to be referred to the Living Well programme, a free group self-management programme run by the HSE at various times throughout the year in all CHO areas. The Living Well programme supports patients, regardless of which condition they have, to develop the skills which will help them to live well with a long-term health condition(s). The Living Well programme has proven to be effective in helping people to manage their health conditions better. Further information is available on www.hse. ie/eng/health/hl/selfmanagement/ living-well-programme/ along with dates and times of upcoming programmes. This issue has focused on a number of chronic conditions which the GPN has a significant role to play in supporting and ongoing management. The GPN is frequently the first port of call for these patients when the need arises. It is important that we have forged links with the CNS in the acute setting to support us as we don’t always have the answers.

A message from Ruth Morrow, Consulting Editor

SEPTEMBER-OCTOBER 2021 1


Contents EDITOR Priscilla Lynch CONSULTING EDITOR Ruth Morrow SUB-EDITOR Emer Keogh emer@greenx.ie CREATIVE DIRECTOR Laura Kenny laura@greenx.ie ADVERTISEMENTS Graham Cooke graham@greenx.ie ADMINISTRATION Daiva Maciunaite daiva@greenx.ie

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

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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.

NEC and Irish healthcare news

COVID-19 VACCINATION

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A look at the key role general practice nurses have played in the roll-out of Covid-19 vaccines this year

EAR EXAMS AND EAR IRRIGATION

Kathy McSharry, Practice Nursing PDC for CHO2, describes the reestablishment of the Ear Exam and Ear Irrigation Programme workshops for general practice nurses

RHEUMATOLOGY CPD

© Copyright GreenCross Publishing Ltd. 2021

Please email publishing enquiries to Publisher and Director, Graham Cooke graham@greenx.ie

14

NEWS

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Pharmacist Eamonn Brady outlines diagnosis, treatment, and support strategies for Sjögren’s syndrome

CROHN’S DISEASE

Pharmacist Eamonn Brady looks at the latest management and ongoing support approaches for caring for patients with Crohn’s disease

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CHOLESTEROL

Pharmacist Eamonn Brady gives a comprehensive overview of cholesterol, its negative impact on health, as well as evidence-based prevention and treatment approaches

HERPES ZOSTER (SHINGLES) Theresa Lowry-Lehnen outlines the pathophysiology, symptoms, and treatment of this common, painful condition in older adults

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POLYCYSTIC OVARY SYNDROME (PCOS)

Theresa Lowry-Lehnen examines the presentation and treatment of this common condition, which can have a serious negative impact on many areas of a woman’s health

BOOK REVIEW

Prof Denis Gill reviews Lawrence Trevelyan Weaver’s fascinating breastfeeding tome White Blood: A History of Human Milk

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CROSSWORD

2 SEPTEMBER-OCTOBER 2021

Test your word knowledge


For COPD patients on treatment with ICS/LABA and at risk of exacerbation*1 *A worsening of symptoms or a history of exacerbation treated with antibiotics or oral corticosteroids in the past 12 months

It’s the things you do today that make a big difference 1-3 to their tomorrows TRELEGY Ellipta provides your patients with statistically superior improvements in lung function and health-related quality of life, and reduction in annualised rate of moderate/ severe exacerbations** vs. budesonide/formoterol***1–3 Fictional patient, for illustrative purposes only

Start your patients on TRELEGY Ellipta today, expect more from tomorrow1,2

**Moderate exacerbation is a worsening of symptoms or a history of exacerbation treated with antibiotics or oral corticosteroids. A severe exacerbation is a worsening in symptoms that required hospitalisation.

TRELEGY Ellipta (FF/UMEC/VI) 92/55/22 mcg OD is indicated for maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an ICS and a LABA or a combination of a LAMA and a LABA1

Today. Tomorrow. TRELEGY. 2-3

▼This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. ***Co-primary endpoints were change from baseline in trough FEV1 and SGRQ at week 24 (n=1810). A subset of patients (n=430) remained on blinded study treatment for 52 weeks. Trelegy showed an improvement in trough FEV1 of 171mL versus budesonide/formoterol (p < 0.001, 95% CI 148,194) at week 24. Trelegy showed an improvement in health-related quality of life (SGRQ) of 2.2 units (p <0.001, 95% CI 3.5, 1.0) at week 24. At week 52 in a subset of patients Trelegy showed a 44% reduction in annualised rate of moderate/severe exacerbations versus budesonide/formoterol (95% CI 15,63, p=0.006, Absolute difference 0.16). TRELEGY Ellipta is generally well tolerated. Common adverse reactions include: pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough, oropharyngeal pain, constipation, arthralgia, back pain1 FF, fluticasone furoate; ICS, inhaled corticosteroid; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol References: 1. TRELEGY Ellipta SmPC 2019. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA et al.N Engl J Med 2018; 378:1671–1680. Trelegy▼ Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) Prescribing information. Please consult the full Summary of Product Characteristics (SmPC) before prescribing. Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg), umeclidinium bromide (UMEC) 62.5 micrograms and vilanterol as trifenatate (VI) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting ß2-agonist (LABA) or a combination of a LABA and a long acting muscarinic antagonist. Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or life-threatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of ß-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or long acting ß2-adrenergic agonists is not

Find out more here:

www.trelegy.ie or request a visit from a GSK representative recommended. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough, oropharyngeal pain, arthralgia, back pain. Uncommon (≥1/1,000 to <1/100): viral respiratory tract infection, supraventricular tachyarrhythmia, tachycardia, atrial fibrillation, dysphonia, dry mouth, fractures. Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions, including anaphylaxis, angioedema, urticaria, and rash. Not known (cannot be estimated from the available data): vision blurred. Marketing Authorisation (MA) Holder: GlaxoSmithKline Trading Services Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA No. [EU/1/17/1236/002]. Legal category: POM B. Last date of revision: September 2020. Code: PI-6725. Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling: (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255. TRELEGY Ellipta was developed in collaboration with ©2020 GSK Group of Companies or its licensor Trademarks are owned by or licensed to the GSK Group of Companies PM-IE-FVU-ADVT-200014 | October 2020


News

NEWS MINISTER FOR HEALTH OPENS PUBLIC CONSULTATION ON THE NATIONAL ADULT PALLIATIVE CARE POLICY Minister for Health Stephen Donnelly has announced the public consultation on the National Adult Palliative Care Policy. He made the announcement during a visit to Our Lady’s Hospice and Care Services Wicklow Hospice to mark National Palliative Care week. Minister Donnelly said: “In line with the Programme for Government, we are planning to update our national palliative care policy for adults next year. We are using an online survey to get the views of the public on how services for people with a serious and progressive illness are delivered, which will inform the policy update. Survey participants will be asked about their awareness of palliative care, their views on current services and future priorities for palliative care services. This survey can be accessed from today and will be open for six weeks closing on 25 October 2021.” Minister Donnelly continued: “The survey will provide valuable information about the views of the nation on how care for people with a serious and progressive illness

is delivered in Ireland and help to shape the development of the update to the Palliative Care Policy for adults. I would urge everybody to take part in the survey. Getting the views of both those who work in the field of palliative care, interested organisations and members of the public is vital to the development of this policy." The survey was launched during National Palliative Care Week 2021, which ran from the 12 to 18 of September. A number of events were facilitated by the AllIreland Institute of Hospice and

Palliative Care (AIIHPC) during the week, with the objective of increasing public understanding of palliative care and raising awareness of its benefits. The survey can be accessed at: www.gov.ie/en/consultation/066a8public-consultation-on-the-update-ofthe-adult-palliative-care-policy/ Meanwhile, a new survey of the public’s perceptions of palliative care commissioned by the AIIHPC to highlight Palliative Care Week, found that four-infive people, if living with a serious illness, would like their doctor

or healthcare professional to talk to them about palliative care if it could help them. The survey of 1,000 people in the Republic of Ireland, carried out in July 2021, also highlighted some of the misconceptions that exist about palliative care.    One-in-four people would think they only have days to live if their doctor or healthcare professional talked to them about palliative care, whereas palliative care may be appropriate for several years, not just for weeks and days at a person’s end of life.   One-in-four would feel their doctor is giving up on them if they talked to them about palliative care.    Over 60 per cent say they don’t mind where they receive palliative care as long as they have a good quality-oflife and their physical and emotional pain is managed, and they are comfortable. Palliative care can be received in many different settings, such as in a hospice/specialist palliative care unit, a hospital, a nursing home, or the person’s own home. 

A NEW APPROACH TO MENOPAUSE CARE FOR WOMEN IN IRELAND Minister for Health Stephen Donnelly TD has announced his commitment to establish dedicated specialist menopause clinics across Ireland. These clinics will form a core part of a new approach to menopause care for women in Ireland and will be supported by enhanced community and primary care supports as well as the publication of targeted and trusted sources of information for women experiencing menopause. The development follows the advice of the Women’s Health Taskforce and ringfenced investment through the Women’s Health Fund.   The first phase of change will include the

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development of a dedicated specialist clinic in the National Maternity Hospital, Holles Street, this year. The clinic will be multidisciplinary and supported by GPs with a certified special interest in the area of menopause and clinical nurse/midwife specialists. In addition to seeing women who meet the clinical criteria for referral to the service, the clinical team will also provide advice and guidance to GPs in the community to support the effective management of menopausal symptoms for women closer to home within primary care. The specialist GPs working under the governance of the National Maternity Hospital

will also have direct access to escalation pathways for women who require additional investigations and management from other healthcare professionals, including consultant gynaecologists, ultrasonographers, and pelvic floor specialists. While the majority of women who seek support for their menopause can be effectively supported within primary care by their GP and general practice nurse, approximately 25 per cent of symptomatic women will require specialist medical expertise in menopause. Specifically, this cohort of women will fall


News

within four broad categories:  Treatment does not improve their menopausal symptoms;   They have ongoing troublesome sideeffects, eg, bleeding;   They have contraindications to HRT; and   There is uncertainty about the most suitable treatment option for their menopausal symptoms, eg, complex medical history.  This clinic will accept referrals from GPs based on the four criteria identified above, with a view to this cohort of women being provided with specialist medical advice and management regarding their menopausal management.   Minister Donnelly said: “Our first priority in the Women’s Health Taskforce has been to listen to women. Through that process women across

the country have shared their experiences of menopause and have asked us clearly to change our approach to supporting them. I am making menopause a priority within our women’s health programme and I am proud to announce my commitment to fund this first dedicated specialist menopause clinic within public health system this year. This is an important part of an integrated solution to delivering better health experiences for women before, during and after the menopause.” It is intended that the clinic will begin to see patients in the course of 2021 and will be supported by the development of additional regional clinics in the course of 2022.  Dr Peter McKenna, Clinical Director of the National Women and Infants Health Programme in the HSE, warmly welcomed this development:

"Once operational, this clinic will significantly increase the support available to women going through the menopause. It will deliver benefits to primary care practitioners as women's main health partners through the menopause in terms of providing guidance and advice to them, and will provide specialist support for a number of women who require additional care, thereby helping to look after women throughout their life course.” A 2022 plan for women’s health is in development informed by engagement with women across the country, key stakeholders, clinicians, and advocates for women’s health through the Women’s Health Taskforce. It is intended the plan will be brought to Government and published later this year. 

THE NATIONAL SCREENING SERVICE LAUNCHES NEW LGBT+ CERVICAL SCREENING STUDY REPORT The National Screening Service has launched a new report entitled LGBT+ Cervical Screening Study, in partnership with LINC – an NGO working with lesbian and bisexual women and their families, and CervicalCheck – the national cervical screening programme.  This study examines the knowledge of; attitudes towards; participation in; and experiences of cervical screening in Ireland. It was open to lesbian and bisexual women, trans men, non-binary, and intersex people. Approximately 450 people who identify as LGBT+ took part in the study between October 2020 and March 2021. It was found that while the majority said they had positive experiences of cervical screening, only about two-thirds (or 66 per cent) of people said they attended cervical screening regularly. This compares to an 80 per cent attendance by the general population.  Despite widespread common perceptions among health professionals, as well as service users, that HPV is only spread during heterosexual sex, cervical cancer-related HPV can affect anyone with a cervix who has engaged in any sexual activity with another person, including sharing sex toys or skin-to-skin contact, regardless of the age, gender, or sexual orientation of either partner.  Dr Sarah Fitzgibbon, Primary Care Clinical

Advisor for CervicalCheck, said: “One finding that stands out is the inaccurate information circulating in the LGBT+ community that cervical screening may not be necessary for them. CervicalCheck invites every person with a cervix in Ireland aged 25-to-65 years for free cervical screening, every three or five years depending on age. The aim of the programme is to detect abnormalities in the cervix that, if left untreated, could develop into cancer. Therefore it’s important that everyone who is invited attends.” Anyone with a cervix is at risk from cervical cancer and should avail of regular screening. International evidence, spanning more than two decades and from a broad range of countries, demonstrates that lesbian and bisexual (LB) women and gender minorities with a cervix (GMC) have significantly lower rates of uptake of HPV and cervical screening. This study set out to examine the situation in Ireland against this backdrop. The main barriers to attending screening were found to be:   Heteronormative assumptions made by healthcare professionals regarding people's circumstances;   The person being asked heterosexual questions by healthcare professionals, which do not accurately reflect their gender identity, and;

Fear of the test procedure itself. Over 62 per cent of those surveyed do not state their gender/sexual identity when attending for screening.  LINC member and cervical screening advocate Ruth O’Mahony said: “A number of lesbian and bisexual women think they don’t need to go for screening because they are not having sex with men. And just like women in the community as a whole, many also don’t like the invasiveness of the procedure. A positive experience with your GP can help you focus on taking care of your body. And if you can see yourself represented in the information being given out about female health, you’ll be more likely to consider it’s for you.” Dr Nóirín Russell, Clinical Director of CervicalCheck, said: “Following the publication of this report, CervicalCheck is committed to a number of actions, such as: Increased training and supports for sample takers; inclusion of and communication with the LGBT+ community in cervical screening; more targeted messaging and campaigns for the LGBT+ community, working in partnership with the people we care for in screening; and further research. “We look forward to implementing these recommendations alongside our partners in LINC and the wider LGBT+ community.” 

SEPTEMBER-OCTOBER 2021 5


News

NEWS BREAST MILK PROVEN TO ENHANCE HEART PERFORMANCE IN PREMATURE BABIES – RCSI RESEARCHERS New research from RCSI University of Medicine and Health Sciences demonstrates the beneficial effect of breast milk consumption on cardiovascular health and early cardiovascular development in premature infants. Published in JAMA Network Open, the study of 80 preterm infants is the first of its kind to show that preterm infants with higher exposure to their mother’s own milk had enhanced cardiac function at age one year, with values approaching those of healthy full-term infants.  The research was led by Prof Afif EL-Khuffash, Clinical Professor of Paediatrics at RCSI and Consultant Neonatologist at the Rotunda Hospital, Dublin, in collaboration with researchers at University of Oxford; Mount Sinai Hospital, Toronto; Northwestern University Feinberg School of Medicine; Washington University School of Medicine; and Harvard Medical School. Children and adults who are born preterm are at increased risk of cardiovascular disorders, including ischaemic heart disease, heart failure, systemic and pulmonary hypertension, and are more likely to die as a result of cardiovascular disease. The hearts of young people born early are known to have unique traits such as reduced biventricular volume, shorter length, lower systolic and diastolic function and a disproportionate increase in muscle mass. This results in

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impaired heart function, which is significantly lower than that of healthy infants who are born at term. This dysfunction is detectable at hospital discharge and persists throughout their adolescence.   This study shows that exclusive breast milk consumption in the first months after birth is associated with a normalisation of some of these traits. Premature infants exposed to a high proportion of their mother’s own milk during the first few weeks after delivery had greater left and right heart function and structure with lower lung pressures and enhanced right heart response to stress at one year of age compared to preterm infants who had a higher intake of formula, with all measures approaching those seen in term-born healthy children. These findings were apparent before discharge from the hospital and persisted up to a year of age (the duration of follow up). Prof EL-Khuffash said: “This study provides the first evidence of an association between early postnatal nutrition in preterm-born infants and heart function over the first year of age, and adds to the already known benefits of breast milk for infants born prematurely. “Preterm infants have abnormal heart function. However, those who are fed their mother’s own milk demonstrate recovery of their heart function to levels comparable to healthy term born infants. Preterm infants fed formula do not demonstrate this recovery.”

NEW LEGISLATION CHANGES HOW NMBI DEALS WITH COMPLAINTS AGAINST NURSES AND MIDWIVES As part of its aim of protecting the public, the Nursing and Midwifery Board of Ireland (NMBI) is legally responsible for considering complaints against nurses and midwives who practise in Ireland. The NMBI’s Fitness to Practise department aims to deal with all complaints fully, fairly and in accordance with the legislation, which gives it its regulatory powers. New legislation, the Regulated Professions (Health and Social Care) Amendment Act, 2020, which came into effect on 1 August 2021 means a number of changes to the manner in which the NMBI deals with these complaints.  Many of the changes introduce efficiencies and remove some of the cumbersome administrative steps which delayed the process, including the following:   The NMBI CEO can now decide not to progress a complaint if it is deemed that it is not made in good faith or is frivolous or vexatious. For example, this could be where the complaint may not relate to a registrant’s practice as a nurse/midwife or where there are repeated complaints from the same

complainant. It also arises where a complainant is already in a conflicted position with a registrant.  The Preliminary Proceedings Committee (PPC), which is the first stage of the process, can now request the registrant to offer undertakings and where these are offered, the investigation into the complaint is completed.  The inquiry panel for new inquiries will be reduced from five persons to three. Smaller inquiry panels are less daunting for registrants. Further, more detailed information will be available on the NMBI website in the coming weeks at www.nmbi.ie. Meanwhile, the NMBI has announced that the upcoming 2022 annual registration renewal window is being extended to allow nurses and midwives more time to register. It will be open for registration from 25 October 2021 until 31 January 2022. The NMBI said it hopes that additional time will make the process as user-friendly as possible for registrants. For the second year, the annual renew process will be done exclusively through the MyNMBI online system, which has recently been upgraded.


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LESS INVASIVE SALIVA PCR TEST PROVES ACCURATE IN DETECTING COVID-19 A study conducted by the RCSI has demonstrated that a PCR test using saliva to test for Covid-19 is almost as accurate as the standard nose and throat swab. The saliva screening represents a less invasive alternative to the nasal/throat swab and could enable greater capacity for, and uptake of frequent testing of people who require regular screening. The research, carried out in Ireland by RCSI University of Medicine and Health Sciences, published in HRB Open Research, has been approved by an international panel of peer-reviewers.  The study evaluated the performance of the established 'gold standard' nasal/throat swabbing and the more recently developed SalivaDirect approach that tests for Covid-19 in saliva specimens.   The study involved the collection of nasal/throat swabs and saliva samples from a cohort of over 300

symptomatic and asymptomatic participants between November 2020 and March 2021. The participants included asymptomatic RCSI students who participated in the study as part of the routine Covid-19 screening programme at the university and patients admitted to Beaumont Hospital, Dublin, with Covid-19related respiratory symptoms. The results revealed that 94 per

cent of the positive nose/throat samples also tested positive on the saliva test, while 96 per cent of those that tested negative on the nose/ throat swab also tested negative on the saliva test. The results of the Irish study are consistent with the original results on the SalivaDirect method and indicate that the use of saliva to detect the Covid-19 virus represents a valid, and accurate and less invasive alternative to

nasal/throat sampling. “Our study has further validated that saliva testing can offer an accurate alternative to the more invasive commonly used nose and throat swabbing method,” said Prof Steve Kerrigan, the joint lead author of the study and Deputy Head of RCSI School of Pharmacy and Biomolecular Sciences. “The saliva sample to test for Covid-19 can be easily collected by the person themselves so has the potential to increase compliance with screening, particularly those who require frequent repeated testing. As the saliva test does not require a healthcare professional to conduct it, this method also reduces the risk of infection for test-centre staff associated with conducting the nasal/throat swabbing.” SalivaDirect was developed by the Yale School of Public Health and has been authorised for emergency use by the US Food and Drug Administration (FDA).

NEW MEASURES ON SMOKY FUELS WILL SAVE LIVES – IRISH HEART FOUNDATION AND ICGP Strict new measures on the burning of solid fuels in homes will reduce the number of lives lost to dirty air, the Irish Heart Foundation has said. The charity welcomed the recently announced Department of the Environment, Climate and Communications regulations - which include a national ban on smoky fuels in 2022 - as a "huge step" in reducing the impact of toxic air pollution. “Air pollution is responsible

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for over 1,300 deaths every year in Ireland, with the vast majority of these due to heart disease and stroke,” said Mark Murphy, Advocacy Officer with the Irish Heart Foundation. “These measures will have a significant impact on this largely preventable loss of life as well as improving overall levels of public health. “There is simply no safe level of exposure to air pollution, and while these updated domestic

solid fuel regulations still permit the burning of some solid fuel with stricter standards, they are a huge step in the right direction and will reduce the number of lives lost to dirty air.” Although the new measures will effectively ban and curtail the burning of smoky coal, wet wood, and sod peat, the national heart and stroke charity said thousands of fuel-poverty households in Ireland still hugely reliant on these

fuels, cannot be left behind. In its 2022 pre-budget submission, the Foundation calls for the introduction of a Green Transition Fuel Allowance to support and facilitate those most vulnerable in moving away from the worst affecting solid fuels to more sustainable and healthier forms of heating. The Irish College of General Practitioners (ICGP) has also welcomed the measures.


Recruitment

PRACTICE NURSE REQUIRED Practice nurse for Tipperary town required.

PRACTICE NURSE REQUIRED Practice nurse required two days a week Southside Cork City practice. Apply to: jmrosslee@gmail.com

New build clinic 4 doctor, 4 nurse practice Full-time position Previous GP experience required with skills in CervicalCheck, vaccination, maternity, stock ordering etc. Please send CV to Tom Purcell at Tipperary Primary Care or email to jbsurgery@hotmail.com

PRACTICE NURSE REQUIRED

Practice nurse required to join our existing nurse in our small friendly practice in Drumcondra. Prior experience preferred, but not essential, onsite training can be provided by our existing nurse and doctors. Role would include administering infant, childhood, flu, and other vaccinations. Administering travel vaccinations and travel advice. Chronic disease management. Blood pressure monitoring. Nursing management of chronic respiratory disease and diabetes. Cervical screening, family planning, sexual health, skin/wound care, health promotion and education. Telephone triage and advice Wednesday, Thursday, and Fridays ideally. Must be registered general nurse with An Bord Altranais. We offer a friendly supportive working environment. Please email to whitworthmedical@gmail.com

PRACTICE NURSE REQUIRED Full- or part-time practice nurse required for GP practice in Bettystown, Co Meath. Experience in general practice desirable, but not essential. Responsibilities will include standard practice nurse duties, such as phlebotomy, childhood vaccinations, smears. Contact: Olivia Commons  practicemanager@ bettystownmedicalpractice.ie

PRACTICE NURSE REQUIRED Practice nurse required for North Dublin City practice. Experience helpful, but not essential for right candidate. Duties include, but not limited to, phlebotomy, ECG, vaccines, smears tests, and managing smear recall system, stock ordering, chronic disease management. Hours flexible. Salary negotiable. Please email CV to practicenursevacancy @outlook.com

PRACTICE NURSE REQUIRED Practice nurse required to join the team at Banagher Family Practice, Co Offaly. Fully computerised, four GP practice with one practice nurse and phlebotomist currently, and based in new-build primary care centre. Previous experience would be an advantage, but not essential as training can be arranged, but nurse needs to be organised, enthusiastic, and a good communicator. Hours are flexible (full-time/ part-time considered) and excellent remuneration for right candidate. See our website www.bfphealth.com  Apply with CV and cover letter to practice manager  diane@bfphealth.com

If you would like to place a recruitment advert in the next edition, please contact Louis@mindo.ie.

SEPTEMBER-OCTOBER 2021 9


News

NEWS NEW NATIONAL CLINICAL GUIDELINE FOR SEPSIS MANAGEMENT FOR ADULTS (INCLUDING MATERNITY) On World Sepsis Day earlier this month the HSE published a new and fully updated national clinical guideline to help healthcare professionals recognise and treat sepsis and septic shock patients. The National Clinical Guideline No 26 Sepsis Management in Adults (including Maternity) replaces the 2014 National Clinical Guideline No.6 Sepsis Management, which will now be retired from the suite of National Clinical Effectiveness Committee (NCEC) National Clinical Guidelines. This initiative was led by a group from the HSE National Clinical Programme on Sepsis and supported by the department’s Clinical Effectiveness Unit. The clinical guideline is based on best research evidence and was developed in line with international best practice, and quality assured by the NCEC. Sepsis is a potentially life-threatening complication of most common infections that can affect anyone, and which is frequently under-diagnosed at the early stages when it is potentially reversible. Prompt identification and treatment are vital. In Ireland, in 2019, sepsis or septic shock was documented in 12,908 non-pregnant adults and these patients had a mortality rate of 19.7 per cent. There has been an overall age-adjusted decrease in mortality from sepsis and septic shock of 2.9 per cent from 2018. Patients with a diagnosis of sepsis spend longer in hospital than those that had a diagnosis of infection. The National Sepsis Outcome Report is published by the HSE and describes the burden of sepsis on the Irish healthcare system. The newly published fifth (2019) report shows a 26.5 per cent reduction in age-adjusted mortality from sepsis and septic shock since 2011 in Ireland. This shows the positive impact that the National Sepsis Programme has had on the care of patients with sepsis in the Irish healthcare system. Welcoming the publication of the new clinical guideline, Chief Medical Officer Dr Tony Holohan said: “Sepsis is a global public health crisis and a leading cause of preventable mortality, with 20 per cent of all deaths worldwide associated with sepsis. Vigilance and rapid response saves lives and protects quality of life in survivors. It is gratifying that we have seen a 26.5 per cent reduction in ageadjusted mortality in Ireland since 2011 and I

commend the HSE National Sepsis Programme on this achievement. “I greatly welcome this latest National Clinical Guideline, which was developed by a multidisciplinary Guideline Development Group, led by Dr Vida Hamilton and supported by the HSE National Sepsis Programme. It takes the best international clinical evidence and provides updated recommendations for the recognition and care of adult and maternity patients with sepsis and septic shock in Ireland.” Noting the role of healthcare professionals in using the guideline in practice, the Chief Nursing Officer, Rachel Kenna said: “The development and implementation of NCEC National Clinical Guidelines is only possible with the expertise and commitment of clinicians at the front line. This latest guideline covers the very important topic of sepsis and septic shock. We know that well developed and implemented clinical guidelines can help improve care and outcomes for patients and their families. This World Sepsis Day, I am pleased to welcome this new and updated guideline on sepsis in adults and maternity patients.... I see these as key tools to help staff at the frontline manage this complex condition.” The most commonly reported symptoms of sepsis include:  Slurred speech, confusion, excessive drowsiness;  Excessive sleepiness or drowsiness, confusion;  Pain or discomfort in the muscles or joints, passing very little or no urine;  Severe breathlessness, a racing heart, shivering, fever, feeling very cold;  “I feel like I’m going to die;”  Skin changes – pale, cold, discoloured skin or a rash that won’t fade when pressed on. In children the signs to look out for include:  Abnormally cold to touch;  Skin looks mottled, bluish or pale;  Breathing very fast;  Is unusually sleepy and difficult to wake;  Has a rash that does not fade when you press it;  Having fits or convulsions. Also in children under five:  Not feeding;  Vomiting repeatedly;  Has not had a wet nappy in the last 12 hours.

10 SEPTEMBER-OCTOBER 2021

27


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News

NEC NEWS We hope you all had a good Summer. The NEC have been busy over the summer months working, recruiting new staff and putting processes in place for a new centralised bank account.

NEW ROLES WITHIN IGPNEA

We are very pleased to welcome two new members of the IGPNEA national team on board. Megan Sutherland joined us in July as our new website and social media officer. Megan is working five hours a week, and her main focus will be updating and maintaining the website content. She will also be working with the IGPNEA PRO Theresa Lowry-Lehnen to produce and update the social media content. Megan comes from a digital background, previously working as Digital Marketing Manager

Sara Garrett

folders. Sara brings a unique perspective with work experience in North America, along with a background in operations and project coordination. She studied psychology in her undergrad where she went on to work in the clinical side of behavioural therapy. Her patient-facing experience has fuelled her desire to implement more efficient systems for people doing vital work. Sara also worked as membership administrator with the Registered Nurses Association of Ontario Toronto, Canada.

MEMBERSHIP

A warm welcome to our new members, as our membership is continuing to grow. Megan Sutherland

for WellExpo in Donegal. Megan has also recently completed a Bachelor of Business in Digital Marketing where she received a distinction for her studies Sara Garrett joined us in August as our new membership officer. Sara will be working 7.5 hours a week to update new members and databases. She will also be managing Siilo and branch emails and

12 SEPTEMBER-OCTOBER 2021

TANYA KING

Theresa (National PRO), Jane (National Chairperson) and Una (National Vice-Chair) had a very productive meeting with Deputy Chief Nursing Officer Tanya King on 18/08/21 about progressing the development of general practice nursing, recognition of learning, and funding of educational opportunities.

SIILO

Over 50 per cent of members

are now using Siilo for secure messaging and news alerts. We would encourage all members to download the Siilo app to keep up to date with IGPNEA news and related educational events. Siilo works like WhatsApp, but is specific for our needs, with security and privacy ensured. It is a great way to communicate with your branches, find out what is happening within IGPNEA, and get news alerts such as Covid-19 vaccine bulletins.

To get Siilo on your phone: a. Go to the Play store or Apple store on your phone. b. Download Siilo - Medical Messenger. c. Open the app and follow the steps on your phone once downloaded. d. You can choose to import your phone’s contacts or not (your choice). e. As an IGPNEA member, you are automatically verified for our network. f. To access the full Siilo network (ie, people outside IGPNEA), you must verify your account with passport and ID, if you choose not to verify your account you can still access IGPNEA news etc, and communicate with other members. g. Enter your NMBI number (This may say IMC number). h. You will then be added to your branch group on Siilo.

IGPNEA WEBINARS

We hope you are enjoying the IGPNEA webinars in partnership with medcafe. ie. The monthly webinars have been a great success and feedback from members has been very positive. Our most

recent webinar on 7 September 2021 focused on the ‘Role of the Practice Nurse in Making Every Contact Count’, with guest speaker Sandra Coughlan: HSE, Head of Training and Programme Design, and provided great insight and increased understanding of the MECC programme, as well as highlighting the importance of behaviour change in reducing chronic disease and the role general practice nurses can play in making every contact count. Our next IGPNEA webinar will take place on Tuesday, 28 September on the topic of dermatology with guest speakers Dr Geraldine Morrow, Consultant Dermatologist, and Kelly Impey, Dermatology Clinical Nurse Specialist, Tallaght University Hospital. Recordings of our webinars are available for members on our website and at medcafe.ie.

EDUCATIONAL HUB

The Educational Hub is the resource centre on the IGPNEA website for our educational materials. There are 20 Hubs, of which 18 are currently live. HUBS: Women’s Health, Men’s Health, Immunisations, Chronic Disease Respiratory, Cardiovascular, Gastrointestinal, Genito-Urinary, Mental Health, Dermatology, ENT, Endocrinology, Bone Health, Blood Disorders, Neurology, Health Promotion, Procedures, Infection Control, Stocks and Maintenance, Professional Development. Each hub contains a number of topic related e-learning courses/ modules, where available. There are over 30 e-learning courses in total, and a range of educational videos, clinical articles, webinars, podcasts, weblinks


News

Put the dates in your diaries. We are looking forward to an interesting programme and of course the chance to meet up at the conference.

NEW NEC OFFICERS

At the AGM each year the new NEC Officers are voted in. The current NEC are inviting members to put themselves forward for roles of National Chairperson, Vice-Chair, PRO and Treasurer. The deadline for nominees is 30 September 2021.

TWITTER

Don’t forget to follow us on Twitter @PracticeNurses. We now have almost 1,700 followers.

PHOTO COMPETITION Photo Competition for the AGM. Get your phones out and start snapping! Prizes will be a surprise!

and additional resources to enhance our clinical practice. Some 20 new IGPNEA educational video presentations and a variety of clinical articles produced by IGPNEA PRO Theresa Lowry-Lehnen have been added to the Hub this year, including: Anxiety Disorders, Atrial Fibrillation, Prostate Cancer, The Menopause, Smoking Cessation Interventions, Making Every Contact Count, Social Prescribing, Haemochromatosis, Cystic Fibrosis, Allergic Rhinitis, Epilepsy, Migraine, Herpes Zoster, Osteoporosis, Rheumatoid Arthritis, Thyroid Disorders, Atopic Eczema, Melanoma, Crohn’s Disease, GORD, Irritable Bowel Syndrome, Otitis Media, Measles, Mumps, and Rubella, Meningitis, UTIs, Diabetic Foot Disease, and a Book of Clinical

Guidelines and Procedures that was published in 2018. A selection of objective structured clinical examinations (OSCEs) have also recently been uploaded to the Procedures Hub, which demonstrate clinical skill performance and competence in a range of nursing and medical skills. The Educational Hub is everybody’s learning resource centre and if you have any clinical resources suitable for the Educational Hub, please submit them to the IGPNEA for addition.

VOLUNTEER PANEL

Many thanks to those of you who responded to our call for volunteers, we really appreciate your willingness to get involved

and are delighted with the uptake. The role of volunteer liaison person is still open, the panel will remain open for this role and any future opportunities as they arise so, please contact Mary via email (admin@irishpracticenurses.ie) at any stage if interested, as we would love to hear from you.

REMINDER TO SAVE THE DATE FOR AGM 2021 AND CONFERENCE 2022

The AGM this year will be held on Saturday, 16 October 2021, and it will be a virtual format similar to last year. We are delighted that the Waterford Branch will be hosting our next conference on Friday, 13 and Saturday, 14 May 2022 in the Tower Hotel in Waterford.

Categories 1. Your branch locale - a scenic view or a view that represents your area (one photo from each branch). 2. Wellbeing - Wellbeing means different things to different people. For this reason we want to capture something that represents wellbeing to you; it could be a photo of something you knitted, cooked, you at the top of the mountain, a bubble bath (no nude photos please!) – the list is endless. We will add all your wellbeing photos to a wellbeing wall in the members area of our website to inspire others.

3. Something humorous!

You can send your contribution to Sara through Siilo or the service desk, or by email to membership@ irishpracticenurses.ie

SEPTEMBER-OCTOBER 2021 13


Feature

Covid-19

Author: Theresa LowryLehnen, National PRO, Irish General Practice Nurses Educational Association

GENERAL PRACTICE NURSES AND

COVID-19

General practice nurses have been key players throughout the pandemic and have been at the forefront of the planning, preparing, and implementation of the roll-out and delivery of Covid-19 vaccines in general practice continued on the age-based programme. Recent walk-in vaccination clinics around the country and the delivery of Covid-19 vaccines in pharmacies, in conjunction with GP practices and the mass vaccination centres, have greatly boosted the national Covid-19 vaccination programme.

T

he objective of the vaccination programme for SARS-CoV-2 is to ensure equitable access to a safe and effective vaccine with the goals of limiting mortality and morbidity from Covid-19, protecting healthcare capacity and enabling social and economic activity. Nationally, Covid- 19 vaccination statistics are increasing daily and Ireland’s covid-19 vaccination programme has proven to be one of the most successful in Europe. Figures provided by the HSE show that by mid-September, over seven million doses of Covid-19 vaccines had been administered, with 90 per cent of adults (18 years+) fully vaccinated, 92.5 per cent of adults having received at least one vaccine dose, and 83 per cent of the eligible population (12+) fully vaccinated. Over 1,300 GP practices participated in the Covid-19 vaccination programme for the over-70s and vulnerable patients in cohort 4 and 7, and almost 650 practices

14 SEPTEMBER-OCTOBER 2021

Nurses and vaccination Over 50 per cent of all Covid-19 vaccines delivered by early summer in Ireland this year had been administered in general practice, and well over two million Covid-19 vaccines to date have been administered by general practice teams. In many general practices the roll-out and delivery of covid-19 vaccines has been mainly nurse-led. The past 18 months has been challenging in general practice. General practice nurses (GPNs) have been key players throughout the pandemic and have been at the forefront of the planning, preparing and implementation of the roll-out and delivery of Covid-19 vaccines in general practice. In the early days of the pandemic, general practice responded swiftly by changing work practices almost overnight. The health and safety of practice teams and patients became a top priority as we worked together to ensure all precautions with health protection measures such as PPE and public health guidelines were implemented. To reduced footfall, a large part of our

work moved to virtual platforms via video or tele-consultations, electronic prescribing, online triage, and management of care. These changes were made possible by adopting a team approach to problem solving, collaborative practice and flexibility. GPNs remained on the frontline throughout the pandemic, not only providing Covid-19 vaccines, but also maintaining vital services and healthcare provision including face-to-face and direct contact for patients who needed to be seen in practice. We maintained a non-Covid service, implemented chronic disease management in practice, managed additions to immunisation programmes, delivery of new treatments and the reintroduction of the HPV Cervical Screening programme, as well as managing requests for extra work from hospitals in terms of bloods and patient monitoring.


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MORE THAN 90% OF 1-3 YEAR OLDS IN IRELAND DO NOT GET ENOUGH VITAMIN D1

APTAMIL TODDLER MILK New FSAI Dietary Guidelines for Toddlers 2020 Fortified foods and drinks can contribute to the intakes of Vitamin D, Iron & Omega 3 in toddlers2 Just 2 beakers a day (300ml) of Aptamil Toddler milk provides toddlers with 93% of the RDA3 for Vitamin D and 45% of the RDA3 for Iron Available in 800g powder, 200ml & 1 litre liquid

For more information, call our dedicated freephone on 1800 22 12 34 or visit nutricia.ie This information is for healthcare professional use only. Aptamil Toddler Milk should be used as part of a varied and balanced diet from 1 year. Recommended serving per day is 300ml. 1. Irish Universities Alliance (IUNA), National Pre-school Nutritional Survey. Further analysis for Danone Nutricia (data available on request). Main survey available at: https://www.iuna.net/surveyreports 2. Food Safety Authority of Ireland (FSAI), Scientific Recommendations for Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ 3. Food Safety Authority of Ireland (FSAI), Recommended Dietary Allowances for Ireland 1999. Available at: https://www.lenus.ie/handle/10147/44808

June 2021


Feature GPNs across the country carried out Covid-19 risk assessment and organised screening when appropriate, provided clarity for patients and reinforced advice specifically about their Covid-19 concerns, and remotely monitored and provided wellness checks for patients with chronic conditions helping them stay well and avoid hospital admission. The important role general practice and GPNs play in shielding and supporting secondary care services has been evident throughout the Covid-19 pandemic. Within Irish general practice, 90 per cent of an estimated 20 million episodes of patient care are completed and managed annually without requiring onward referral. GPNs and

general practice teams have demonstrated flexibility, dedication, and innovation in maintaining our day-to-day activities during the pandemic, including continuing immunisations, screening, chronic disease, acute and minor illness management, whilst also providing care to over 80 per cent of Covid presentations. GPNs are knowledgeable, skilled, and competent at managing and delivering vaccination programmes and vaccinating our practice populations is a major part of what we do every day. We are acknowledged by the HSE National Immunisation Office as experts in the delivery of immunisations. Delivery of all national vaccine programmes within general practice is mainly nurse led, with GPNs constituting the largest and most experienced group of vaccinators in the country. Five visits are necessary to the GPN with babies at two, four, six, 12, and 13 months of age to protect babies with the necessary childhood vaccines. GPNs are also involved in administering other vaccines, including boosters, vaccines in pregnancy, travel

16 SEPTEMBER-OCTOBER 2021

Covid-19 misinformation and ill-informed concerns. GPNs are particularly aware of the responsibility they have regarding Covid-19 immunisation. Following the impact of the Covid-19 virus, the importance of enlisting public confidence in the safety and efficacy of these new vaccines cannot be over emphasised.

Looking to the future

vaccines and of course play a lead role in the delivery of the national flu vaccine programme in general practice every year Vaccines are among the greatest public health achievements of modern times. They have saved and continue to save millions of lives throughout the world. Concern about vaccine safety continues however, to be a driver of decreased vaccine uptake in many countries. This concern is often fuelled by misinformation and propagated through organised anti-vaccine groups, social media, and celebrity endorsements. The World Health Organisation (WHO) has listed vaccine hesitancy as one of the top ten threats to global

As society starts to re-open, nationally, we still face an uncertain future, finely balancing health and illness, economic contraction and recovery

health. The reasons why people choose not to vaccinate are complex, but lack of confidence in vaccine safety, driven by misinformed concerns about adverse effects, has been identified as one of the key factors. Healthcare workers, especially those in primary care, remain key influencers on vaccine decisions. In particular, GPNs play a crucial role in increasing vaccination uptake among the general practice population through the provision of evidence-based information and patient education, therefore reducing vaccine hesitancy and health inequalities caused by

Due to the success of the national Covid-19 vaccination programme, the Government plan for the final easing of Covid-19 restrictions was released on 31 August. An Taoiseach Micheál Martin said: “Because of the effort of our vaccination teams and because you have stepped up to the mark and taken the vaccine when it was offered, we are now entering a whole new phase of the pandemic. The time is now right to begin to move from regulation and widespread restrictions on people’s personal freedom to an approach primarily defined by public health advice, personal judgement, and responsibility.” As society starts to re-open, nationally, we still

face an uncertain future, finely balancing health and illness, economic contraction and recovery. This pandemic has resulted in unprecedented global, societal, and economic disruption and has challenged healthcare services and workers across the globe, unlike anything most of us have ever witnessed before. The stakes remain high as Covid-19 infection continues to be an issue, nationally and internationally, with rising Delta prevalence and new variants occurring. The Covid-19 vaccination booster and flu vaccination programmes will commence in the coming weeks. As we look with hope to the benefit of vaccines and the suppression of Covid-19, nurses in general practice and general practice teams are proud to continue to play a lead role and be part of the solution.


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Feature Author: Kathy McSharry, Professional Development Coordinator for Practice Nurses, CHO 2 (Galway, Mayo and Roscommon); CNME, St Mary’s Campus, Castlebar, Co Mayo

Professional Development

O

18 SEPTEMBER-OCTOBER 2021

RE-ESTABLISHING EAR EXAM AND EAR IRRIGATION PROGRAMME WORKSHOPS

n the 28 July on board to support a Train the 2021 in the Trainers programme was the Regional Centre solution we were looking for. of Nurse and He immediately saw the need Midwifery Education for and value in continuing to (RCNME) Tullamore, a Train support primary care services the Trainers programme to carry out ear irrigations was delivered to facilitate the for low-risk clients who have rollout of the Ear Examination troublesome earwax. Patients and Ear Irrigation Programme with normal ears and earwax Workshop. From September build up should not be referred Front row L- R: Glory George, Toni Finnigan, onwards this programme to ENT departments. Ear Prof Michael Walsh, Philippa McGavigan, Mary O’Connor, and will now be available irrigation performed by a Grainne Glacken. Back row L-R: Karen O’Sullivan, Rose Doyle, through six Centres of Nurse suitably trained healthcare Eilish Brosan, Kathy McSharry, and Mary Florence Doherty. and Midwifery Education professional is still an Missing from the photo are: Marie Cantwell and Carmel McGrath (CNMEs) across the country. evidence-based practice The geographic areas covered include: that has a place in the care pathway for on offer. The demand for places resulted North West, West, South West, South management of impacted ear wax in in programmes being oversubscribed, East, North East, and the Midlands. primary care. which led to disappointment for learners Working with Prof Walsh we and frustration for trainers not being Background reviewed and updated existing able to meet demand. This standardised national programme programme materials and agreed Solutions to address the supply and builds on the previously established content and timetables in preparation for demand problem were explored with programme, which commenced in 2010. the Train the Trainers programme on the colleagues in the CNMEs and with other Originally 12 facilitators had trained to 28 July for 12 programme facilitators. relevant stakeholders, which included: deliver the programme and, for a time, To ensure sustainability in the future, The Royal Victoria Eye and Ear Hospital availability to this programme was this programme will now be anchored (RVEEH), Irish Collage of General consistent and geographically accessible. in the CNMEs. The model for delivery Practitioners (ICGP), and the HSE ENT However, over the years, trainers retired of the programme is co-facilitation and Clinical Programme. Having Prof and were not replaced, which resulted requires one nurse educator (CNME Michael Walsh, Clinical Advisor for the in a reduced number of programmes staff) and one nurse from clinical HSE’s National ENT Programme, come practice (practice nurse) competent in these skills. In the Train the Trainers PROGRAMME WORKSHOP WILL BE OFFERED THROUGH programme we had six CNME staff THE FOLLOWING CNME s: and six clinical-based general practice nurses complete the programme. As a CNME LOCATION CONTACT NAME CONTACT DETAILS consequence the Ear Examination and Letterkenny, Co Donegal Philippa McGavigan philippa.mcgavigan@hse.ie Ear Irrigation Programme will be offered through the CNME locations on the left. Mayo/Roscommon CNME Grainne Glacken grainne.glacken@hse.ie If you are interested in registering Tralee, Co Kerry Mary O’Connor Mary.OConnor3@hse.ie for this programme, please Waterford, Co Waterford Karen O’Sullivan KarenT.OSullivan@hse.ie contact your local CNME or contact Tullamore, Co Offally Carmel McGrath carmelm.mcgrath@hse.ie Kathy McSharry directly if you Adree, Co Louth Glory George glory.george@hse.ie require further information. Email: kathy.mcsharry@hse.ie


nurse

Rheumatology Author: Eamonn Brady, MPSI (Pharmacist), Whelehans Pharmacies, Mullingar, Co Westmeath

.ie Free independent CPD for Irish nurses

C A

B

TRUE/FALSE QUESTIONS

Q1 Dry eyes and dry mouth occur in 95 per cent of Sjögren’s syndrome cases.

Q5 In the treatment of dry mouth in Sjögren’s syndrome, pilocarpine can only be used for those with no salivary function left.

Q8 The development and use of biological DMARDs in the treatment of Sjögren’s syndrome has been a real success.

True or false?

True or false?

Q6 Disease-modifying anti-rheumatic drugs (DMARDs), commonly used in the treatment of Sjögren’s syndrome, are suitable for everyone with the disease.

Q9 About 50 per cent of people with primary Sjögren’s syndrome experience severe fatigue as a troublesome lifeaffecting symptom of the disease.

True or false?

True or false?

Q4 Once diagnosed and given the right treatment, Sjögren’s syndrome is easily cured.

Q7 Methotrexate is most effective in the treatment of Sjögren’s syndrome with a daily 20mg dose.

Q10 If left untreated, Sjögren’s syndrome can develop into a life-threatening condition.

True or false?

True or false?

True or false?

True or false? Q2 Most people (especially older people) who develop dry eyes and dry mouth have Sjögren’s syndrome. True or false? Q3 Once symptoms are obvious, Sjögren’s syndrome is quick and simple to diagnose. True or false?

To complete this module and earn free CPD points, go to www.nurseCPD.ie and answer the 10 true or false questions and complete the five MCQs based on this case study.

SEPTEMBER-OCTOBER 2021 19


nurse

Rheumatology

SJÖGREN’S SYNDROME

I

This CPD module is focused on Sjögren’s syndrome, including its links to conditions such as rheumatoid arthritis and other inflammatory autoimmune conditions, including systemic lupus erythematosus, fibromyalgia, and systemic sclerosis. On completion of this module, it is expected the reader will have an enhanced understanding of this area of rheumatology, including treatment options, such as DMARDs

f a patient is suffering from dry eyes, dry mouth or dry skin and the cause has not been diagnosed, Sjögren’s syndrome is a possible diagnosis. Sjögren’s syndrome is an autoimmune condition and remains undiagnosed in many people. The cause is unknown. It was first discovered by Swedish ophthalmologist Henrik Sjögren in the 1930s. Sjögren’s is pronounced ‘show-gren’. The main symptoms of Sjögren’s syndrome are dry eyes and dry mouth and enlargement of the parotid glands (salivary gland located in the cheeks just in front of the ears). Dry eyes and mouth occur in 95 per cent of cases.1 The hallmarks of Sjögren’s syndrome (ie, dry mouth and dry eyes) are called sicca syndrome. Fatigue and joint and muscle pains are other debilitating features in many who have the condition.

Epidemiology Research has identified many factors (ie, immunological, genetic, hormonal, and inflammatory) that may be involved in causing Sjögren’s syndrome. One theory is that inflammation or abnormality of the body’s glands causes an autoimmune reaction.2 It is thought to affect 3-to-4 per cent of adults.3 It increases with age and usually starts in the 30s and 40s; the average age of onset is the late 40s and it does not occur until after menopause in many cases. It is rare in childhood and younger adults. It is nine times more common in women than men; the exact reason for this is unknown, but it is suspected to be related to women’s hormones and the fact women’s immune system tends to be more active than in men. Over half of Sjögren’s syndrome patients have the condition secondary to an

20 SEPTEMBER-OCTOBER 2021

accompanying autoimmune or rheumatic condition, such as rheumatoid arthritis (RA) or lupus. Because it is mixed-up with other conditions, it is estimated that the average length of time it takes for diagnosis is 10 years.4

Diagnosis A rheumatologist and/or an ophthalmologist are best equipped to diagnose Sjögren’s syndrome. There are many diagnostic tools available to confirm diagnosis. The specialist will pick and choose which to use, depending on their preference, availability and depending on the individual case. The sensation of dry mouth and dry eyes along with joint inflammation is often sufficient to suspect Sjögren’s syndrome. An ophthalmologist can test for tear production using a Schirmer test (a filter paper strip is placed inside each lower eyelid for five minutes). An ophthalmologist may test for damage to the cornea using fluorescein staining.8 Salivary gland function scans assess the glands on the sides of the neck, below the ears and under the jaw. A salivary gland biopsy can help confirm diagnosis. A biopsy of the glands of the lip (glands that release saliva and tears) can determine the level of inflammation. A biopsy of the lip is performed because the salivary glands under the lip’s inner surface are the easiest glands to access. Sialometry, which measures the flow of saliva, is another diagnostic tool. Ultrasonography of the major salivary glands to reveal characteristic structural changes can aid diagnosis.14 Blood tests may be required to confirm diagnosis. An ANA (antinuclear antibody) test will confirm if it is an autoimmune

disorder, helping to confirm if Sjögren’s syndrome is the cause.

Links with other conditions Sjögren’s syndrome is called primary if it develops in isolation, and secondary if it occurs with other autoimmune or rheumatic conditions like RA, systemic lupus erythematosus (lupus), fibromyalgia, and systemic sclerosis. It is estimated that in 60 per cent of cases, Sjögren’s syndrome occurs with or is linked to other inflammatory autoimmune conditions. RA is a severe inflammatory condition that causes swelling, pain, and deformities in the joints; it tends to run in families. Lupus is nine times more common in women; it can cause inflammation in all organs, leading to fever, joint pain, muscle pain, fatigue and damage to all major organs if not controlled. Lupus is rarer in Europe and more common in people of AfroCaribbean decent. Fibromyalgia is a chronic pain disorder characterised by extreme tiredness and fatigue. Scleroderma is an inflammatory condition that affects the skin, leading to hard skin and skin lesions; it can go on to damage other organs if not controlled.

Symptoms of Sjögren’s syndrome For some, the symptoms are no more than a nuisance; for others, they are more severe and have a profound effect on quality-of-life if not treated adequately. Whilst dry eyes and dry mouth are commonly associated with Sjögren’s syndrome, most people who develop these symptoms do not have the disease. For example, dry eyes and dry mouth affect about 30 per cent of older people and most cases are not due to Sjögren’s syndrome. Dry mouth and eyes can also


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Rheumatology be caused by many medicines, such as tricyclic antidepressants, antihistamines, decongestants, beta-blockers, codeine-type painkillers, diuretics, etc. General practice nurses have a role in assessing whether side-effects from medication are contributing to dry eyes and mouth. Dry eyes lead to itchy eyes, grittiness and soreness and can lead to permanent damage of the cornea if not controlled. Dry mouth may not be immediately obvious, and the person may not complain of dryness, but of an unpleasant taste, insatiable thirst, difficulty eating dry food such as cream crackers, and soreness. Dry mouth can lead to:  Swallowing problems and dysphagia (the feeling of something getting stuck in the throat on swallowing).  Loss of taste.  Tooth decay and gum disease.  Sore or cracked tongue.  Difficulty talking.  Thrush (fungal infection) in the mouth. Severe fatigue occurs in about half of people with primary Sjögren’s syndrome5 and many find this feature of the disease the most troublesome. Many with the condition need to sleep more, but often do not feel refreshed upon awakening.4 The cause of this fatigue is not fully understood, however hypothyroidism, which is frequently linked with Sjögren’s syndrome, may contribute to it.6 Dry skin is a common feature of Sjögren’s syndrome; which can lead to itchiness and irritation of the skin or a ‘burning’ of the skin in some cases.7 Other symptoms of Sjögren’s syndrome include glandular swelling; dryness of the airways, which can lead to dry cough and chest infections; swelling of the parotid (salivary) glands occurs in one-third of cases and can be painful in some cases;8 swelling of other salivary glands located under the jaw or in the neck area; muscle ache and aching joints (joint ache occurs in one-third of cases);8 and Raynaud’s phenomenon (coldness in the extremities of the body, such as hands and fingers) occurs in about 20 per cent of cases of Sjögren’s syndrome. Sjögren’s syndrome can also cause peripheral neuropathy in about a quarter of cases, which is damage to the nerve endings in the extremities, such as fingers and toes.

Peripheral neuropathy can cause numbness, tingling, itching, pins and needles, etc.9

Self-help15 Dry mouth and dental care  Regularly take small sips of water.  Chewing sugar-free gum or sucking sugarfree hard sweets or lozenges stimulates saliva.  Using products with artificial sweetener xylitol rather than sugar prevents tooth decay.  Regular dental check-ups.  Use an electric toothbrush.   Use fluoride products specifically for dry mouth.  Brush and floss teeth regularly (after meals especially). If regular daytime brushing is not possible, rinse regularly with water.  Avoid sugar-containing foods and drinks between meals.  Use artificial saliva in the form of mouth gels, mouthwashes and chewing gum.

For dry eyes  Regularly use tear substitute eye drops, with single-dose preservative-free drops possibly showing more benefit.  Limit use of drops with preservatives, which can cause dryness and irritation.  Use lubricating eye ointments or gels at night.  Wraparound sunglasses can prevent moisture loss from the eyes.

For dry nose, throat and upper airways:  Regularly use saline nasal sprays.  A home humidifier may help.

For joint pain  Rest when joints are swollen and painful.  Rest instead of trying to fight the fatigue during flare-ups.  Be more active, especially between flare-ups.

Treatment There is no specific cure for Sjögren’s syndrome; the aim of treatment is to control symptoms using the likes of saliva substitutes and eye drops, and to limit long-term damage. The person must be referred to a rheumatologist for assessment and diagnosis. An ophthalmologist is often involved in the treatment of the eye problems.

Patients should be advised to avoid alcohol and smoking and maintain good oral hygiene. Exercising as much as possible and a healthy balanced diet are important. To relieve the dry eyes, artificial tears are effective and should be used regularly. They come in drop form and gel form. Gel form has a longerlasting effect, so is especially suitable before going to bed as it will work longer throughout the night while sleeping. There are many brands available over-the-counter from pharmacies; there is no evidence that one brand is any more effective than the next, though preservative-free versions are recommended by some eye specialists to reduce the risk of irritation. To relieve dry mouth, drinking plenty of fluids helps keep the mouth moist. Artificial saliva comes in the form of mouth gels, mouthwashes and chewing gum; brands available over-thecounter in pharmacies include BioXtra and Biotene. As well as moisturising, these brands of artificial saliva have enzymes that help stimulate saliva glands. Another option for dry mouth is pilocarpine tablets; they are licensed for those who have some residual salivary function left.10 The dose is 5mg tablets to be taken four times daily, before each meal and at night. Vaginal lubricants may be required. Vaginal candidiasis (thrush) is more likely with Sjögren’s syndrome due to vaginal dryness. Hydroxychloroquine (Plaquenil) has been shown to be useful in some studies to relieve and control joint and muscle pain, fatigue, and skin symptoms.11,12 Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help relieve muscle and joint pain, but must be used in moderation, as they can cause side-effects like stomach irritation and ulcers, raised blood pressure and kidney problems, and must be used with caution in other conditions like asthma, heart disease, and kidney disease. Mild corticosteroid cream such as hydrocortisone 1 per cent cream used sparingly and occasionally may give some relief from the dry skin irritation (though regular moisturisation is key to relieve and prevent dry skin).

Treatment of complications Sjögren’s syndrome may progress to involve organs such as the kidneys, lungs, skin, and

SEPTEMBER-OCTOBER 2021 21


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lymph glands. Stronger anti-inflammatory medication may be required in these situations. These include:  Steroids: Taken orally, reduce inflammation. They are usually limited to when symptoms are particularly bad, as they can cause side-effects if used long-term (ie, prednisolone).

Immunosuppressants: These drugs include disease-modifying anti-rheumatic drugs (DMARDs) that suppress the abnormal antibody production that causes Sjögren’s syndrome, ie, stops the body attacking itself. Examples include methotrexate, azathioprine, penicillamine, and hydroxychloroquine. They are reserved for more severe cases, as they can have side-effects and are only commenced by specialist rheumatologists. Close monitoring with regular blood tests is required while taking them, as they can cause blood disorders and suppress the immune system. It is recommended that use of immunosuppressive agents is limited to cases where Sjögren’s syndrome is affecting the major organs, such as skin, lungs, and kidneys.12 Hydroxychloroquine tends to be used more frequently than other DMARDs, but some studies suggest that evidence in regards to the benefits of hydroxychloroquine is lacking.13 

Rheumatology biological DMARDs in recent years. Similar efficacy has been reported for methotrexate and sulfasalazine in studies of up to 12 months.16,17 The patient's response to DMARDS is usually monitored every one-to-three months initially until symptoms improve. Methotrexate is often the first-choice DMARD for RA, but not so much in the case of Sjögren’s syndrome. It can be taken on its own or in combination with another DMARD. The most common side-effects of methotrexate are sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Regular blood tests to monitor blood count and liver are required, as methotrexate can cause potentially very serious liver and blood count problems. Very rarely, it can affect the lungs, so chest x-rays and possibly breathing tests are performed when starting methotrexate. This

DMARDs help to ease symptoms and slow down the progression of inflammatory conditions

More detail about DMARDs DMARDs help to ease symptoms and slow down the progression of inflammatory conditions. When antibodies attack the tissue in the joints, they produce chemicals that can cause further damage to the bones, tendons, ligaments, and cartilage and in the case of Sjögren’s syndrome, they attack the eyes and salivary glands. DMARDs block the effects of these chemicals. The earlier a DMARD is started, the more effective it will be. They must be started by a consultant rheumatologist, therefore, it is important to seek treatment with a rheumatologist early if showing signs of a severe inflammatory aspect of Sjögren’s syndrome that is causing damage to other organs, or if Sjögren’s syndrome is secondary to an accompanying autoimmune or rheumatic condition, such as RA or lupus. The most common DMARDs include methotrexate, hydroxychloroquine, and sulfasalazine. These are often known as conventional DMARDs since the advent of

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is to provide a comparison for if the patient develops shortness of breath or a persistent dry cough while taking methotrexate. Most people tolerate methotrexate well and more than 50 per cent of patients take it for at least five years. Doses of methotrexate up to 20mg weekly may be needed. Parenteral administration (SC, IM, starting at 7.5-10mg weekly) may be considered in severe acute flare-ups of inflammatory conditions like RA, if oral treatment is ineffective or in those unable to tolerate oral methotrexate, but is rarely needed for Sjögren’s syndrome.11 It takes six-to-12 weeks for methotrexate to start working. Methotrexate may also be combined with biological treatments for inflammatory conditions like RA, but very rarely is this combination needed for Sjögren’s syndrome. It is very important to emphasise that methotrexate is a weekly dose. Giving it daily is a potentially serious medication error. Sulfasalazine has a slow onset of effect

(one-to-three months).18 Patients may need to discontinue long-term treatment of sulfasalazine due to gastrointestinal complaints. Hydroxychloroquine takes several weeks to exert its effect.19 It has been reported to be less effective than the other DMARDs for inflammatory conditions like RA, but is welltolerated; therefore, it may be useful in mild disease or in combination therapy.19 However, it is the most used DMARD in Sjögren’s syndrome. Somewhat paradoxically in the case of Sjögren’s syndrome, it can cause eye damage, so regular eye checks are needed.19 It is important to keep taking DMARDs, even if there is no improvement at first. Traditionally, for inflammatory conditions like RA, patients must try two or three types of DMARD before finding the one that is most suitable for them. Once the most suitable DMARD is found, the patient will usually have to take it long-term. There tends to be less trial and error of DMARDs for Sjögren’s syndrome, except where Sjögren’s syndrome is secondary to the likes of RA. Newer biological DMARDs are used less often for Sjögren’s syndrome, but there are some ongoing clinical trials on them for Sjögren’s syndrome, with mixed results (more below).

New treatment options Biological DMARDs Biological treatments include TNF (tumour necrosis factor) alpha inhibitors (etanercept, infliximab, adalimumab and certolizumab), rituximab and tocilizumab. Etanercept (Enbrel) and adalimumab (Humira) are the most-prescribed biological treatments for autoimmune conditions like RA in Ireland. In general, use of biological agents is reserved for patients with moderate-to-severe active autoimmune conditions like RA, where conventional DMARDs have failed. Despite initial optimism that biological treatments could be a game-changer for Sjögren’s syndrome, as they have been for other conditions like RA, clinical trials have proven this not to be the case. Previous trials of biological therapies (infliximab, etanercept), for example, showed no improvement in tear and salivary flow, leading to initial disappointment among researchers.21 The biological DMARD


Rx Methofill® by brand.


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rituximab (MabThera) is used as a treatment option in systemic inflammatory disease conditions such as vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and severe neuropathy. However, two randomised, placebo-controlled clinical trials failed to demonstrate the clinical effectiveness of rituximab for the end-points of dryness, pain, and fatigue in those with primary Sjögren’s syndrome.21 Despite this, several new diseasemodifying drugs currently undergoing clinical trials for Sjögren’s syndrome have renewed clinical optimism.21 Clinical trials of the likes of abatacept and tocilizumab continue.21 An issue researchers find in designing clinical trials of biologics for Sjögren’s syndrome is restricted inclusion criteria, which significantly reduces the proportion of patients with primary Sjögren’s syndrome that are eligible for clinical trials,22,23 for example, not enough patients with the inflammatory indicators in blood tests or severe enough primary disease to warrant inclusion in trials. This has meant clinical trials of the likes of biologics for Sjögren’s syndrome have been small, thus providing limited effective data. Another issue is that traditionally, clinical trials for primary Sjögren’s syndrome have been limited compared to RA and lupus. This was partly due to a previous misconception that the disease was mostly a nuisance, without recognising that it can threaten the function of vital organ systems.22,23

Monoclonal antibodies Monoclonal antibodies block the type 1 interferon (IFN) pathway, thus blocking immune activation, and are being researched for the likes of lupus, but results for Sjögren’s syndrome have so far been disappointing. Itolizumab clone T1h is a newly-developed, humanised IgG1 monoclonal antibody that targets CD6 SRCR-D1 and blocks immune activation. Itolizumab has been proposed to be effective in autoimmune diseases, such as RA, Sjögren’s syndrome, and multiple sclerosis. In a French study, itolizumab-positive target cells were characterised within both peripheral blood and salivary glands to

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Rheumatology provide a rationale for anti-CD6 treatment in Sjögren’s syndrome.20 However, monoclonal antibodies, while in theory offer hope for future treatments options, have so far failed to give sufficient benefit in the case of primary Sjögren’s syndrome. For example, treatment with belimumab, a monoclonal antibody that inhibits BAFF, led to some improvement in systemic disease activity and serologic markers of B-cell function, but failed to show any significant benefit in terms of reducing symptoms of fatigue, pain, and dryness. Despite these setbacks and challenges, research into newer treatments is still in its relative infancy, so there is confidence that there will be new treatments launched due to ongoing trials in the coming years.

Prognosis Prognosis is generally good in Sjögren’s syndrome, unless the condition is part of an associated disorder, such as other inflammatory conditions like RA or lupus. Sjögren’s syndrome is not usually lifethreatening. Sometimes symptoms can disappear for long periods (go into remission). Rarely, it can develop into more serious problems, such as the kidney and lung conditions. About one-in-100 people with Sjögren’s syndrome develop a form of cancer called lymphoma, most commonly nonHodgkin’s lymphoma. Patients with Sjögren’s syndrome should pay close attention to any abnormal swelling in glands around the face or neck, under the arms or around the groin area, as this can be a sign of lymphoma.

REFERENCES 1. Ramos-Casals M, Brito-Zerón P, Sisó-Almirall A, Bosch X. Primary Sjögren’s syndrome. British Medical Journal. 2012;344: e3821 Doi: 10.1136 2. Nikolov NP, Illei GG; Pathogenesis of Sjögren’s syndrome. Current Opinion on Rheumatology. 2009 Sep; 21(5):465-70 3. Thomas E, Hay EM, Hajeer A, et al; Sjögren’s syndrome: A community-based study of prevalence and impact. British Journal of Rheumatology. 1998 Oct; 37(10):1069-76 4. Manthorpe R, Asmussen K, Oxholm P. Primary Sjögren’s syndrome: Diagnostic criteria, clinical features, and disease activity. Journal of Rheumatology. 1997; 24(supplement):8-11 5. Kassan SS. Managing dry eyes and dry mouth in Sjögren’s syndrome. American Journal of Managed Care. 2001;7 (supplement): S444-S450 6. Anaya JM, Talal N. Sjögren’s syndrome. In: Kassirer JP, Greene HL, eds. Current Therapy in Adult Medicine. 4th ed. Baltimore, Md: Mosby; 1997: 1291-1298 7. Skopouli FN, Dafni U, Loannidis JP, Moutsopoulos HM. Clinical evolution, and morbidity and mortality of primary Sjögren’s syndrome. Seminars in Arthritis and Rheumatism. 2000; 29:296-304 8. Chang HJ, Burke AE, Glass RM. Sjögren’s syndrome. The Journal of the American Medical Association, July 28, 2010-Volume 304, No.4 9. Gemignani F, Marbini A, Pavesi G, et al. Peripheral neuropathy associated with primary Sjögren’s syndrome. Journal of Neurology, Neurosurgery, and Psychiatry. 1994; 57:983-986 10. Papas AS, Sherrer YS, Charney M, et al; Successful treatment of dry mouth and dry eye symptoms in Sjögren’s syndrome. Patients with oral pilocarpine: A randomised, placebo-controlled, dose-adjustment study. Journal of Clinical Rheumatology. 2004 Aug;10(4):169-177 11. Phelan D. Sjögren’s syndrome. eMedicine, November 2009 12. Ramos-Casals M, Tzioufas AG, Stone JH, Sisó A, Bosch X. Treatment of primary Sjögren’s syndrome: A systematic review. JAMA 2010; 304:452-60

13. Fox RI, Dixon R, Guarrasi V, Krubel S. Treatment of primary Sjögren’s syndrome with hydroxychloroquine: A retrospective, open-label study. Lupus. 1996; 5 (supplement 1): S31-S36 14. Sjogren’s syndrome - Diagnosis. Health. John Hopkins Health. 2021 15. Arthritis Foundation. Sjögren’s syndrome. Self-Care, 2021 16. Lee D, Weinblatt M, Rheumatoid arthritis. The Lancet 2001; 358: 903-11 17. Young A, Rheumatoid arthritis: Current approaches to drug treatment. Prescriber 19 Jan 2004; pages 48-55 18. Summary of product characteristics for salazopyrin. Available at www.medicines.ie 19. Summary of Product Characteristics for Plaquenil. Available at www.medicines.ie 20. Le Dantec C, Alonso R, Fali T et al. Rationale for treating primary Sjögren’s syndrome patients with an anti-CD6 monoclonal antibody (Itolizumab). Immunol Res 56, 341–347 (2013). https://doi.org/10.1007/s12026-013-8423-x 21. Tim Pittman. New drugs raise hopes for patients with Sjögren’s syndrome. Clinical Practice Today, Rheumatology. Published May 23, 2017 22. Devauchelle-Pensec V, Gottenberg J, Jousse-Joulin S, et al. Which and how many patients should be included in randomised controlled trials to demonstrate the efficacy of biologics in primary Sjögren’s syndrome? PLoS One. 2015;10(9):e0133907. 10.1371/journal.pone.0133907 23. Oni C, Mitchell S, James K, et al: Eligibility for clinical trials in primary Sjögren’s’s syndrome: Lessons from the UK Primary Sjögren’s Syndrome Registry. Rheumatology (Oxford). 2016;55(3):544–52. 10.1093/rheumatology/kev373 24. De Vita S, Quartuccio L, Seror R, et al: THU0392 Efficacy and safety of belimumab given for 12 months in primary Sjogren’s syndrome: The Beliss Open-Label Phase II Study. Ann Rheum Dis. 2015;74(2):338–339. [Poster Presentation]. 10.1136/annrheumdis-2015-eular.3101 


Feature

Crohn's Disease Author: Mr Eamonn Brady, MPSI, Whelehans Pharmacies, Mullingar, Co Westmeath

C

AN OVERVIEW OF CROHN’S DISEASE

rohn’s disease is one of the two main forms of inflammatory bowel disease (IBD), the second being ulcerative colitis. Crohn’s disease causes inflammation of the digestive system, and while it is due to an immune response, it does not appear to be an autoimmune disease. Crohn’s is a chronic condition, with many experiencing it as an ongoing and life-long disease, often with periods of remission as well as relapses or flare-ups. There is currently no cure for Crohn’s, but medication and sometimes surgery can give long periods of relief. Ulcerative colitis only affects the inner lining of the colon; the large intestine. In Crohn's disease, inflammation can appear anywhere in the digestive tract, from the mouth to the anus. Crohn’s generally affects all the layers of the bowel walls, not just the inner lining, so tends to have more serious symptoms.

Causes The exact cause is not known, but it is commonly accepted that Crohn’s is caused by a combination of factors, including:  Genetic factors.  An abnormal reaction of the digestive system to bacteria in the intestine.  An unknown trigger or perhaps set of triggers that may include viruses, other bacteria, diet, stress, or other environmental factors.

How Crohn’s disease affects the intestinal tract The most common area of the intestinal tract to be affected by Crohn’s

is the last part of the small intestine (terminal ileum) and the first part of the large intestine (colon), near the appendix. For some, only the colon is affected, in a pattern like ulcerative colitis. In others, multiple parts of the intestinal tract are affected. Rarely, the mouth, throat, oesophagus, or stomach may be affected. A patch of inflammation may be as small as a few centimetres or extend most of the distance along the intestinal tract. As well as affecting the lining of the bowel, Crohn’s may also go deeper

It is estimated that Crohn’s disease affects one in every 650 people in the UK. The figures in Ireland are not thought to be significantly different

into the bowel wall. In some cases, the inflammation in the intestinal tract triggers inflammation outside the intestine, leading to other inflammatory complaints affecting the joints, eye, skin, and endocrine system, to name the most common.

Symptoms Crohn’s disease is a very individual condition, ranging from very few symptoms, to frequent flare-ups or constant disease. The part of the intestinal tract most affected by

Crohn’s influences the symptoms. In general, the most common symptoms during a flare-up are:  Abdominal pain and diarrhoea. Sometimes mucus, pus or blood is mixed with the diarrhoea.  Tiredness and fatigue. This can be due to the illness itself, from the weight loss associated with flare-ups or surgery, anaemia from blood loss, or simply due to a lack of sleep due to pain, diarrhoea and other symptoms which inevitably affect sleep.  Feeling generally unwell. Some people may have a raised temperature and feel feverish.  Mouth ulcers.  Loss of appetite and weight loss.  Anaemia. Crohn’s makes anaemia more likely due to blood loss, not eating enough because of symptoms like pain and diarrhoea, and because the body is not fully absorbing nutrients from food. Anaemia is a major factor in tiredness.

Prevalence It is estimated that Crohn’s disease affects one in every 650 people in the UK. The figures in Ireland are not thought to be significantly different. Crohn’s appears to be slightly more common in women than in men. The Irish Society for Colitis and Crohn’s Disease indicated that there were 5.9 new cases of Crohn’s disease in Ireland per 100,000 population in 2011, compared to 14.9 new cases of ulcerative colitis per 100,000 the same year. The incidence of Crohn's disease is higher than ulcerative colitis in children, however.

SEPTEMBER-OCTOBER 2021 25


Feature

Crohn's Disease

The peak age of incidence of Crohn’s is between the ages of 15 and 35 years, with a second (smaller) peak from the 50s to 70s. IBD diagnosed in children can behave differently and can be treated differently to that diagnosed in adults. It is more common in urban rather than rural areas and in northern developed countries, although the numbers are beginning to increase in developing nations. Crohn's is also more common in smokers.

Main types of Crohn’s disease Crohn’s is often categorised according to which part or parts of the intestinal tract are most affected. The main types are:

Terminal ileal and ileocecal

Crohn’s in the ileum (the last part of the small intestine) is known as ileal or sometimes ‘terminal ileal’ Crohn’s because it affects the terminus or end of the ileum. If it affects the beginning of the large bowel, it is known as ileocecal Crohn’s. In this type of Crohn’s, pain is often experienced in the lower right side of the abdomen, especially after eating. There is often weight loss, and diarrhoea may occur. Because Crohn’s in the ileum can make it difficult for the body to absorb bile salts, this can build up, leading to irritation in the bowel lining; diarrhoea often occurs and is most likely to be watery. The diarrhoea is unlikely to be bloody, as any blood lost will be digested by the time it reaches the rectum. About four-in-10 people with Crohn’s have ileal or ileocecal disease.

Small bowel Abdominal pain and diarrhoea are also common symptoms if Crohn’s occurs further up the small bowel. Again, the diarrhoea is unlikely to be blood-stained, but weight loss and anaemia may be experienced. Nearly a third of people with Crohn’s have it in the small bowel.

Colonic Crohn’s disease in the colon (large intestine or large bowel) is known as ‘Crohn’s colitis’. This is a common form of Crohn’s disease. The main symptom tends to be blood-stained diarrhoea. Because of the inflammation, the colon cannot hold as much waste as normal, so very frequent

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Crohn’s in the upper intestinal tract (the oesophagus, stomach, or duodenum) is much less common. Symptoms that indicate Crohn’s in the upper intestinal tract include indigestion-like pain, nausea, loss of appetite, and weight loss.

 Fistulas: Narrow tunnels or passageways between the intestinal tract and the skin or another organ. In perianal Crohn’s, fistulas often run from the anal canal to the skin around the anus. They appear as tiny openings in the skin that leak pus or sometimes faecal matter. They can irritate the skin and are painful, but can usually be treated with medication and/or surgery.

Perianal

Oral Crohn’s

Crohn’s in the area around the anus can occur on its own or at the same time as inflammation in other parts of the body. It can cause symptoms such as:  Fissures: Tears in the lining of the anal canal, which can cause pain and bleeding, especially during bowel movements.  Skin tags: Small fleshy growths around the anus.  Haemorrhoids: Swollen areas in the anal canal.  Abscesses: Collections of pus that can become swollen and painful. Most often found in the area around the anus and can cause a fever or lead to a fistula.

Crohn’s can occasionally affect the mouth. True oral Crohn’s, which typically causes swollen lips and mouth fissures, is rare. However, about one-in-five people with Crohn’s tend to develop mouth ulcers.

bowel movements occur (six or more a day), especially if the rectum is inflamed.

Gastroduodenal

Complications Complications of Crohn’s may occur in the intestinal tract or other areas of the body and can include strictures, perforations, and fistulas.

Complications of Crohn’s disease affecting the intestinal tract Strictures

Ongoing inflammation and then healing in the


Feature

Crohn's Disease bowel may cause scar tissue to form. This can create a narrow section of the bowel, known as a stricture. A stricture can make it difficult for food to pass, leading to a blockage. Symptoms include severe cramping abdominal pain, nausea, vomiting and constipation. The abdomen may become bloated and distended and the intestinal tract may make loud noises. Strictures are usually treated surgically, (mainly stricturoplasty).

percentage develop swelling and pain in the smaller joints of the hands or feet. This may be longer-lasting and persist while the IBD is in remission. More rarely, ankylosing spondylitis can develop, in which the joints in the spine and pelvis become inflamed. This can flare up independently of the Crohn’s. Medication and physiotherapy can be helpful in treating arthritic symptoms.

Perforations Very occasionally, a severe blockage caused by a stricture may lead to a perforation or rupture of the bowel, making a hole. The contents of the bowel can leak through the hole and form an abscess. This causes pain and a fever. An abscess may also develop into a fistula.

Fistulas (fistulae) A fistula can form when inflammation in Crohn’s spreads through the whole thickness of the bowel wall and continues to tunnel through the layers of other tissues. These tunnels or passageways can connect the bowel to other loops of bowel, to the surrounding organs, such as the bladder and vagina, or to the outside skin, including the skin around the anus (discussed earlier). Fistulas may be treated medically or with surgery.

Complications of Crohn’s disease on other parts of the body Crohn’s disease can also cause problems outside the intestinal tract. Some people with Crohn’s develop conditions affecting the joints, eyes, or skin. These often occur during active disease, but they can develop before any signs of bowel disease or during times of remission.

Joints Inflammation of the joints affects up to one-inthree people with IBD. In people with Crohn’s, arthritis is more commonly associated with Crohn’s colitis (Crohn’s disease in the colon). The inflammation usually affects the large joints of the arms and legs, including the elbows, wrists, knees, and ankles. Fluid collects in the joint space, causing painful swelling, although there can be pain without obvious swelling. Symptoms generally improve with treatment for intestinal symptoms and there is mainly no lasting joint damage. A small

A rare condition called primary sclerosing cholangitis (PSC) affects up to one-in-25 people with Crohn’s, usually those with the disease in the colon

Skin Crohn’s can cause skin problems. The most common skin problem is erythema nodosum, which affects about one-in-seven people with Crohn’s. Painful red swellings appear, usually on the legs, and then fade, leaving a bruise-like mark. This condition tends to occur during flare-ups and generally improves with treatment for the Crohn’s. More rarely, a skin condition called pyoderma gangrenosum affects people with Crohn’s disease. This starts as small tender blisters, which become painful, deep ulcers. These can occur anywhere on the skin, but most commonly appear on the shins or near stomas. It is usually treated with steroids or immune suppressants, but may need biological therapy.

Eyes Eye problems affect approximately one-in-20 people with Crohn’s. The most common condition is episcleritis, which affects the layer of tissue covering the sclera (the white outer coating of the eye) making it red, sore, and inflamed. Two other eye conditions associated with Crohn’s are scleritis (inflammation of the sclera itself) and uveitis (inflammation of the iris). These conditions can usually be treated with local steroid drops, although uveitis and

scleritis may need treatment with immune suppressants or biologic drugs. Patients with Crohn’s should be aware to mention any eye condition promptly to their doctor.

Bones Crohn’s increases the risk of bone-thinning; this is mainly due to poor absorption of calcium needed for bone formation. Sometimes, low calcium levels are because the diet does not contain enough dairy foods or the use of steroid medication. Calcium supplementation and, for some, drug treatment with the likes of alendronate is needed.

Liver About one-in-four people with Crohn’s develop gallstones. These are small ‘stones’ made of cholesterol, which can get trapped in the gallbladder and can be very painful. Several factors linked with Crohn’s can make gallstones more likely, including poor absorption of bile salts often caused by inflammation. Bile salts help to digest fats during digestion. Some of the drugs used to treat Crohn’s, such as azathioprine and methotrexate, may increase liver problems. A rare condition called primary sclerosing cholangitis (PSC) affects up to one-in-25 people with Crohn’s, usually those with the disease in the colon. PSC causes inflammation of the bile ducts and can eventually damage the liver. Symptoms include fatigue, pain, itching, jaundice, and weight loss. Treatment is usually with ursodeoxycholic acid.

Blood circulation Crohn’s disease doubles the risk of blood clots in the veins, including DVT (deep-vein thrombosis) in the legs. Risk is highest during a flare-up or if confined to bed, ie, during a hospital visit. Warning symptoms that patients need to be aware of include pain, swelling and tenderness in the leg, or chest pains and shortness of breath.

Anaemia People with inflammatory bowel disease are most likely to develop iron deficiency anaemia. This is caused by a lack of iron in

SEPTEMBER-OCTOBER 2021 27


Feature the diet or poor absorption of iron from food and can be made worse by ongoing intestinal blood loss due to inflammation. Vitamin deficiency anaemia, caused by a low intake or poor absorption of certain vitamins such as vitamin B12 or folic acid, particularly affects people with Crohn’s who have had sections of the small intestine removed. Some of the drugs used for Crohn’s, such as sulfasalazine and azathioprine, can also cause anaemia.

Crohn’s disease and the link to cancer Severe or extensive Crohn’s disease affecting all or most of the colon for many years can mean a slightly increased risk than normal of developing colon cancer.

Diagnosis Diarrhoea, abdominal pain, and weight loss lasting for several weeks or longer indicate that Crohn’s is a possibility, particularly if there is a family history of IBD. Tests and physical examinations can confirm a diagnosis.

Treatment Treatment for Crohn’s may be medical, surgical (not covered in this article) or a combination of both. For mild Crohn’s, no drug treatment may be needed. Dietary therapy may be another option for some. Treatment will depend on the type of Crohn’s. Drug treatment for Crohn’s aims to reduce symptoms and control flare-ups, and then to prevent a relapse once the disease is under control. This can mean taking medication on an ongoing basis, sometimes for many years.

Anti-inflammatory drugs These help to reduce inflammation and include:  5-ASAs or aminosalicylates, such as mesalazine and sulfasalazine.  Corticosteroids such as prednisolone, hydrocortisone, and budesonide.  Immunosuppressants such as azathioprine, methotrexate, and tacrolimus.  Biological, anti-TNF, drugs such as infliximab and adalimumab.

28 SEPTEMBER-OCTOBER 2021

Crohn's Disease Biological therapies are generally reserved for people in poor general health with severe symptoms of Crohn's disease, especially if corticosteroids and immunosuppressants are unsuitable or ineffective. Biological treatment usually lasts at least 12 months unless these drugs stop being effective sooner or the patient cannot tolerate them. After this time, the condition will be assessed to determine if further treatment is necessary.

Symptomatic drugs These help control and reduce common symptoms such as pain, diarrhoea, and constipation. They include:  Anti-diarrhoeals such as loperamide and cholestyramine.  Bulking agents such as ispaghula husk.  Painkillers such as paracetamol and aspirin.

Dietary treatment for Crohn’s disease Enteral nutrition is widely used for children with Crohn’s disease, because it helps their growth and avoids the use of steroids. There is less evidence for the effectiveness of enteral nutrition in adults, particularly for active Crohn’s disease. Research has shown it to be less effective than steroids. However, enteral nutrition may be recommended for adults who prefer not to use drug therapy and it can be useful as a supplement for people who need extra nutrition.

Does a change in diet help? No clear evidence indicates that any food or food additive directly causes or improves Crohn’s. Generally, the most important thing is to try to eat a nutritious and balanced diet to help maintain weight and strength, and to drink sufficient fluids to prevent dehydration. Some people with Crohn’s find that certain foods trigger symptoms or make them worse and that reducing or adjusting the amount of fibre they eat or cutting out wheat or dairy products may help. To ensure the diet remains healthy and well balanced, it is important the patient gets advice from a doctor or from a qualified dietitian before making significant changes.

If the patient has a stricture, avoiding ‘hard to digest’ or ‘lumpy’ foods that might cause a blockage is advised. Such foods might include nuts and seeds, fruit and vegetable skins, and tough meat or gristle. It may also help to have small, frequent meals or snack and to chew food thoroughly. If the bowel is not absorbing nutrients properly, perhaps because of extensive inflammation or a shortened bowel after surgery, some people find a low-fat diet reduces diarrhoea. Avoiding carbonated drinks or other foods containing benzoates or cinnamon can help prevent symptoms. Many Crohn’s patients lack certain vitamins and minerals, such as iron, calcium, vitamin D or vitamin B12, especially if they have a poor appetite or active diarrhoea or blood loss. Some of the drugs used for Crohn’s can also lead to deficiencies; for example, sulfasalazine can affect the body’s ability to absorb folates, and steroids can cause calcium loss. In these cases, a supplement may be useful, but should be discussed with the doctor, pharmacist, or dietitian. If tests show a serious deficiency, a course of supplements or enteral nutrition may be advised. Vitamin B12 supplements are sometimes given by injection and iron supplements intravenously, as this can make them easier to absorb.

Are complementary and alternative approaches helpful? Some people with Crohn’s disease have found complementary and alternative medicines helpful for controlling symptoms such as abdominal pain and bloating. However, there are few reliable scientific studies to show the effectiveness of such therapies and it is possible that their symptoms may have gone into remission coincidentally, given the unpredictable course of Crohn’s, or there may be a placebo effect. One area where there has been some scientific research is the use of omega 3 fish oils. However, a recent review concluded that fish oils were probably not effective at keeping people with Crohn’s in remission, as although some studies found symptoms improved, two larger studies showed no benefit. References on request


30 30

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Feature

Cholesterol

Author: Eamonn Brady, MPSI (Pharmacist), Whelehans Pharmacies

CONTROLLING CHOLESTEROL

C

A clinical overview of the importance of controlling cholesterol levels to prevent atherosclerosis, heart attacks, and strokes

holesterol is a lipid manufactured by the liver from the fatty foods that we eat, and plays a vital part in allowing the body to function normally. Cholesterol is present in the membrane of every cell in the body. It insulates nerve fibres and is an essential building block for hormones, such as the sex hormones, and the hormones of the adrenal cortex. It also enables the body to produce bile salts. Cholesterol is carried in the blood by molecules called lipoproteins. There are several different lipoproteins, but the three main types are:  Low-density lipoprotein (LDL). This is often known as ‘bad’ cholesterol and is thought to promote arterial disease. It carries cholesterol from the liver to the cells and can cause a harmful build-up if there is too much for the cells to use. Normally, the blood contains about 70 per cent of LDL, but the level will vary from personto-person. The recommended LDL level is below 3.37mmol/l.  High-density lipoprotein (HDL). This is often referred to as 'good’ cholesterol, and is thought to prevent arterial disease. It takes cholesterol away from the cells and back to the liver, where it is either broken down, or is passed from the body as a waste product.

30 SEPTEMBER-OCTOBER 2021

The recommended LDL range is 1.45-4mmol/l.  Triglycerides are another type of fatty substance present in the blood. They are found in dairy products, meat, and cooking oils. Triglycerides are also produced by the liver. Those who are overweight, have a diet that is high in fatty or sugary foods, or drink a large amount of alcohol, have an increased risk of having

a high triglyceride level. The recommended triglyceride level is below 1.71mmol/l. The amount of cholesterol present in the blood can range from 3.6-to-7.8mmol/litre. A level above 6mmol/litre is considered high, and a risk factor for arterial disease. A total cholesterol level of below 5.2mmol/litre is recommended to prevent heart disease.


Feature

Cholesterol Evidence strongly indicates that high cholesterol levels can cause narrowing of the arteries (atherosclerosis), heart attacks, and strokes. The risk of coronary heart disease also rises as blood cholesterol levels increase. If other risk factors, such as high blood pressure and smoking, are present, the risk increases even more.

Symptoms High cholesterol is not a disease in itself, but it is linked to serious conditions, such as cardiovascular conditions, angina, stroke, and mini-stroke, known as transient ischaemic attack (TIA). A high level of cholesterol in the blood, together with a high level of triglycerides, can increase risk of developing coronary heart disease. Coronary heart disease is caused by narrowing of the arteries that supply the

 Blood clots and ruptured blood vessels, which can result in a stroke or TIA.  Ruptured plaques, which can lead to a blood clot forming in one of the arteries delivering blood to the heart (coronary thrombosis), and may lead to heart failure if a significant amount of heart muscle is damaged.  Thick yellow patches (xanthomas) around the eyes or elsewhere on the skin. These are cholesterol deposits and can often be seen in people with inherited or familial cholesterol (where close family members have a history of high cholesterol).

Causes A number of different factors can contribute to high blood cholesterol:

1. Lifestyle risk factors

There are a number of preventable lifestylerelated risk factors that can increase the risk

A high cholesterol level may only be revealed with symptoms of atherosclerosis

heart with blood. This narrowing of the arteries is called atherosclerosis. Fatty deposits such as cholesterol, cellular waste products, calcium and other substances build-up in the inner lining of an artery. This build-up (plaque) usually affects small and medium-sized arteries. The flow of blood through the arteries is restricted, as the inside diameter is reduced. Blood clots, which often happen in the coronary arteries during a heart attack, are more likely to develop when arterial walls are roughened by the build-up of fatty deposits. A high cholesterol level may only be revealed with symptoms of atherosclerosis. These can include:  Angina, caused by narrowed coronary arteries in the heart.  Leg pain on exercising, due to narrowing of the arteries that supply the lower limbs.

of developing high blood cholesterol. They include:  Unhealthy diet — consumption of foods that are high in saturated fat  Lack of exercise or physical activity — can increase levels of LDL and decrease levels of HDL.  Obesity — being overweight means increased risk of high LDL and a decreased level of HDL, increasing overall blood cholesterol level.  Smoking.  Drinking excessive amounts of alcohol — the recommended amount is three-to-four units a day for men, and two-to-three units a day for women.

2. Treatable risk factors  Hypertension

(high blood pressure).

 Medical conditions, such as kidney and liver diseases, and an under-active thyroid gland.

3. Fixed risk factors A

family history of heart disease or stroke — it is more likely to have high cholesterol if one has a close male relative (father or brother) aged under 55, or a female relative (mother or sister) aged under 65, who has been affected by coronary heart disease or stroke.  A family history of cholesterolrelated conditions, for example, if a close relative, such as a parent, brother, or sister has familial hypercholesterolaemia, or combined hyperlipidaemia.  Being male — men are more at risk of having high blood cholesterol than women.  Age — the older we get, the greater the likelihood of developing atherosclerosis.  Early menopause in women.  Ethnic group — people who are of Indian, Pakistani, Bangladeshi, or Sri Lankan descent have an increased risk of high blood cholesterol. If a patient has a fixed risk factor (or several fixed risk factors), it is even more important to take steps to address any lifestyle, or treatable, risk factors.

Reduction in death rate from CHD in Ireland over the last 35 years According to research published in the Journal of Epidemiology and Community Health in 2006, changes in three classic cardiovascular risk factors (smoking, cholesterol, and blood pressure) contributed to a 61.9 per cent decrease of total coronary heart disease (CHD) mortality in Ireland between 1985 to 2000; this was consistent with studies in other developed countries. In Ireland in 2000, heart disease was the leading cause of death, being responsible for 41 per cent of all deaths. In 2020, CSO figures show that diseases of the circulatory system (which includes CHD) was responsible for 26.3 per cent of all deaths. Smoking reduction is a big factor, but better diagnosis of cholesterol and hypertension

 Diabetes. A

high triglyceride blood level.

SEPTEMBER-OCTOBER 2021 31


Feature along with better and earlier treatment interventions is a big factor in this drop in deaths from heart disease. The better availability and affordability of statins in controlling cholesterol is also seen as a major factor in this reduction of deaths from CHD.

Diagnosis To measure cholesterol, a simple blood test is often carried out. GPs, general practice nurses or pharmacists can carry out the blood test. There is no longer a requirement to fast for lipid testing. The blood test will be used to determine the amount of LDL, HDL, and triglycerides in blood. Blood cholesterol is measured in units called millimoles per litre of blood (mmol/litre). It is recommended to have a total blood cholesterol level of less than 5mmol/litre, and an LDL cholesterol level of under 3mmol/litre. Anyone can have their blood cholesterol level tested, but it is particularly important to have it checked if:  Aged over 40.  A family history of cardiovascular disease, for example, if one’s father or brother developed heart disease or had a heart attack, or a stroke before the age of 55, or if one’s mother or sister had these conditions before the age of 65.  A close family member has a cholesterol-related condition, such as familial hypercholesterolaemia, or combined hyperlipidaemia.  Are overweight or obese.  Have high blood pressure (hypertension).  Have a medical condition such as a kidney condition, an under-active thyroid gland, or acute inflammation of the pancreas (acute pancreatitis). This is because these conditions can cause an increased level of cholesterol. In assessing risk of cardiovascular disease, heart attack, or stroke, cholesterol ratio should not be taken on its own. Lifestyle factors should also be taken into consideration. For example:  Smoking.  Diet.

32 SEPTEMBER-OCTOBER 2021

Cholesterol  BMI (body mass index – weight in relation to height).  Treatable risk factors, such as high blood pressure (hypertension) and diabetes.  Fixed risk factors, such as age, sex, and ethnicity.

Complications of high cholesterol High cholesterol levels can be made worse by any other medical conditions. An underactive thyroid gland, an overactive pituitary gland, liver disease, or kidney failure, can all contribute to high cholesterol levels. Some people have inherited disorders, such as familial hypercholesterolaemia, or combined hyperlipidaemia, that prevent fats

After a few months, if the cholesterol level has not dropped, advice may be to take cholesterollowering medication

from being used properly and eliminated from the body. This allows the level of cholesterol to build up in the blood. The major complications of raised blood cholesterol are heart attacks, strokes and arterial disease. The risks of all of these are increased if the patient is/has:  Overweight.  A smoker.  Has high blood pressure.  Strong family history of these conditions.  Diabetic.

Prevention Patients can prevent high blood cholesterol by eating a healthy, balanced diet that is low in saturated fat. Including a small amount of unsaturated fats in the diet is a healthy choice, as this type of fat can actually reduce cholesterol levels. Current thinking is that the traditional Mediterranean diet, with

its emphasis on raw olive oil in many foods and low animal fat content, is effective in ensuring cardiovascular health. Foods high in unsaturated fats include:  Oily fish.  Avocados.  Nuts and seeds.  Sunflower, rapeseed, and olive oil.  Vegetable oils.

Treatment When diagnosed with high cholesterol, the first method of treatment will usually involve making dietary changes (adopting a low-fat diet), and ensuring plenty of regular exercise. After a few months, if cholesterol level has not dropped, advice may be to take cholesterol-lowering medication.

Diet Ensuring a healthy diet by changing to one that is low in saturated fats can reduce level of LDL or bad cholesterol. If in a highrisk category of getting cardiovascular disease, altering diet will not lower risk sufficiently. A healthy diet includes foods from all different food groups, including carbohydrates (cereals, wholegrain bread, potato, rice, pasta), proteins (for example, from lean meat, such as chicken and oily fish like mackerel or sardines), and fats (varieties that unsaturated, such as low-fat mono- or poly-unsaturated spreads, and vegetable or sunflower oil). Eat at least five portions of a variety of different fruit and vegetables daily.

Cholesterol-lowering medication There are several different types of cholesterol-lowering medication which work in different ways. Commonlyprescribed medication includes:  Statins (HMG-CoA reductase inhibitors). Statins, such as simvastatin and atorvastatin, work by blocking the enzyme (chemical) in the liver that is needed for making cholesterol. Statins are used to reduce cholesterol to less than 4mmol/l and LDL cholesterol to less than 2mmol/l. They are therefore useful in preventing and treating atherosclerosis, which can cause chest pain, heart attacks, and strokes.


Feature

Cholesterol

they were first launched over 30 years ago. Statins work by blocking the enzyme HMGCoA reductase, which plays an important role in the production of cholesterol in the liver. They are therefore useful in preventing and treating atherosclerosis, which can cause chest pain, heart attacks, strokes and cardiac deaths. Most statins must be taken at night, as most cholesterol is made while we sleep. The only statin which does not have to be taken at night is atorvastatin, which can be taken morning or night. Statins are more effective in reducing LDL cholesterol than other cholesterol medication.

How effective are statins? A study published in the British Medical Journal in 2003 showed that on average, statins reduce LDL cholesterol by 1.8mmol/ litre. This resulted in a 60 per cent reduction in the risk of cardiovascular events such as heart attacks, clots, and sudden cardiac death and a 17 per cent reduction in the risk of stroke.

Table 1: Statin intensity table (NHS England)* Statins sometimes have mild side-effects, which can include constipation, diarrhoea, headaches, and abdominal pain.  Aspirin is no longer recommended,due to the risk of gastrointestinal bleeding.  Niacin is a B vitamin that is found in foods and in multivitamin supplements. In high doses, available by prescription, niacin lowers LDL cholesterol and raises HDL cholesterol. Minor side-effects include flushing or tingling skin, itching, and headaches. More research is needed to prove the effectiveness of niacin in reducing cholesterol.  Other medications, such as cholesterol absorption inhibitors (ezetimibe), and bileacid sequestrants (ie, cholestyramine), are sometimes used to treat high cholesterol. However, bile-acid sequestrants may be less effective than other forms of treatment and have more side-effects. PCSK9 inhibitors are a new type of cholesterol medication for resistantly high cholesterol administered in subcutaneous form either twice-weekly or monthly. If the patient has high blood pressure

(hypertension), the GP may also prescribe medication to lower it.

Statins Statins are the world’s most prescribed drugs and are effective in reducing cholesterol in most patients. There are several types of statins on the market, but they all work in the same way. Examples of statins available on the market are atorvastatin, pravastatin, rosuvastatin, simvastatin, and fluvastatin. Statins are only available with prescription in Ireland. Since 2004, simvastatin 10mg has been available over-the-counter in pharmacies in the UK; however, they are sold under strict guidelines under the supervision of the pharmacist and the patient must meet specific criteria, ie, patients targeted are those at a 10-to-15 per cent risk of an event in 10 years. Clinical trials show that statins are very effective at reducing cholesterol and hence heart disease. Statins are one of the major reasons for the significant fall in death rates from heart disease in Ireland since

Which statin is best? No major study has shown one statin to be significantly more effective than others. The CURVEs study in America in 1998 indicated that atorvastatin was more effective than other statins at lowering cholesterol and this was one of the major reasons that atorvastatin became the most prescribed statin in the intervening years. However, the effectiveness of atorvastatin over other statins has since been somewhat challenged; for example, another study published in the American Heart Journal in 2006 showed that there was no significant difference between atorvastatin and other statins (simvasatin and pravastatin) at reducing heart disease. A study published in the International Journal of Endocrinology and Metabolism in 2017 (study was on an Asian population) indicated effects of statins on lipid profile are dose-dependent and showed that rosuvastatin has the best effect on lipid profile. However, overall studies indicate there is no real reason to recommend one

SEPTEMBER-OCTOBER 2021 33


Feature

Cholesterol

Table 2: LDL-C concentrations above which PCSK9s are recommended by NICE

statin over another. Atorvastatin has the benefit that it can be taken in the morning. The HSE recommends simvastatin as first choice on State PCRS schemes for cost reasons, however all generic statins have become similarly priced in Ireland in recent years with the advent of reference pricing by the HSE.

When should statins be prescribed? In Ireland, over 20 per cent of adults are at risk of coronary heart disease due to high cholesterol. There is some controversy on who should be prescribed statins. The general guideline for people who have no previous heart problems is that they should be used if cholesterol is high (over 6mmol/litre) and there is a cardiovascular risk of greater than 20 per cent over the next 10 years. Cardiovascular risk over 10 years is defined as having any cardiovascular event, such as stroke or heart attack, over the next 10 years. It depends on many factors, such as

34 SEPTEMBER-OCTOBER 2021

age, sex, weight, blood pressure, cholesterol, family history of heart disease, and whether a smoker or diabetic. For those who have already suffered a cardiovascular event such as a stroke, statins are recommended if total cholesterol is over 3.5mmol/l. Guidelines state that they should be considered in all diabetic patients over 40. Statins are very frequently prescribed in the elderly, as older patients generally have a higher risk of heart disease.

Side-effects of statins Like all medication, statins can cause side-effects. The most serious side-effect of statins is a muscle complaint called myalgia. It is characterised by muscle pain and weakness. If it occurs, the statin should be stopped as it can lead to a potentially fatal condition called rhabdomyolysis. It is estimated that one-in-1,000 people using statins may suffer from myalgia and onein-10,000 may suffer from rhabdomyolysis. Patients must report to their doctor immediately if suffering from muscle

pain, tenderness or weakness while taking a statin. The myalgia from statins is reversible if the statin is stopped promptly. Statins can also raise liver enzymes, which can lead to liver problems. It is very important to conduct a liver function test for those starting statins. Current guidelines are to get a liver function test before starting a statin, three months after starting and again after 12 months. Gastrointestinal effects (nausea, indigestion, constipation, diarrhoea, and flatulence) are the most common sideeffects of statins. Headache, dizziness, and rash occur less frequently. Sleep disturbance can occur, although it seems to be more of a problem with simvastatin and atorvastatin. Most people who take statins have no problems and they are proven to save lives by preventing heart disease.

Can co-enzyme Q10 reduce muscle problems from statins? Statins can reduce naturally-occurring coenzyme Q10 in the body. Co-enzyme


Feature

Cholesterol Q10 has a role in muscle cell energy production, so some studies have proposed that a co-enzyme Q10 supplement could reduce risk of muscle-related side-effects. However, scientific studies to determine how effective co-enzyme Q10 is in reducing statin-related muscle pain have mixed results. Some studies show a benefit, while other studies show no effect. So, as coenzyme Q10 rarely has any side-effects, a trial to determine if it helps any potential muscle problems would do no harm.

cardiovascular events. According to NICE, additional lipidlowering therapies should be considered if: 1. Target LDL-C level is not attained on statins alone, add ezetimibe and trial for at least three months. 2. Target LDL-C level is still not attained, consider PCSK9 inhibitor, subject to NICE criteria in Table 1, in addition to existing lipid-lowering therapy.

Non-statin cholesterol medication Statins are less effective than fibrates in reducing triglycerides. Fibrates are another type of cholesterol-lowering medicines but are rarely used nowadays mainly due to gastrointestinal side-effects such as nausea, ie, gemfibrozil (Lopid). Other non-statin drugs used to lower cholesterol include ezetimibe, which reduces the absorption of cholesterol and is used instead of a statin if a statin is not tolerated or in addition to a statin if a statin is not reducing cholesterol sufficiently.

PCSK9 inhibitors PCSK9 inhibitors are a new class of cholesterol-lowering drugs that show excellent results in bringing down non-HDL levels in certain high-risk patients. They work by blocking a protein called PCSK9, which has a role in moderating cholesterol levels in the blood. In June 2016 in the UK, NICE recommended two PCSK9 inhibitor drugs for the NHS — Repatha (evolocumab) and Praluent (alirocumab) for treating certain patients with primary hypercholesterolaemia or mixed dyslipidaemia who cannot tolerate statins or who have reached the maximum statin dose without sufficient cholesterol reduction. Researchers on the FOURIER trial investigating the effectiveness of evolocumab in the UK described it as “probably the most important trial result of a cholesterol-lowering drug in over 20 years”. Results showed a 59 per cent drop in cholesterol levels compared to placebo and a 15 per cent lower risk of

For those who have already suffered a cardiovascular event, such as a stroke, statins are recommended if total cholesterol is over 3.5mmol/l

PCSK9 inhibitors in Ireland Evolocumab and alirocumab are both licensed in Ireland. Evolocumab, for example, is a 140mg solution for injection in Sureclick pre-filled pen and has been available under the HighTech Scheme in Ireland from 1 July 2019. Specific criteria must be satisfied for a patient to be recommended for reimbursement of evolocumab under the High-Tech Scheme. The prescribing of evolocumab under the High-Tech Scheme is confined to designated clinicians who have agreed to the terms of the HSE-Managed Access Protocol and have been approved by the HSE Medicines Management Programme. The clinician must submit an online application for individual reimbursement approval for each patient. Applications for individual reimbursement approval will only be considered from approved clinicians. Pharmacists like myself have noticed a small number of high-risk patients with very stubbornly high cholesterol being prescribed PCSK9 inhibitors in the last two years under the High-Tech Scheme.

Other therapies Omega 3s High strength omega 3 supplements, such as Omacor, are sometimes prescribed to lower triglycerides and are sometimes added to statin therapy when triglycerides are high. However, the HSE took omega 3 supplements off the PCRS reimbursement list for the GMS schemes (Medical Card and Drug Payment Schemes) due to the National Centre for Pharmoeconomics (NCPE) indicating that evidence of their overall benefits was not strong enough to warrant the HSE paying for omega 3 supplements for treatment of triglycerides. For example, one study quoted by NICE indicated (for diabetic patients) that while Omacor reduced triglycerides in the blood of diabetic patients by 5.6 per cent, there was no reduction in estimated CVD risk. However, there is significant evidence of the benefit for the secondary prevention of myocardial infarction (MI) for up to four years after the patient’s first MI.

Lecithin Lecithin reduces cholesterol by binding cholesterol and fats to water in the intestinal tract, hence reducing the absorption of cholesterol. Evidence indicates lecithin reduces LDL-cholesterol and can promote HDL-cholesterol production. A study published in the Hindawi Journal of Cholesterol in 2010 suggested that soy lecithin-rich diets can be used as an adjunct in the treatment of hypercholesterolaemia; however, no large enough study has yet been done, so further studies with a large number of patients should be done to find the ideal dose-response. A major source of lecithin is soy-bean oil. It can be purchased in powder or capsule form in pharmacies, health food stores, and supermarkets. References available on request Disclaimer: Brands mentioned in this article are meant as examples only and not meant as preference to other brands.

SEPTEMBER-OCTOBER 2021 35


Feature Theresa LowryLehnen, RGN, GPN, RNP, PhD, National PRO of the Irish General Practice Nurses Educational Association, Clinical Nurse Specialist, and Associate Lecturer at Institute of Technology Carlow

Shingles

HERPES ZOSTER IN FOCUS

Herpes zoster, also known as shingles, is a secondary potentially painful infection that can occur later in life due to reactivation of the chicken pox virus

V

aricella zoster virus (VZV) is one of eight herpes viruses known to cause human infection. VZV causes a primary infection known as varicella (chicken pox) a selflimited disease characterised by disseminated skin lesions that mainly occurs in childhood. The virus (VZV) then migrates to spinal and cranial sensory ganglia where it becomes dormant. Herpes zoster, also

is compromised the virus can re-activate. Once this happens, it can lead to a painful, blistery rash and the pain can last for months to years. When reactivated, the virus travels along the affected sensory nerve to reach the corresponding dermatome in the skin where a vesicular rash develops. Prior to the rash appearance, the frequent prodromal itching or pain can lead to erroneous and delayed diagnosis. The vesicles pustulate and then scab, usually within two-to-four

Patients with conditions that decrease cell-mediated immunity are 20-to-100 times more likely to develop herpes zoster

known as shingles, is a secondary infection that occurs later in life in some individuals as the result of reactivation of the latent VZV, usually within a single ganglion. Herpes zoster occurs more frequently in older adults and immunocompromised individuals and can be very debilitating.1 Patients with conditions that decrease cell-mediated immunity are 20-to-100 times more likely to develop herpes zoster.14 When the immune system

36 SEPTEMBER-OCTOBER 2021

weeks, but residual scarring is common.4 People with herpes zoster can transmit VZV to their seronegative contacts, who may develop varicella, but not herpes zoster.4 More than 10 per cent of patients who develop shingles will experience a complication, including blindness, neuropathic pain, and cerebrovascular events.2 Postherpetic neuralgia is the most common complication, occurring in about one-in-five patients.14

Pathophysiology VZV is a double stranded DNA human neurotrophic alphaherpes virus.1 Any person who contracted varicella infection through natural infection by the VZV or the varicella vaccine can develop herpes zoster. Once the VZV primary infection resolves, it forms a lifelong latency within the cranial or dorsal root ganglia.2 Herpes zoster infection occurs after reactivation of the latent VZV. The cause of reactivation of VZV is not fully understood, but risk factors include advancing age, stress and immunocompromised status from conditions such as HIV infection, lymphoma, leukaemia, bone marrow transplant, solid organ transplant, and immunosuppressive medications.1 Other risk factors include Caucasian race, female sex, physical trauma, diabetes mellitus, a prior history, and family history of herpes zoster. During latent varicella, specific varicella zoster memory T-cells are produced, suppressing the virus in the sensory root ganglia cells. Over time, the memory T-cell immunity begins to weaken and decline. This decline below the ‘zoster threshold’ leads to reactivation of the virus and development of the herpes zoster infection.


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Shingles Reactivation occurs when VZV is able to overpower immune controls and spreads through the affected ganglions and nerves to reach the skin and manifest as herpes zoster.1 Once the virus reactivates, it travels along the affected sensory nerves, causing neuronal damage as it reaches its respective dermatome and forms the vesicular rash of shingles. The most common dermatome affected is the thoracic dermatome. Because the virus typically follows a dermatome, the hallmark herpes zoster rash does not usually cross the body’s midline. The rash may take days or weeks to develop. Many patients may have a prodrome period during which they develop headache, photophobia, or malaise.2

incorrect diagnosis. These symptoms are commonly followed by sensations of burning pain, itching, hyperesthesia, or paraesthesia. Pain can be mild to severe in the affected dermatome with sensations such as stinging, tingling, aching, numbing or throbbing interspersed with quick stabs of agonising pain.2 After one-to-two days, but sometimes as long as three weeks, the initial phase is followed by the appearance of the characteristic skin rash. The pain and rash most commonly occur on the torso, but can appear on the face, eyes, or other parts of the body. A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Usually limited to one (sometimes

Incidence The individual lifetime risk of developing herpes zoster is between 24-to-30 per cent. Although herpes zoster can occur at any age, incidence increases with age. Twothirds of cases occur in individuals aged 50 years and older and the risk of developing the disease in those aged 85 years and above is 50 per cent.5

More than 10 per cent of patients who develop shingles will experience a complication, including blindness, neuropathic pain, and cerebrovascular events

Risk factors The immune system becomes less effective with age, and ageing increases the risk of a person developing herpes zoster. Diseases such as human immunodeficiency disease (HIV) and lymphoma, and medications such as steroids depress the immune system and increase the risk of herpes zoster and other infections.12 Depression increases the risk of developing herpes zoster because it affects the immune system. Statins are known to affect the immune system and increase the risk of herpes zoster by 13 per cent.7,10 In people with diabetes; the rate of herpes zoster is higher among statins users.10 People who have taken statins in the past have a higher risk of developing herpes zoster than those who have not.11 

Symptoms, presentation and diagnosis Early symptoms of herpes zoster including headache, fever and malaise are non-specific, and may result in an

two) dermatome, a maculopapular rash occurs in a stripe or belt-like pattern on one side of the body and does not cross the midline. Later the rash becomes vesicular, forming small blisters filled with a serous exudate, as the fever and general malaise continue. The painful vesicles eventually become cloudy or darkened as they fill with blood and crust over within sevento-10 days. Usually the crusts fall off and the skin heals, but sometimes, after severe blistering, scarring and discoloration remain.2 Less commonly, the rash can affect three or more dermatomes (disseminated zoster). This generally occurs in individuals with compromised immune systems. Disseminated zoster can be difficult to distinguish from varicella.5 A prodrome of tingling of the forehead may occur. In addition to the painful forehead rash, signs and symptoms may

include severe ocular pain; marked eyelid oedema; conjunctival, episcleral, and circumcorneal conjunctival hyperaemia; corneal oedema; and photophobia.13 Zoster of the trigeminal nerve should be considered in a patient with a prior history of varicella presenting with blurred vision and a painless red eye. Urgent ophthalmological opinion should be sought.5 Herpes zoster ophthalmicus (HZO) is a viral infection of the trigeminal nerve, which supplies sensation to the eye surface, eyelids, forehead, and nose. Around 10 per cent of people with shingles develop ophthalmic complications. In HZO the skin of one side of the forehead and scalp is affected, along with the eye on the same side. Any part of the eye can be involved, but most commonly it is the eye surface, including the conjunctiva and the cornea. The cornea reacts to the infection in various ways; the most serious long-term effects result from damage to the corneal nerves, causing loss of sensation. A small number of people who develop eye complications or neurological complications may not have a rash.9 Antiviral treatment should be prescribed as soon as possible. People with moderate to severe HZO should be seen by an ophthalmologist.7,8 Herpes zoster is diagnosed clinically, based on history and symptom presentation. If necessary, diagnosis can be confirmed from a swab of vesicular fluid by culture or biopsy for electron microscopy. Serology is also available and can be used to demonstrate immunity. A typical history for herpes zoster can include neuropathic pain for around three days followed by a vesicular rash in a dermatomal distribution.3 The hallmark zoster rash is unilateral, vesicular, and pruritic on an erythematous vesicular base that does not cross the midline. The prodrome period typically precedes the hallmark rash by a few hours to several days. The prodromal symptoms include pain, fever, malaise, headache, itch, and paraesthesia. There are three phases of herpes zoster

SEPTEMBER-OCTOBER 2021 37


Feature pain; the acute pain phase lasting up to a month, the subacute pain phase, and the postherpetic neuralgia phase, which is persistent pain lasting ≥30 days, often more than 90 days after the onset of rash. Acute pain, largely inflammatory, may progress to persistent neuropathic pain resulting from peripheral and central nerve damage and secondary sensitisation.4 Postherpetic neuralgia is the most common complication of herpes zoster. Although the pain often resolves within a few weeks it can be severe and incapacitating and can persist for months and occasionally for years. It is a debilitating complication that is challenging to treat and is responsible for most of the herpes zoster-related burden of disease.4 Affected patients usually report constant burning, darting pain that may be radicular in nature. Patients may also complain of pain in response to non-noxious stimuli and even the slightest pressure from clothing or bedsheets may elicit pain. Older adults are most likely to have postherpetic neuralgia and to have longer lasting and more severe pain.5

Herpes zoster vaccines Herpes zoster and postherpetic neuralgia are vaccine preventable. Herpes zoster vaccines are licensed for individuals aged 50 years and above to reduce the risk of developing zoster and postherpetic neuralgia. It is not necessary to determine whether patients have a history of varicella or herpes zoster prior to vaccination because waning antibodies in previously exposed patients’, particularly older adults, may lead to negative results despite past infection. The US Centers for Disease Control and Prevention's Advisory Committee on Immunisation Practices recommends two doses of adjuvant recombinant varicella zoster virus vaccine for adults 50 years and older, including those who have already had the live varicella zoster virus vaccine.14 The recombinant vaccine decreases the chance of getting herpes zoster by 97 per cent for adults aged 50-to-69 years and 91 per cent for adults 70 years or older.13 There are two licensed zoster vaccines: Zostavax, a live attenuated vaccine

38 SEPTEMBER-OCTOBER 2021

Shingles (designated zoster vaccine live [ZVL]) is indicated for prevention of herpes zoster and herpes zoster-related postherpetic neuralgia in individuals aged ≥50 years, and Shingrix, a non-live recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]) is indicated for prevention of herpes zoster and postherpetic neuralgia in adults aged ≥50 years. Zostavax is available in Ireland, however, the vaccine is not part of the national immunisation programme and individuals wishing to receive it should consult with their GP or pharmacist.5 Shingrix is currently not freely available in Ireland. Herpes zoster vaccines should be stored at +2 to +8 0 C and protected from light. After reconstitution the vaccine should be used immediately and any vaccine unused after 30 minutes should be discarded. The dose of Zostavax is 0.65ml administered IM or SC, preferably in the upper arm.5 The vaccine may be given to those who have had herpes zoster. It is preferable to defer vaccination for 12 months after the herpes zoster has resolved so that the vaccine can produce a more effective immune response. The approach to vaccination in immunocompromised patients depends upon when immunosuppression is planned, underlying condition, and the choice of vaccine. Patients should ideally be vaccinated ≥four weeks before the initiation of immunosuppressive therapy. Patients receiving low-dose immunosuppressive therapy are likely to respond to vaccination but disseminated zoster with vaccine type virus may rarely occur.5

Contraindications 5  Anaphylaxis to any of the vaccine constituents.  Immunocompromised from disease or treatment.  Active untreated tuberculosis.  Pregnancy.

Precautions 5  Acute severe febrile illness – defer until recovery.

 Pregnancy should be avoided for one month following vaccination.  Administration to individuals who are immunocompromised may result in disseminated VZV disease, including fatal outcomes. Patients who previously received immunosuppressive therapy should be carefully evaluated for reconstitution of their immune system prior to receiving ZVL.  The safety and efficacy of ZVL has not been established in adults infected with HIV with or without evidence of immunosuppression.  This vaccine should be given subcutaneously to individuals with severe thrombocytopaenia or any significant coagulation disorder, because they may bleed following IM injections. ZVL can be administered concomitantly with inactivated influenza vaccine, at a different site. Concomitant administration of ZVL and pneumococcal polysaccharide vaccine (PPV23) has not been shown to reduce effectiveness of either vaccine. No data are currently available regarding concomitant use with other vaccines or with antiviral medications known to be effective against VZV.5

Treatment The treatment of herpes zoster has three major objectives; treatment of the acute viral infection, treatment of the acute pain associated with herpes zoster, and prevention of postherpetic neuralgia. Early identification and prompt treatment of herpes zoster with antiviral drugs and analgesics frequently reduces acute rash and pain and may prevent some complications. Antiviral drugs have been shown to reduce acute pain and rash severity, accelerate rash resolution and reduce duration of pain. However, many patients experience postherpetic neuralgia despite antiviral drug use.6 Herpes zoster can be treated with antiviral medications acyclovir, valacyclovir, or famciclovir, which are most effective when started within 72 hours after the onset of the rash. Acyclovir, the prototype antiviral drug, is a DNA


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Shingles polymerase inhibitor. Major drawbacks of orally administered acyclovir include its lower bioavailability compared with other agents and its dosing frequency of five times daily.7 Valacyclovir, a prodrug of acyclovir, is administered three times daily. Compared with acyclovir, valacyclovir may be slightly better at decreasing the severity of pain associated with herpes zoster, as well as the duration of postherpetic neuralgia. Valacyclovir is also more bioavailable than acyclovir, and oral administration produces blood drug levels comparable to the intravenous administration of acyclovir.7 Famciclovir is also a DNA polymerase inhibitor. The advantages of famciclovir are its dosing schedule of three times daily, longer intracellular half-life compared with acyclovir and its better bioavailability compared with acyclovir and valacyclovir.7 The choice of which antiviral agent to use is individualised. Dosing schedule and cost may be considerations. All three antiviral agents are generally well tolerated. The most common adverse effects are nausea, headache, vomiting, dizziness and abdominal pain.7 The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster. Glucocorticoids are an adjunct to antiviral therapy. They reduce acute pain and promote early healing; however, they do not reduce the incidence of postherpetic neuralgia and should not be used without antivirals.14 Paracetamol alone or in combination with a weak opioid such as codeine is frequently used as analgesia. Although postherpetic neuralgia is generally a selflimited condition, it can last indefinitely and patients with postherpetic neuralgia may require narcotics for adequate pain control. Addition of drugs active against neuropathic pain, eg, tricyclic antidepressants such as amitriptyline, α-2-δ ligands such as gabapentin or pregabalin, or strong opioids such as oxycodone are used for resistant pain, but older adults often experience adverse effects. Generally, systemic drugs are poorly effective for the treatment of

postherpetic neuralgia and have significant side-effects. The potential harms of systemic therapies for postherpetic neuralgia should be considered before treating older patients or those with comorbidities.14 Capsaicin, lidocaine patches and nerve blocks can also be used in selected patients.4 Tricyclic antidepressants can be effective adjuncts in reducing the neuropathic pain of postherpetic neuralgia. These agents most likely lessen pain by inhibiting the reuptake of serotonin and norepinephrine neurotransmitters. Tricyclic antidepressants commonly used in the treatment of postherpetic neuralgia are best tolerated when they are started at a low dosage and given at bedtime. The dosage is increased every two-to-four weeks to achieve an effective dose. Tricyclic antidepressants share common side-effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention. Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated. Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver

toxicity and the potential for these problems should be considered in elderly patients and those with cardiac or liver disease.14 Ocular herpes zoster is treated with orally administered antiviral agents, mydriatics and corticosteroids. Although most patients with ocular herpes zoster improve without lasting sequelae, some may develop severe complications, including loss of vision. When herpes zoster involves the eyes, ophthalmologic consultation is recommended. Early treatment with acyclovir 800mg orally five times/day or famciclovir 500mg or valacyclovir 1g orally three times/ day for seven days reduces ocular complications. Patients with uveitis or keratitis require topical corticosteroids, for example, prednisolone acetate 1 per cent instilled every hour for uveitis or four times/day for keratitis initially, lengthening the interval as symptoms lessen. The pupil should be dilated with atropine 1 per cent or scopolamine 0.25 per cent one drop three times/day. Intraocular pressure must be monitored and treated if it rises significantly above normal values.13

REFERENCES 1. John A, Canaday D. (2017). Herpes Zoster in the Older Adult. Infectious Disease Clinics of North America. Volume 31, Issue 4, 2017, pp 811-826. https://doi.org/10.1016/j. idc.2017.07.016 2. Carter T. (2019). Shingles: Not Just a Rash. JNP, Journal for Nurse Practitioners. Available at: www. npjournal.org/action/showPdf?pii =S1555-4155%2819%2930957-2 3. BMJ. (2019). Herpes Zoster infection. 364. doi: 10.1136/bmj. k5095  4. Ther Adv Vaccines. (2015). Herpes zoster epidemiology, management, and disease and economic burden in Europe: A multidisciplinary perspective. 3(4): 109-120. July 2015 doi: 10.1177/2051013615599151 Available at: www.ncbi.nlm.nih.gov/ pmc/articles/PMC4591524/ 5. HSE (2020). Chapter 23 VaricellaZoster. Available at: www.hse.ie/

eng/health/immunisation/hcpinfo/ guidelines/chapter23.pdf 6. Cohen J. (2013) Clinical practice: herpes zoster. N Engl J Med 369: 255–263  7. Nazarko L. (2019). Pain relief in the treatment of shingles: A guide for nurses. Independent Nurse. Available at: www.independentnurse.co.uk/ clinical-article/pain-relief-in-thetreatment-of-shingles-a-guide-fornurses/216317/ 8. Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. (2014). Antiviral treatment for preventing post herpetic neuralgia. Cochrane Database Syst Rev. 2014, Issue 2. Art. No.: CD006866. doi: 10.1002/14651858. CD006866.pub3 9. Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. (2013). Corticosteroids for preventing post herpetic neuralgia. Cochrane Database Syst Rev. 2013 Mar 28; 3:CD005582. doi:

10.1002/14651858.CD005582.pub4 10. Chung S, Tsai M, Liu S, Lin C, Kang J. (2014). Herpes zoster is associated with prior statin use: A populationbased case-control study. PLoS One. 24; 9(10):e111268 11. Nagel M, Gilden D. (2013). Complications of Varicella Zoster Virus Reactivation. Curr Treat Options Neurol. 15(4): 439-453 12. Oakley A. (2015). Shingles (Herpes Zoster). DermNet NZ, New Zealand 13. Roat M. (2020). Herpes Zoster Ophthalmicus. MSD Manual Professional Version. Available at: www.msdmanuals.com/professional/ eye-disorders/corneal-disorders/ herpes-zoster-ophthalmicus 14. AFP (2017). Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Available at: www. aafp.org/afp/2017/1115/p656.html

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Women's Health

Author: Theresa LowryLehnen, CNS, GPN, RNP, PhD, and National PRO of the Irish General Practice Nurses Educational Association

P

POLYCYSTIC OVARY SYNDROME (PCOS): AN OVERVIEW

olycystic ovary syndrome (PCOS), a heterogeneous disorder characterised by hyperandrogenism and chronic anovulation, is a common endocrine, metabolic, and menstrual disorder in women. Depending on diagnostic criteria, PCOS affects 6-to-10 per cent of women of reproductive age. While the aetiology is not completely understood, PCOS is believed to be multifactorial in nature with a complex interaction of genetic and environmental factors. PCOS is exacerbated by obesity and has significant metabolic, reproductive, and psychological features, including an increased risk of type 2 diabetes mellitus with an earlier age of onset, subfertility, and an increased risk of depression and anxiety symptoms. A family history confers a higher risk of developing PCOS and other contributing factors include low birth weight, premature pubarche, obesity, diabetes mellitus, and antiepileptic drug use.

Pathophysiology The abnormal findings in PCOS are a result of ovarian hyperandrogenism and insulin resistance. Evidence suggests that the ovarian hyperandrogenism in PCOS is a result of primary ovarian dysfunction and is secondary to disordered gonadotropin activity. While not included in diagnostic criteria for PCOS, the elevated level of serum luteinising hormone (LH) in affected patients due to inappropriate secretion has long been recognised. In addition,

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PCOS pathophysiology appears to have a polygenic predisposition that is exacerbated by environmental factors, especially obesity.3,7

Diagnosis The diagnosis of PCOS has lifelong implications, with increased risk for infertility, metabolic syndrome, type 2 diabetes mellitus, and possibly cardiovascular disease and endometrial carcinoma. Typical clinical features include hirsutism, irregular menses, chronic anovulation, acne, obesity, insulin resistance, and infertility. Patients typically present with acne and menstrual irregularities.1,2,5 PCOS should be considered in any adolescent girl with hirsutism, treatment-resistant acne, menstrual irregularity, or acanthosis nigricans, and evidence of these signs and symptoms should be especially sought in patients being evaluated for obesity.4 As PCOS is associated with insulin resistance, all women with PCOS should be screened for diabetes or

SUGGESTED SCREENING TESTS  Luteinising hormone  Follicle-stimulating hormone  Total testosterone, sex hormone binding globulin  Lipid profile  Fasting glucose with or without oral glucose tolerance test, glycated haemoglobin

pre-diabetes, especially if they are planning to conceive, as poorly controlled diabetes is associated with adverse pregnancy outcomes.5 Three sets of diagnostic criteria; Androgen Excess and PCOS Society (AES), Rotterdam (Figure 2), and National Institutes of Health (NIH), are commonly used for PCOS and all require the exclusion of other known disorders.3 Among the different diagnostic criteria used to define PCOS, the Rotterdam criteria are the most widely used and recommended, and like the more liberal AES criteria they allow for different phenotypes of the disorder. Based on the Rotterdam criteria, a diagnosis of PCOS requires two out of three of the following; hyperandrogenism, menstrual irregularities and polycystic ovaries on ultrasonography.5 Diagnosis of PCOS requires the exclusion of other conditions, such as pregnancy, thyroid dysfunction, hyperprolactinaemia, Cushing’s syndrome, non-classical congenital

 Serum prolactin  Thyroid function  Serum ferritin  25-hydroxy vitamin D

IF CLINICALLY INDICATED  17 hydroxyprogesterone  1mg overnight dexamethasone

suppression or 24 hour urine-free cortisol  Sleep study


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Women's Health adrenal hyperplasia, and androgen-secreting tumours. In women with signs or symptoms of androgen excess, serum total testosterone should be checked and the patient referred to a specialist for evaluation if the level is greater than two times the upper limit of normal. According to clinical findings, further tests may be necessary including beta-HCG, thyroid function, prolactin, 1mg overnight dexamethasone suppression and early morning serum 17-OHP (17-hydroxyprogesterone) tests. Mild elevations in serum prolactin are common in PCOS, but after excluding macroprolactin, levels that are greater than twice the upper limit of normal warrants further investigation. High levels of antiMüllerian hormone, a hormone produced by ovarian follicle granulosa cells, are also seen in PCOS and may be useful in the diagnosis of the condition.5 As PCOS is associated with insulin resistance, all women with PCOS should be screened for diabetes or pre-diabetes, especially if they are

planning to conceive, as poorly controlled diabetes is associated with adverse pregnancy outcomes. Screening for coronary artery disease and obstructive sleep apnoea (OSA) should be considered in women who are at high risk. Obesity increases the risk of endometrial cancer three-fold in women with PCOS. While routine screening for endometrial cancer using ultrasonography is not currently recommended, it is important to have a high level of suspicion for patients with prolonged oligomenorrhoea for more than three months between menses.5 Iron deficiency is common in PCOS, and may contribute to fatigue and androgenic alopecia. Screening and treatment with iron if necessary is suggested, targeting serum ferritin in the upper quartile of the reference range. Vitamin D deficiency is also common in patients with PCOS and may have an additive adverse effect on fertility, insulin resistance, and glucose intolerance, therefore screening levels and replacing any deficiency may be helpful.

Psychological well-being due to the effects of PCOS on physical appearance, such as weight gain, acne, and hirsutism, is an important consideration as is being alert for mental health issues, such as depression, anxiety, and self-harm.5

Treatment Treatment for PCOS is multi-targeted and individualised to suit each patient’s phenotype, symptoms, goals and expectations, such as wanting to become pregnant. First-line therapy for women with PCOS and obesity is lifestyle modification in the form of diet and exercise. This is particularly important in women who are preparing for pregnancy, in order to reduce the risk of complications, such as gestational diabetes, pre-eclampsia, pre-term delivery, macrosomia, birth defects, and stillbirth. Antiandrogens, such as spironolactone, should be stopped for three months before conception, and patients should be counselled about recurrence of androgen excess symptoms

Figure 1: Assessment and management of PCOS: Summary of an evidence-based guideline (Teede H, et al, 2011)8

SEPTEMBER-OCTOBER 2021 41


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Women's Health

Figure 2: Rotterdam criteria for the diagnosis of PCOS while preparing for fertility. Metformin may help, although it is unclear if this is independent of the weight loss benefit it confers. Ovulation induction with clomiphene citrate or letrozole is effective for fertility treatment.5 Obesity is prevalent in 50-to-80 per cent of women with PCOS.3 Even modest lifestyle changes can have a significant impact and reducing body weight by 2-to-5 per cent has been shown to restore ovulation and increase insulin sensitivity in obese anovulatory women. Weight reduction has additional benefits – reducing the risk of diabetes, hypertension, cardiovascular disease, and certain malignancies.5,6 To induce periods for those with menstrual irregularities, cyclical progesterone can be used every two months to ensure regular shedding of the endometrium. The oral contraceptive pill (OCP) is also effective in controlling menses, with the added benefit of providing contraception and improving androgenic symptoms. However, given many women with PCOS are obese this, together with the OCP, causes an increased risk of thrombosis, so patient selection is important. It is advisable to avoid OCPs with higher oestrogen doses or those containing 19-norprogesterone derivatives, as androgenic progestin may adversely affect the patient’s cardiovascular risk. Starting with low-dose ethinylestradiol combined with a third- or fourth-generation progestin is recommended, as these have the least intrinsic androgenic activity. Metformin can also help to restore menstrual cyclicity.4,5 Hyperandrogenism in PCOS is caused by insulin resistance, hypersecretion of luteinising

42 SEPTEMBER-OCTOBER 2021

hormone and ovarian androgens. Medications commonly used to treat androgen excess target these pathways. Spironolactone is an antiandrogen that blocks the effect of testosterone at the level of the androgen receptor. OCPs suppress LH secretion and reduce ovarian androgen production and metformin improves insulin resistance. If hirsutism is severe, all three medications may be used. The OCP remains the first-line treatment for hirsutism because of its effect on androgen production. OCP use offers the additional benefit of reducing acne if present, and provides protection against endometrial cancer and menstrual cycle irregularity.3,5 Patients need to be informed that the symptoms of androgen excess, particularly hirsutism, take at least six months to improve. Eflornithine can be applied topically

for rapid control of facial hirsutism, although fastidious use is required for the treatment to be effective. Permanent laser hair removal can be an effective treatment and may be considered if the symptoms are causing severe distress. Metformin is beneficial for improving insulin sensitivity and can aid in weight loss, but it is ineffective in controlling hirsutism in the majority of women. Antibiotics and retinoic acid derivatives can also be used for acne treatment.4,5 If first-line measures for cycle control or androgen excess are ineffective in controlling symptoms, then referral to an endocrinologist, gynaecologist or reproductive medicine specialist should be considered. References on request

REFERENCES 1. Witchel S, Oberfield S, Pena A (2019). Polycystic ovary syndrome: Pathophysiology, presentation, and treatment with emphasis on adolescent girls. Journal of the Endocrine Society, Volume 3, Issue 8, August 2019. doi:10.1210/ js.2019-00078. Available at: https://academic.oup.com/jes/ article/3/8/1545/5518341 2. Pfieffer M. (2019). Polycystic ovary syndrome. Nursing. August 2019. doi: 10.1097/01. NURSE.0000569748.65796.d1. Available at: www.com/ nursing/Fulltext/2019/08000/Polycystic_ovary_syndrome__ An_update.9.aspx 3. Havelock J. (2018). Polycystic ovarian syndrome. BCMJ, Volume 60, Issue 4, May 2018. Available at: https://bcmj. org/articles/polycystic-ovary-syndrome 4. Rosenfield R., Ehrmann D. (2016). The pathogenesis of polycystic ovary syndrome (PCOS): The hypothesis of PCOS as functional ovarian hyperandrogenism revisited. Endocr Rev

2016; 37:467 5. Yin Lua A, How C, King T. (2018). Managing polycystic ovary syndrome in primary care. Singapore Medical Journal 59(11): 567–571.doi: 10.11622/smedj.2018135 6. NHS (2019). Polycystic ovary syndrome. NHS. Available at: www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/ diagnosis/ 7. Hiam D, Moreno-Asso A, Teede H, Laven J, Stepto N, Moran L, Gibson-Helm M. (2019). The genetics of polycystic ovary syndrome: An overview of candidate gene systematic reviews and genome-wide association studies. Journal of Clinical Medicine. Available at: file:///C:/Users/Admin/Downloads/ The_Genetics_of_Polycystic_Ovary_Syndrome_An_Overv.pdf 8. Teede H, Misso M, Deeks A, Moran L, Stuckey B, Wong J, Norman R, Costello M. Assessment and management of polycystic ovary syndrome: Summary of an evidence-based guideline. Med. J. Aust. 2011, 195, S65–S112


Life

Book Review

BREAST IS ALWAYS BEST TITLE:

White Blood: A History of Human Milk

AUTHOR:

Lawrence Trevelyan Weaver

PUBLISHER:

Unicorn 2021

REVIEWER:

Prof Denis Gill

W

hite Blood: A History of Human Milk is an extraordinary, semiautobiographical, scientific and historical dissertation by Lawrence Weaver. Weaver is a paediatric gastroenterologist, nutritional scientist and an historical scholar. His career direction has led inexorably to the grand finale production of White Blood. This is a thorough history of breast milk, but deviates into paediatrics; child health; childhood malnutrition; mismanagement; poverty; foundling hospitals; children’s hospitals; and much more. ‘Wet nurses’ and wet nursing receive a red card early and often. I learned a lot from it. Weaver’s forte is clearly medical history and scholarly writing. The text runs to some 260 pages, with a good index, and excellent biography of 12 pages. The illustrations are numerous and of good quality, but not numbered. Some could be enlarged and many would make useful slide material, particularly the man-midwife, the ‘murder bottle’, King Henry’s mistress, and the terrific triptych on ‘the drop of milk’. Weaver is an expert with voluminous knowledge on childhood nutrition. Weaver and three colleagues wrote the World Health Organisation Declaration (2000) on ‘The Feeding and Nutrition of infants in the European Region’. Their four themes are: (1) The vitality of human milk; (2) The transformation or transmutation of human milk (3); Reproduction and nutrition; (4) Morbidity to baby from deprivation of human milk. Infant mortality in Europe 1900 was 15 per cent; it was about 0.5 per cent in 2020. In the first six months a lactating mother produces some 100 litres of human milk, largely driven by the demands of the suckling infant.

Human milk is replete with immune factors, trophic factors, and digestive enzymes. Breastfeeding reduces diarrhoeal disease, infections, sudden infant death syndrome, obesity, and other conditions. Whether done for three days, three weeks, three months, or more, there is a benefit. In the ancient Greco-Roman world, breast milk was a humoral fluid and sacred substance – white blood – with material and spiritual qualities. Leonardo da Vinci claimed that “the newborn baby was nourished on mother’s milk, made from blood diverted from the womb to the breast”. However, even in those historic times, infants of aristocrats were often fed by “wet nurses”. Later, maternal nursing was deemed a Puritan religious duty, an exhibition of motherly love. In 1720 Jonathon Swift drew attention to the dire condition of infants in Dublin and London due to their deprivation of “Nature’s Bountiful Urn”. Many wet nurses were feeding their “charges” on bread and water pap, cereals, and gruel. Today, it is crisps and coke. But, did you know that the prophet Mohammed was an orphan, whose life was preserved by a wet nurse? This is a well-woven scientific tome. The book contains serious science, including an impressive list of antimicrobial and anti-inflammatory agents in breast milk – some 20 in all. Historically, midwives,

accoucheurs, and obstetricians took no interest in infant feeding. It was long known that ‘hand feeding’ or ‘dry nursing’ was almost entirely confined to the very poor. The death rate of children less than five years was 35 per cent in London 1815. Farming out babies to others was pretty much their death sentence. Thames river water was found to be swarming with “hydras, gorgons, and chimeras dire”. Cholera was rampant in the mid-18th century. 'Puericulture' – the rearing and hygienic care of children – became widespread in Europe. The French led the way with children’s hospitals. Lister and Semmelweis promoted sterility. It was known that 80 per cent of deaths of children under two years were due to defective nutrition and dirty practices. Baby bottles with long, dirty, rubber tubes were called ‘murder bottles’. About 80 per cent of infants were breastfed in England in 1900. Breast milk was seen as the salvation of the poor child. There were much higher rates of malnutrition, gastroenteritis, and rickets in bottle-fed babies. Artificial baby formulae appeared. The UK infant mortality rate dropped from 150 per 1,000 births in 1900 to 10 per 1,000 births in 1990. Some shocking stats from the Rotunda Hospital and the Dublin Foundling Hospital are covered. Joseph Clarke (1758-1834), Master of the Rotunda Hospital, recorded that the mortality of babies there not nursed by their mothers was 99 per cent. The Dublin Foundling Hospital 1781-1791 was atrocious, woefully managed, had appalling hygiene, and an infant death rate of 90 per cent. Weaver is to be complimented on an outstanding book, which is very well-written and presented. White Blood should be compelling and compulsory reading for neonatal nurse tutors and lecturers; neonatal paediatricians; nutritionists; dieticians; lactation consultants; GPs and general practice nurses; public health nurses; and others concerned with the wellbeing of newborn infants. Breast milk has been, and always will be, the best for all babies. Learning lessons from history is imperative. Weaver’s wisdom is nurture for practitioners and historians.

SEPTEMBER-OCTOBER 2021 43


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Across ACROSS1 - Yellow fruit (6) DOWN 1 Yellow fruit (6) 1 Chess piece (6) 7 Space objects (8)two objects 2 Standard; 7 -between Spacetwo between (8) usual (6) 8 Male aristocrat (3) 3 Allow entry to (5) 9 Nautical (6) 8 - Male aristocrat (3) 4 Vital content (7) 10 Smile broadly (4) 5 Female offspring (8) 11 Lentil or chickpea (5) 6 Opposite of passive (6) 9 - Nautical (6) 13 Disperse (7) 12 Discrete; distinct (8) 15 Notwithstanding (7) 14 Extend an arm or leg (7) 10 - Smile broadly (4) 16 Complete (6) 17 Fault (5) 21 Agitate a liquid (4) 18 Of the immediate past (6) 11 - Lentil 22 Excitingly strangeor (6) chickpea (5) 19 Cause to become (6) 23 Extremity (3) 20 Cloud (anag) (5) 13 -(8)Disperse (7) 24 Crucial 25 Medical practitioner (6)

Down 1 - Chess piece (6)

SCRIBBLE BOX

2 - Standard; usual (6) 3 - Allow entry to (5) 4 - Vital content (7) 5 - Female offspring (8) 6 - Opposite of passive (6) 12 - Discrete; distinct (8)

15 - Notwithstanding (7)

14 - Extend an arm or leg (7)

17 - Fault (5)

16 - Complete (6)

21 - Agitate a liquid (4)

18 - Of the immediate past (6)

22 - Excitingly strange (6)

19 - Cause to become (6)

44 SEPTEMBER-OCTOBER 2021


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