OTC Update Summer 2021

30%

For bottle-fed infants with frequent regurgitation

March 2018

a stepped-care approach...

the feeding history.

ESPGHAN RECOMMENDS REDUCE

the feed volumes by trialling smaller, more frequent feeds (while maintaining an appropriate daily total).

TRIAL a thickened formula.

Aptamil Anti-Reflux is a thickened formula for the dietary management of reflux and regurgitation in bottlefed infants

AVAILABLE IN RETAIL AND PHARMACY OUTLETS

* European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Clinically

reduce infant regurgitation episodes by 78%2

References: 1. Vandenplas Y et al., J Pediatr Gastroenterol Nutr 2015; 61(5): 531–537. 2. Wenzl TG et al. Pediatrics 2003;111:e355-9.

Ireland: www.aptamilhcp.ie

Northern Ireland: www.eln.nutricia.co.uk

IMPORTANT NOTICE: Aptamil Anti Reflux is a food for special medical purposes for the dietary management of frequent reflux and regurgitation. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. This product should not be used in combination with antacids or other thickeners and is not suitable for premature infants. Suitable for use as the sole source of nutrition for infants from birth and as part of a balanced diet from 6 months. FOR

proven to

EDITOR

Pat Kelly pat@greenx.ie

MANAGING DIRECTOR

Graham Cooke graham@greenx.ie

CREATIVE DIRECTOR

Laura Kenny laura@greenx.ie

ADMIN

Daiva Maciunaite daiva@greenx.ie

CONTENTS

HOT TOPICS

09

INFANT HEALTH

A look at the range of considerations in infant health and the most common conditions, as well as nutritional needs and pain relief

13

FATIGUE

GreenCross Publishing Ltd, Top floor 111 Rathmines Road Lower, Dublin 6 Tel: 014410024

OTC UPDATE is produced by GreenCross Publishing Ltd. as a supplement to Irish Pharmacist. GreenCross Publishing was established in 2007.

© Copyright GreenCross Publishing Ltd. 2020

The contents of OTC UPDATE 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 OTC UPDATE 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.

17

There can be many reasons a person becomes fatigued, including medical conditions, inadequate nutrition and over-exercise

BONE HEALTH

An overview of the importance of bone health at all stages of life, including what characterises more serious bone conditions and how they are treated

22

WOUND CARE

How to ensure the best conditions for healing different types of wounds, including chronic wounds, and the role of nutrition and the right dressings

24

FOOT CARE

A look at common foot conditions that present at the pharmacy and the best treatment options

PHARMACISTS ISSUE ADVICE ON KNOWING THE DIFFERENCE

BETWEEN HAY FEVER AND COVID-19 SYMPTOMS

As hay fever season began, the Irish Pharmacy Union (IPU) issued advice on recognising the difference in symptoms between hay fever and Covid-19. With one-in-five Irish people living with hay fever, it is important that people understand how to recognise the key differences; for example, a fever or chills is common with Covid-19, but isn’t seen in those suffering with hay fever.

Pharmacists also wanted to emphasise that even during the ongoing Covid-19 pandemic, pharmacies are still open and available to support people in the community.

Hay fever, also known as seasonal allergic rhinitis, is caused by pollen and spores creating an allergic reaction affecting the nose and sinuses. While it can occur at any time of year, sufferers are particularly impacted from the spring until autumn. Although hay fever is a relatively common condition, the symptoms can be extremely unpleasant.

Ms Ann Marie Horan, a community pharmacist and Executive Committee member of the IPU, issued the following advice: “Hay fever can make life miserable, especially for people with severe symptoms. However, the condition can often be effectively managed with a range of

treatment options, including antihistamines, decongestants, corticosteroid nasal sprays and anti-allergy eye-drops. The key to treating hay fever is finding the treatment that works for you.” The IPU also issued guidance (right) on how to differentiate the symptoms of both conditions.

Ms Horan added: “With everyone

on high alert for Covid-19 symptoms, it can be difficult to rationalise which symptoms could be hay fever and which are associated with Covid-19.”

Ms Horan also provided some general advice on managing hay fever: “Sufferers should monitor the pollen forecast and take particular care when the count is high. You can reduce hay fever symptoms by doing the following:

 Keep doors and windows closed at home and when driving;

 Apply a little Vaseline inside the nose to trap pollen and stop it being inhaled;

 Wear sunglasses, preferably wraparound glasses, which prevent pollen entering the eyes;

 Don’t mow the grass and avoid working in the garden;

 Don’t dry clothes outside if possible; and

 Wash your hair, hands and face when you come back indoors and change your clothes to get rid of any pollen.”

Pharmacists also warned that as hay fever is a significant trigger for asthma, asthma patients should ensure they carry their inhaler at all times and use it as prescribed. Up-to-date information on pollen forecasts in your region can be found at: https://www.met.ie/forecasts/pollen.

NATIONAL STUDY OF COVID-19 IN IRELAND SHOWS LINKS BETWEEN UNDERLYING CONDITIONS AND POORER OUTCOMES

A national study of 20,000 patients conducted by the RCSI University of Medicine and Health Sciences and the HSE Health Protection Surveillance Centre (HPSC) has identified the underlying conditions that are associated with more severe outcomes from Covid-19 in an Irish setting.

The research, which has been published in The Lancet Regional Health –Europe , will help inform national public health policies and assist in future

treatment and prevention strategies for people at most risk from the virus.

The study, which took place during the first wave of the pandemic between March and July 2020, is the first national surveillance study in Ireland that captures data from both hospital and community settings. Data was collected by HPSC for almost 20,000 confirmed cases of Covid-19. The association between underlying conditions and more severe outcomes from Covid-19 was

examined, including mortality, admission to hospital or admission to ICU.

Among the patients studied, there were 1,476 (7.5 per cent) deaths, 2,811 (14 per cent) hospitalisations and 438 (2 per cent) ICU admissions. The conditions that were identified in the study as carrying the most risk were chronic heart disease, a chronic neurological condition, chronic kidney disease, and cancer. Patients who were morbidly obese (defined as a Body Mass Index equal to or greater 

FAST RELIEF OF ALLERGIES 24hr

Cetrine Allergy 10mg Film-Coated Tablets available in packs of 7s and 30s. Always read the leaflet.

ABBREVIATED PRESCRIBING INFORMATION

Product Name: Cetrine Allergy 10mg lm-coated tablets & 1 mg/ml oral solution. Composition(s): Each tablet contains 10 mg cetirizine dihydrochloride. One ml of the oral solution contains 1 mg cetirizine dihydrochloride. Description(s): White, oblong lm-coated tablets, scored on one side. Can be divided into equal halves. Clear, colourless liquid with banana avour.

Indication(s): Tablets: Adults and paediatric patients 6 years and above. Oral solution: Adults and children 2 years and above. Relief of nasal and ocular symptoms of seasonal and perennial allergic rhinitis (hay fever); relief of symptoms of chronic idiopathic urticaria.

Dosage: Tablets: Adults, elderly and children aged 12 years and over: 10 mg once daily. Children from 6 years to 12 years: 5 mg (half a tablet) twice daily. Moderate renal insu ciency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insu ciency (creatinine clearance ≤30 ml/min): 5 mg once every 2 days. Children under 6 years: Not recommended. Oral solution: Children aged from 2 to 6 years: 2.5 mg twice daily (2.5 ml oral solution twice daily (half a measuring spoon twice daily)). Children aged from 6 to 12 years: 5 mg twice daily (5 ml oral solution (a full measuring spoon twice daily)). Adults and adolescents over 12 years of age: 10 mg once daily (10 ml oral solution (2 full measuring spoons)). Not recommended in children aged less than 2 years. Moderate renal insu ciency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insu ciency (creatinine clearance ≤30 ml/min): 5 mg once every 2 days. In paediatric patients su ering from renal impairment: Adjust dose on an individual basis taking into account the renal clearance of the patient, his age and his body weight. Contraindications: History of hypersensitivity to the active substance, to any of the excipients, piperazine derivatives or hydroxyzine. Severe renal impairment < 10 ml/min creatinine clearance.

Warnings and Precautions for Use: Cetirizine may increase risk of urinary retention, therefore caution in patients with predisposition factors of urinary retention (e.g. spinal cord lesion, prostatic hyperplasia). Caution in epileptic patients and patients at risk of convulsions. Discontinue use of cetirizine three days before allergy testing. Pruritis and/or urticaria may occur when cetirizine is stopped, even if the symptoms were not present before treatment initiation. In some cases, the symptoms may be intense and may require treatment to be restarted. The symptoms should resolve when the treatment is restarted. Tablets contain lactose. Oral solution contains sorbitol, propylene glycol, sodium (essentially ‘sodium free’), methyl - & propyl-parahydroxybenzoate.

Interactions: Caution is advised when taken concomitantly with alcohol or other CNS depressants. Cetirizine does not potentiate the e ect of alcohol (0.5 g/l blood levels). The extent of absorption of cetirizine is not reduced with food, although the rate of absorption is decreased.

Pregnancy and Lactation: Caution during pregnancy and breast-feeding.

Ability to Drive and Use Machinery: Usually non-sedative, patients should take their response to the product into account. In sensitive patients, concurrent use with alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance.

Undesirable E ects: Cetirizine at the recommended dosage has minor adverse e ects on the CNS, including somnolence, fatigue, dizziness and headache. In some cases, paradoxical CNS stimulation has been reported. Although cetirizine is a selective antagonist of peripheral H1-receptors and is relatively free of anticholinergic activity, isolated cases of micturition di culty, eye accommodation disorders and dry mouth have been reported. Instances of abnormal hepatic function with elevated hepatic enzymes accompanied by elevated bilirubin have been reported which resolves on discontinuation of the drug. Uncommon: Agitation, diarrhoea, pruritus, rash, asthenia, malaise, paraesthesia. See SPC for all adverse reactions.

Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork.

Marketing Authorisation Number: PA0711/075/002-003. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417

E-mail: rowex@rowa-pharma.ie

Legal Category: Not subject to medical prescription.

Date of Preparation: March 2021

Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie) or by emailing Rowex pv@rowa-pharma.ie

than 40) were also identified as being at higher risk of more severe outcomes from Covid-19.

Prof Kathleen Bennett, Associate Professor in Biostatistics, RCSI, said: “Previous studies conducted have suggested that specific underlying conditions influence adverse health outcomes among those with a confirmed diagnosis of Covid-19. However, the majority of these studies have focused on hospital-based or local populations only. This study is the first populationbased research to capture data across

all settings in Ireland, including both community and hospital settings, and so it gives us a better picture of the impact of the disease on patients at the population level.

“The findings are of particular relevance, as the national vaccination programme is well underway, including those at very high risk and high risk from the most severe outcomes of Covid-19.”

In the study, non-severe cases were interviewed via telephone by regional contact tracing centres or departments of public health. Data on hospitalised

or severe cases was collected by public health or contact tracing teams, with some information being provided by hospital teams. Data collected included age, sex, community health organisation, living in a residential care facility or not, and likely source of transmission (close contact of a known confirmed case, community transmission, travel-related, healthcare-acquired or unknown).

The study was conducted by researchers from RCSI, supported by the Health Service Executive and Health Protection Surveillance Centre.

OBESITY-RELATED DEATHS TO CAUSE A ‘LOST GENERATION’ OF CHILDREN IN IRELAND

Three out of every four people in Ireland want celebrities banned from endorsing unhealthy food and drinks, new data shows, and even more are in favour of a crackdown on fast food ads in kids’ online games and apps, as experts warn we face “losing a generation of children” to obesity-related disease.

The Irish Heart Foundation says research by Ipsos MRBI proves the public is now overwhelmingly demanding the Government keeps a promise to introduce new laws protecting youngsters from junk-food marketing.

The charity says children as young as eight are presenting with high blood pressure and young people are showing early signs of heart disease usually seen in middle-aged men.

It warns that unless “drastic action” is taken, 85,000 of this generation of children will die prematurely due to overweight and obesity — almost the entire population of Co Laois.

“More children will go on to suffer heart disease and stroke in the future,” said Ms Helena O’Donnell, Childhood Obesity Campaign Manager with the Irish Heart Foundation.

“Twenty per cent of children live with overweight or obesity and what we have

noticed is that inequality remains quite strong, with rates in disadvantaged areas reaching one-in-four.”

In 1975, childhood obesity affected just 1 per cent of children in Ireland, but by 2016, 30 per cent of girls and 31 per cent of boys were overweight, with 9 per cent of girls and 10 per cent of boys living with obesity.

Rolling lockdowns during the pandemic are also fuelling the crisis: Separate ESRI research recently showed children, especially girls, are eating more junk food during restrictions.

The Irish Heart Foundation says the Government now needs to wage war on unhealthy food marketing. A partial ban on broadcast advertising to children was introduced in 2013, but the move sparked an upsurge in unregulated digital marketing.

“Brands have now achieved an inappropriate proximity to children online, engaging relentlessly in school, at home and even in their bedrooms, mostly through smartphones. The State is failing to protect children’s health,” said Ms O’Donnell.

The Ipsos MRBI research reveals that 85 per cent of us support a ban on unhealthy food and drink brands’ ads within games and apps played by children under 16.

More than three-quarters (76 per cent) back a ban on celebrities promoting junk food, with 23 per cent against.

A total of 76 per cent are also in favour of prohibiting children’s toys being sold alongside such foods or confectionery, and 75 per cent would support an end to price promotions encouraging larger meal sizes.

Cookbook author Ms Susan Jane White, a founder of the Irish Heart Foundation’s parent campaigner group, described the State’s response to the concerns as “feeble” because it put its faith in preventing junk food marketing in a voluntary code.

“We want to empower parents to challenge the narrative that they are the ones at fault for childhood obesity and I encourage everyone to sign a petition to protect our children’s health,” she said.

“We are specifically calling for the Government to put mandatory restrictions and penalties on junk food companies who market to kids online and on broadcast media.”

The charity is asking the public to join the thousands of people who have already backed the initiative by signing the online petition at w ww.irishheart.ie/ stoptargetingkids.

DRY & ROUGH SKIN UNDER CONTROL, FROM HEAD TO TOE

Clinically proven for use all over the body with moisturising and keratolytic formulations even for plaques associated with psoriasis.

Let your skin benefit from U-LifeTM, the one-stop solution with moisturising and keratolytic action for the management of dry, very dry, and chapped skin in specific areas of the body. U-LifeTM creams and anhydrous pastes are formulated with different urea percentages plus other specific ingredients to meet your skin’s needs and target specific areas (scalp, face, body, hands and feet).

SCREENING FRONTLINE WORKERS COULD SERVE AS EARLY WARNING SYSTEM FOR FUTURE VIRUSES — RCSI RESEARCH

New research has shown that Covid-19 infections in healthcare workers during the first wave of the pandemic provided an accurate sample of the general population, suggesting that data from frontline workers could be used to estimate the severity of future viruses more quickly.

The study, led by researchers from RCSI University of Medicine and Health Sciences in collaboration with IBM Research, was published recently in the journal PLOS ONE

The researchers analysed the infection data from healthcare workers and the progression of the first wave of the Covid-19 outbreak using the reported daily infection numbers in Ireland. Using similar data in four other countries (Germany, UK, South Korea and Iceland), computer models showed how the disease progressed in different countries related to their approach to testing, tracing and lockdown restrictions.

Healthcare workers in Ireland made up 31.6 per cent of all test-confirmed infections, while only representing 3 per cent of the population. However, the researchers found that the healthcare worker data closely related to that of the entire population after using software to create a more accurate picture of how widespread the disease was.

This suggests that governments could use data from only healthcare workers

to inform decisions on whether to implement restrictions, wide-scale testing and contact tracing for future viruses.

“As we have seen with the Covid-19 pandemic, implementing counter-measures early can save lives and reduce the spread of the disease,” said the RCSI’s Professor of Chemistry Prof Donal O’Shea, who led the work.

“However, wide-scale testing can take time to set up, delaying decisions and costing lives. While the healthcare population is no longer an accurate sample of the general population for Covid-19 due to

different vaccination rates, governments could use data from their healthcare worker population to make informed decisions on what measures to implement earlier when future viruses emerge.”

The research noted that very few nations were able to set up effective systems that tested the entire population, carried out contact tracing and quarantined those infected with Covid-19.

“Setting up wide-scale testing systems for healthcare workers is much easier than setting up a similar programme for everyone, since the infrastructure

for testing for diseases is always in place in healthcare settings,” said Dr Dan Wu, honorary lecturer in the RCSI Department of Chemistry and first author on the paper.

“A screening programme that tested all healthcare workers would have the additional benefit of catching asymptomatic spread of the disease, since all healthcare workers would be tested. If governments could catch highly-infectious diseases and implement countermeasures early, this could possibly prevent new viruses from erupting into another epidemic/pandemic.”

steroids, particularly if impairment of adrenal function suspected. Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods. Visual disturbances may occur with use of topical and systemic steroids. Long-term use may cause oedema of the nasal mucosa. Contains benzalkonium chloride which may cause bronchospasm. Side effects: Dryness and irritation of the nose and throat, nasal ulcers, nasal septal perforation, unpleasant taste and smell, headache and epistaxis. Hypersensitivity reactions including skin rash and oedema of the face or tongue. Eye disorders such as glaucoma and blurred vision. Anaphylaxis/anaphylactic reactions and bronchospasm. See SPC for full details. Legal category: Pharmacy Only. Product Authorisation Holder: PA0678/095/001. Product Authorisation holder: GlaxoSmithKline Consumer Healthcare (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. Date of last revision: May 2021. Further information available on request. Contains fluticasone propionate. Always read the label/leaflet. PM-IE-FLIX-21-00012

RESEARCH REVEALS HUMAN IMMUNE SYSTEM REDUCES POTENCY OF ANTIBIOTICS

Recent research from the University of Kent’s School of Biosciences has revealed that a molecule produced by the human immune system can severely diminish the potency of certain antibiotics.

This may explain why antibiotics effective in laboratory settings can be less effective at clearing infections in humans, according to the authors.

The research findings, which have been published recently in the journal Archives of Microbiology, reveal that nitric oxide, a molecule produced by our immune systems, can render aminoglycoside antibiotics ineffective when used against E.Coli strains

isolated from human infections.

E.Coli causes life-threatening infections, including sepsis, bladder infections, kidney failure, and dysentery.

Whilst the human immune system produces nitric oxide to kill invading bacteria, this study reports that nitric oxide can also undermine the function of antibiotics that are used as first-line agents to treat infections caused by drug-resistant E.Coli

It is expected that these findings will greatly influence the choice and dose of antibiotic treatments prescribed by medical professionals.

Corresponding author Dr Mark Shepherd, Senior Lecturer in Microbial Biochemistry at the University of Kent, said: “This work highlights the urgent need for a better understanding of how the human immune system can profoundly affect the activity of antibiotics, which is of great importance for future therapies to treat multi-drug-resistant bacterial infections.”

The paper, ‘Nitric oxide (NO) elicits aminoglycoside tolerance in Escherichia coli but antibiotic resistance gene carriage and NO sensitivity have not co-evolved’, is available at: https://link.springer.com/ article/10.1007/s00203-021-02245-2.

ADVERSITY IN EARLY LIFE LINKED TO HIGHER RISK OF MENTAL HEALTH PROBLEMS

New research has found that childhood adversity, such as parental conflict, death of a close family member or serious injury, before the age of nine was associated with mental health problems in late adolescence.

However, the research also shows that improving the relationship between parents and children could prevent subsequent mental health problems, even in children who have experienced severe adversities. The research also indicated that improving a child’s self-esteem and increasing their levels of physical activity can help to reduce the risk of developing mental health problems.

The study, led by researchers from RCSI University of Medicine and Health Sciences, was recently published in Psychological Medicine.

The research team analysed data from over 6,000 children in Ireland who took part in the Growing Up in Ireland study. The results showed that just over a quarter of children had experienced childhood adversity before the age of nine.

At age 17 and 18, almost one-in-five of the young people were experiencing significant mental health difficulties — 15.2 per cent had

developed internalising problems, such as anxiety or depression, and 7.5 per cent had developed externalising problems, such as conduct problems or hyperactivity.

Those who experienced childhood adversity were significantly more likely to report mental health problems in late adolescence.

Parent-child conflict explained 35 per cent of the relationship between childhood adversity and late adolescent externalising problems. The conflict also accounted for 42 per cent of the relationship between childhood adversity and internalising problems.

The child’s self-esteem (also called self-concept) explained 27 per cent of the relationship between child adversity and later internalising problems. The child’s level of physical activity explained 9 per cent of the relationship between childhood adversity and later internalising problems.

“Children who experience multiple or severe life events are at an increased risk of mental health problems, but not all of those exposed to such events develop such problems. Our research points to some factors

that can be useful for off-setting the risk of mental health problems in those who have been exposed to difficult life events,” said Dr Colm Healy, the study’s lead author and postdoctoral researcher at RCSI University of Medicine and Health Sciences.

The work was funded by the Health Research Board in Ireland and the European Research Council.

“Among children who have experienced adversity, we found that reducing conflict between the parent and child and fostering a warm relationship can protect them from a broad range of later mental health problems,” said Prof Mary Cannon, the study’s principal investigator and Professor of Psychiatric Epidemiology and Youth Mental Health at the RCSI.

“We also found that improving a child’s self-esteem and encouraging physical activity may also be useful intervention targets for preventing difficulties with mood and anxiety following earlier adversity. On the whole, this is a hopeful story that points towards effective interventions to improve outcomes for children who had experienced difficulties early in life.”

AND HOW TO ASSESS THEM AT THE PHARMACY COUNTER

he birth of a child is a joyous event for parents and their families, but it can bring its own stresses, particularly if the child is the first-born and the parents may not have family or social supports to fall back on. Every illness the infant develops, even minor ones, can be a cause of distress to the parents and the huge range of conflicting information on the Internet may only add to the anxiety. In addition, some parents, especially those for whom it is their first

child, may be confused and nervous regarding the proper nutritional intake for their baby and may over- or under-feed the infant and therefore create extra worries. However, many of these issues can be dealt with at the pharmacy counter and there is also the opportunity to suggest that the parent organises a consultation with a GP if necessary. In this article, we look at common issues that arise in infant health and how to address them in the pharmacy. It was reported recently that more than

50 per cent of infants did not receive a vital developmental health check before they reached one year old due to disruption caused by Covid-19, and the HSE could not say when these important checks would resume. Therefore, you may be experiencing more presentations in the pharmacy than usual that are related to infant health. If any of the symptoms of an infant’s illness do not resolve, even after treatment with a product from the pharmacy, the pharmacist on duty should be consulted to evaluate whether a referral to a

doctor or public health nurse is necessary. The list below is not comprehensive, but outlines some of the more common conditions in infants that may present at the pharmacy counter.

COUGHING

It is quite common for infants and young children to develop a common cold, as their immune systems are still developing. However the cough may progress to whooping cough, making the ‘whoop’ sound as sharp intakes of breath are taken in between coughs. This intense cough may develop a week or so after the baby has been infected with the cold virus and is more common at night, with the baby’s face becoming quite red and possibly bleeding in the eye area or under the skin. The symptoms are usually less severe as the child gets older.

Croup is another type of infant cough that has a dry, rasping sound and it is also worse at night. Infant cough can also be caused by hay fever (with the usual symptoms of hay fever, such as itchy eyes and throat, sneezing and runny nose, loss of sense of smell and possibly earache), or the infant may be coughing a lot because they have undiagnosed asthma.

The child may also be coughing due to bronchiolitis, which affects approximately 30 per cent of all children in their first year and is caused by the respiratory syncytial virus. It is similar to a cough accompanied by a cold but also includes difficulty feeding, persistent cough and a fever. If these symptoms are persistent and get worse, the parent should be advised to see their public health nurse or GP.

REFLUX

This is persistent regurgitation of the stomach’s contents. According to the HSE, there may be no symptoms, or the symptoms may manifest as:

 Spitting-up milk during or after feeds.

 Refusing feeds, gagging or choking.

 Persistent hiccups or coughing.

 Excessive crying or crying while feeding.

 Frequent ear infections. There is no need for a parent to be

concerned if the baby is feeding normally, gaining weight and is happy. However, parents should contact their public health nurse, GP or midwife if it starts after six months of age, continues beyond one year old, or if the infant displays any of the following:

 Spitting-up feeds frequently or refusing feeds.

 Coughing or gagging while feeding.

 Frequent projectile vomiting.

 Excessive crying or irritability.

 Green or yellow vomit, or vomiting blood.

 Blood in their faeces or persistent diarrhoea.

 A swollen or tender tummy.

 A high temperature (fever) of 38C (degrees Celsius) or above.

 Not gaining much weight, or losing weight.

 Arching their back during or after a feed, or drawing their legs up to their tummy after feeding.

 Winding regularly during a feed.

 Holding the baby upright for a while after feeding.

COLIC

Colic is also common and affects one-in-five babies. It is characterised by excessive and frequent crying in babies who seem otherwise healthy and usually starts when a baby is two weeks old, and resolves by four months old. However, sometimes it can last a month or two longer. The exact cause is unknown but colic is assumed if the infant cries for more than three hours a day, for more than three days a week, and for more than three weeks. It can also be accompanied by a red face, restlessness, drawing the legs up, arching the back or clenching fists, and the infant apparently seeming to settle before starting another bout of crying. The advice for colic is mainly non-pharmaceutical and includes a warm bath, gentle rocking, music, a walk in a buggy or pram, etc. See www.hse.ie for a full list of recommendations for colic.

DIARRHOEA

This is most commonly caused by an infection but can also be caused by contaminated water or food poisoning. If the diarrhoea is chronic, it may be caused by food allergies or intolerance, disorders of the small intestine such as coeliac disease or short bowel syndrome, or inflammation of the bowel (colitis).

To ease the symptoms, the HSE recommends:

 Continuing the baby’s normal milk feeds.

 Giving them plenty of small sips of water.

Breastfeeding is widely acknowledged to be better for baby’s development, but may not be possible for a number of reasons, including gaps in knowledge or education; social embarrassment; lactation problems; if the mother is returning to work; breast engorgement; mastitis; or blocked breast duct, among other barriers, such as sore or cracked nipples.

If reflux is present with breastfeeding, the HSE recommends:

 Offering smaller but more frequent feeds instead of a large volume in one go.

 Feeding in a more upright position.

 Continuing to offer them small amounts of food — do not worry if they do not want to eat for a day or two.

NAPPY RASH

This is a very common cause of skin irritation that appears as a bright-red patch on the baby’s bottom. In some cases, the baby’s skin can become chapped, swollen or irritated. In some instances, it may appear as a few isolated spots, while in others, it can spread to the inner thighs, and skin folds are particularly susceptible. The irritation is caused by ammonia in the urine.

Croup is another type of infant cough that has a dry, rasping sound and it is also worse at night

To help prevent nappy rash, it is advised to not leave a wet or dirty nappy on for too long and avoid tight-fitting nappies that rub harshly against the skin (this can also cause a yeast infection if the nappy lets no fresh air in). When the nappy is changed, the area should be washed carefully with damp cotton wool and pat or air-dry the skin afterwards (don’t rub dry). It is also advisable to leave the baby’s nappy off for a time while they are on their back in between nappy changes to allow their bottoms to ‘breathe’.

PRODUCTS

The Irish Universities Alliance National Pre-school Nutritional Survey found that more than 90 per cent of one-to-three year-olds do not get sufficient vitamin D. The Food Safety Authority of Ireland has said that fortified foods and drinks can help parents to achieve the recommended intake of vitamin D, omega 3 and iron for toddlers. Aptamil Toddler Milk provides toddlers with 93 per cent of the recommended dietary allowance (RDA) of vitamin D and 45 per cent of the RDA for iron by giving baby two 300ml beakers each day. Calcium and vitamin D are needed for normal growth and bone development, while vitamin D supports the normal function of the immune system.

For nappy rash, Caldesene Medicated Powder protects infants from nappy rash and is specially formulated to create a barrier against wetness on baby’s skin. This medicated powder attacks harmful bacteria and helps to prevent rashes and can be used at every change before putting on a fresh nappy, when the baby’s bottom is clean and dry. As stated above, the infant’s bottom should be exposed to fresh air if possible at each nappy change.

If an infant has a dry, tickly cough, CALCOUGH Infant Syrup is a soothing, non-drowsy, colour- and sugar-free syrup that has been developed to relieve these symptoms in an infant. For infants aged three-to-12 months, the dosage is one 5ml spoonful three-to-four times a day. This Calpol range also includes CALPOL Infant Suspension, CALGEL Teething Gel, CALPOL Vapour Plug and Nightlight, as

well as other products for older children.

As stated above, a cough in an infant may be due to them contracting a cold virus as their immune systems develop. For overall treatment of infant cold, Nurofen for Children Sachets 100/5ml Oral

Suspension 16s provides up to eight hours of fever relief and gets to work within 15 minutes. The 5ml suspension provides fast, effective and long-lasting relief from teething pain, toothache, earache, sore throats, headache, cold and flu symptoms and minor aches/sprains, and reduces a fever. Not suitable for babies under three months or babies weighing less than 5kg.

Another trusted brand is the EASOFEN Ibuprofen range, which includes EASOFEN Ibuprofen For Baby (3+ Months Strawberry. This is a painkiller and non-steroidal anti-inflammatory, for babies, toddlers and children aged from three months to 12 years. The range also includes EASOFEN For Children Six-Plus Strawberry, which is an oral suspension for the short-term symptomatic treatment of mild-to-moderate pain and for the shortterm symptomatic treatment of fever in children aged six-to-12 years.

For babies suffering with colic, a trusted brand is Colief Infant Drops 15ml, which is clinically proven to reduce colicky symptoms associated with temporary lactase intolerance. The natural enzyme lactase in this product breaks down the lactose in milk by up to 70 per cent, making it more easily digestible. Rather than attempting to treat the symptoms of colic, Colief allows babies with to enjoy their normal feed, whilst greatly reducing the digestive discomfort associated with colic.

Also for colic, Colic Calm Infant

Probiotic 12ml helps to rebalance an infant’s delicate digestive system and improve vitamin adsorption, digestion and development of a healthy immune system. Contains five key strains that are specific to helping with colic and intestinal issues.

To treat reflux, Gaviscon Infant Sachets 30 Pack help to prevent gastric regurgitation in infants, gastrooesophageal reflux and reflux associated with hiatus hernia (backflow of acid or stomach contents into the oesophagus or throat) in infants and young children. It thickens the stomach contents to help prevent regurgitation and is suitable for both breast- and bottle-fed infants.

The infant’s bottom should be exposed to fresh air if possible at each nappy change

FAT GUE N FOCUS

THE CAUSES OF FATIGUE ARE VARIED AND COMPLEX BUT THERE ARE OPTIONS FOR PEOPLE WHO VISIT THE PHARMACY SUFFERING FROM EXTREME TIREDNESS

People can suffer from tiredness for a variety of reasons, including lack of correct nutrition, or not getting enough good-quality sleep, among others (see Table 1).

Fatigue can basically be broken down into three overall types:

Transient, cumulative, and circadian:

 Transient fatigue: This is defined as acute fatigue that is brought on by extreme sleep restriction or extended waking hours within one-to-two days.

 Cumulative fatigue: This is triggered by repeated mild sleep restriction or extended hours awake across a number of days.

 Circadian fatigue: This is defined as reduced sleep performance during night-time hours, particularly during an individual’s ‘window of circadian low’, which is typically between 2am and 6am.

It has also been shown that ‘sleep debt’ can be an influencing factor. Sleep debt occurs when there is an hour’s less of sleep for a number of consecutive days, and

a number of days with more sleep than usual are required for a person to recover.

Fatigue affects different people in different ways, including reduced ability to concentrate and lower level of

FATIGUE CAN BE CAUSED BY:

 Physical exertion.

 Lack of physical activity.

 Lack of sleep.

 Being overweight or obese.

 Periods of emotional stress.

 Boredom.

 Grief.

 Taking certain medications, for example antidepressants or sedatives.

Table 1: Common causes of fatigue

attentiveness; impaired memory; impact on mood; and slower reaction time.

One of the most serious consequences arises in drivers or machine operators who have sleep debt. The Road Safety Authority (RSA) states: “It is estimated that driver fatigue is a contributory factor in as many as one-in-five driver deaths in Ireland every year.

"Furthermore, tiredness-related collisions are three times more likely to be fatal or result in a serious injury because of the high impact speed and lack of avoiding action.

“A survey of drivers’ attitudes to driver fatigue conducted by the RSA in 2014 revealed that over one-in-10 motorists have fallen asleep at the wheel. The survey also found that motorists who drive as part of their work, and motorists who admit to driving after taking any amount of alcohol, had a higher than average incidence of falling asleep at the wheel (almost one-infive fell asleep at the wheel).”

In the pharmacy too, fatigue can have serious consequences and it is employers’

responsibility to ensure that working time regulations are adhered to, as well as refusing employees’ requests for extra working hours if they suspect excessive fatigue. This is particularly relevant when it comes to shift work.

CHRONIC FATIGUE SYNDROME

This is when people experience symptoms that can be caused by:

 Mental health problems. Fatigue is also a symptom of a variety of mental health issues that can cause fatigue, including anxiety and depression.

 Sleep disorders. These can also cause chronic fatigue and include obstructive sleep apnoea, insomnia, and restless legs syndrome.

 Medical problems. A number of medical conditions are known to cause serious fatigue. These include an underactive thyroid (hypothyroidism), anaemia, and diabetes. Blood tests can reveal many of these potential causes.

The above list is not exhaustive and chronic fatigue syndrome can also be brought on by conditions such as irritable bowel syndrome and fibromyalgia, for example. Chronic fatigue syndrome can often be brought on by physical, emotional or mental exertion, and can be accompanied by dizziness that worsens with moving from lying down or sitting to standing and problems with memory, focus and concentration.

While there is no specific cure for chronic fatigue syndrome, for a diagnosis, the symptoms must last for at least six months and occur at least half the time at moderate, substantial or severe intensity. The management of the condition is done by controlling the symptoms either with medications (including over-the-counter medications), a reasonable (not excessive) level of exercise, and counselling to help build coping skills.

Chronic fatigue syndrome is a complex condition for a doctor to diagnose, as many of the symptoms overlap with other conditions. According to the Mayo Clinic in the US, as well as the symptoms outlined above, it can manifest via:

 Fatigue.

 Problems with memory or concentration.

 Sore throat.

 Headaches.

 Enlarged lymph nodes in the neck or armpits.

 Unexplained muscle or joint pain.

 Dizziness that worsens with moving from lying down or sitting to standing.

 Unrefreshing sleep.

 Extreme exhaustion after physical or mental exercise.

Clearly, many of these

symptoms can be easily confused with other medical conditions and a person may undergo months or even years of tests to rule out other conditions before chronic fatigue syndrome is finally diagnosed.

In addition, according to the Mayo Clinic, people can be born with a predisposition to chronic fatigue syndrome and it can be triggered by events such as: Viral infections; hormonal imbalances; physical or emotional trauma; or problems with the immune system. Women suffer with the condition more

Chronic fatigue syndrome is a complex condition for a doctor to diagnose, as many of the symptoms overlap with other conditions

often than men and it most commonly affects young and middle-aged people.

In view of all of the above, it is not surprising that fatigue is a problem that is under-treated and under-recognised. In a 2013 study published in the European Journal of Hospital Pharmacy (EJHP) titled ‘Fatigue’, the authors concluded: “Fatigue is a debilitating and severe symptom that may affect more than 90 per cent of patients with certain diseases and undergoing certain treatments. It is now overshadowing pain and nausea/vomiting as the most feared symptom from cancer and cytotoxic drug treatment. Currently, unconventional treatment paradigms like light exercise seem to be the most successful.

“Many disorders and symptoms have a wealth of treatment alternatives. For others, there is a lack of treatment or poor treatment options and many patients have the challenge of dealing with the symptoms. We cannot only elaborate when we have good options; we need to close the gaps and to work across borders to reach those that do not have any treatment. We have to think right, and if possible share our experiences in EJHP.”

TREATMENTS

You are ideally placed at the pharmacy counter to advise customers on steps they can take to alleviate their fatigue, as well as suggest supplements that may help them to ease the symptoms. The list below is not comprehensive, but is meant to provide examples of the types of over-the-counter products that may help, including their active ingredients.

Pharmaton Caps 30 reduce tiredness and fatigue, promote energy release and support the immune system. Pharmaton Capsules contain a balanced combination of G115 concentrated Ginseng extract, vitamins and minerals and are suitable for the relief of short periods of exhaustion (for example, caused by stress), tiredness and a feeling of weakness or lack of vitality, says

suitable for everyday use. Best taken in the morning time.

Metatone Original Flavour Tonic 300ml is designed to restore health and vitality and is effective as a tonic after illness such as colds or flu, or when people are feeling run down and tired, according to the manufacturer. Metatone contains a mixture of vitamins and minerals to help full recovery and is suitable for use from the age of six years.

Vitabiotics Feroglobin B12 30 Capsules help to reduce tiredness and fatigue and support haemoglobin and red blood cells, as well as formulating delivery of iron to the body that supports haemoglobin, while remaining gentle on the stomach. As well as being vital for the body’s blood, iron contributes to the normal function of the immune system and normal cognitive function.

the manufacturer. Suitable for both men and women, but not for children. Can also help prevent and treat symptoms caused by illbalanced or deficient nutritional intake.

Another trusted product is Zenflore

Precision Biotics, a microbacterial and vitamin supplement which contains the unique 1714-Serenitas culture. Zenflore combines the unique Bifidobacterium longum 1714 culture with specially selected B vitamins, which can reduce fatigue and assist the body in managing stress.

Berocca Mango Energy Vitamin 45 Tablets contain 7 B vitamins to help release energy, including B6 & B12, and magnesium to hep reduce tiredness and fatigue. Can be dissolved in a glass of water and is sugar- and caffeine-free and

Revive Active Zest Active-30 Sachets are specially formulated for adults to deliver multiple benefits in one easy sachet and comes as a refreshing orange-flavour supplement with natural sweetener steviol glycosides. Revive Active Zest Active-30 Sachets promote natural energy, brain function, cognitive function, recovery from exercise and immune support for the young adult, say the manufacturers. Contains 25 active ingredients in powder form. Revive Active Mastermind 30 Pack is a food supplement that helps support cognitive function. An orange-flavour supplement, it contains vitamin B12, B5, zinc and DHA. These vitamins and minerals all work together to help support the nervous system, mental performance, normal brain function and normal cognitive function and it is recommended to take one sachet per day.

BetterYou Daily Vitamin B12

Oral Spray is an effective aid to normal psychological functions, expertly blended to help boost energy levels. Vitamin B12 helps contribute to the reduction of tiredness and fatigue, normal energy metabolism and normal psychological function.

According to the manufacturers, four sprays deliver 1,200μg of vitamin B12 to support psychological functions and energy release and this product is stimulant-free, contains natural B12, green tea and chromium, and is a convenient alternative to tablets and capsules, according to the manufacturers.

Many disorders and symptoms have a wealth of treatment alternatives

THE BONES OF A HEALTHY LIFE

RESEARCH HAS SHOWN THAT ENSURING OUR BONES ARE HEALTHY IS IMPORTANT NOT ONLY IN PREVENTING OSTEOPOROSIS, BUT ALSO AT ALL STAGES OF LIFE

The Irish Osteoporosis Society estimates that 300,000 people in Ireland suffer with osteoporosis, however only approximately 19 per cent of people with the condition are diagnosed. While osteoporosis is normally associated with older people, it can affect men and women of all ages and in some cases, even children.

The Society states that there are approximately 200 causes of bone loss, including:

 Menopause.

 Family history, especially of a broken hip.

 Radiation, chemotherapy, and some treatments for breast and prostate cancer.

 Coeliac disease/gluten and wheat sensitivity.

 Anorexia or bulimia.

 Over-exercising.

 Medications such as protein pump inhibitors, as well as others that contain cortisone, some antidepressants and some water pills.

 Low calcium and/or vitamin

D intake or poor absorption.

 Physiological or psychological stress.

 Smoking and excess alcohol.

It is vital that the exact cause of bone density loss is established in order to treat it properly and this is best done using a DXA

scan of the spine and hips — this is the only test recommended by the Society for screening and diagnosing osteoporosis. Osteoporosis is a condition normally associated with women, however men are also at risk, which places them at a disadvantage when it comes to diagnosis and when it comes to supplementation, the Society recommends a sufficient intake of vitamin D and calcium. Osteoporosis in its early stages is known as osteopaenia and this stage of the disease is where most fractures occur, especially

in the moderate-to-marked range. The Society encourages early detection of the condition and the potential early signs of osteoporosis are outlined in Figure 1

The Society states: “We do not ever recommend ultrasound of the heel, shin or forearm, for screening or diagnosing osteoporosis or osteopaenia. Healthy eating, exercise and supplements should not be encouraged on their own to treat bone loss, they should be combined (supplements only, when a person cannot get their nutrients from food) with a scientifically proven osteoporosis medication, which has extensive research to decrease your risk of fractures.”1 Minerals are absorbed into bones during childhood, adolescence and early adulthood, however once a person reaches 30 years of age, they have reached peak bone mass. If insufficient bone mass has been achieved during this time, a person is at risk of bone loss later in life, which may result in fragile bones that break easily. However, customers at the pharmacy counter can be advised that there are lifestyle

choices that can help to build and maintain healthy bones. These include:

Sufficient intake of vegetables. Fresh vegetables are an important source of vitamin C, which helps to form bones and have antioxidant properties to help protect bone cells from damage and build bone density. Vegetable intake has been shown in studies to benefit older women and one study showed that women who consumed more than nine servings of broccoli, cabbage, parsley or other plants high in bone-protective antioxidants had a decrease in bone turnover (the process of breaking down and forming new bone).2

Strength Training and WeightBearing Exercises. This helps promote the formation of new bone in those who are able to perform these exercises and increases the amount of bone created during the years of peak bone growth. However, benefits have also been shown in older men and women.3

Other self-care interventions include getting enough vitamin D and vitamin K; eating high-calcium foods; consuming enough protein; avoiding very low-calorie diets; collagen supplementation; maintaining a healthy weight; sufficient magnesium and zinc intakes; and consuming foods high in omega-3 fats.4

Another study indicated that sufficient folate levels may also be a protective factor. The authors stated: “There is little evidence that folate has any direct involvement with bone biology; however, it may indirectly influence bone quality and fracture risk through its role in homocysteine metabolism. Data from the Framingham Original cohort, were among the first to identify elevated plasma homocysteine concentration as a strong risk factor for hip fracture.”5

OTHER BONE CONDITIONS

Other lesser-known bone disorders can also cause can affect people, one of which is osteomalacia. In osteomalacia, there is a significant softening of the bones, which leads to ‘bowing’ during growth in young adults and children and can particularly affect weight-bearing bones in the legs and in adults,

can lead to fracture risk. This condition is often caused by vitamin D deficiency, as well as suboptimal levels of calcium. Therefore, supplementation is required to strengthen bones in conjunction with treatment for the condition causing the osteomalacia.

Rickets is a condition that causes softening and weakening of children’s

bones and can be caused by rare inherited conditions and extreme and prolonged vitamin D deficiency. While these problems can be addressed by adding vitamin D and calcium to the diet, if the rickets is due to an underlying condition, a medical professional will need to add prescription medications or other treatments or even corrective surgery if deformities have occurred.

Paget’s disease of bone disrupts the process of bone turnover, resulting in excessive breakdown of bone and when the bones regrow too quickly, they grow back larger and softer than normal. This condition normally affects one or just a few bones and is more common in older people and people of European origin. It is easily confused with arthritis as the symptoms are similar, but Paget’s disease of bone often has no symptoms at all. Medicines and surgery are the most common treatments.

A condition that has genetic causes is osteogenesis imperfecta (OI). In this condition, bones fracture easily and seemingly for no apparent reason. It can also cause a curved spine, hearing loss, brittle teeth, and muscle weakness. The symptoms vary from person-

Another study indicated that sufficient folate levels may also be a protective factor

to-person and the condition itself can range from mild to severe. Some of the people most badly affected by OI can suffer hundreds of fractures during their lifetime. There is no cure, but treatments include exercise, pain medicine, physical therapy, wheelchairs, braces, and sometimes surgery.

Another more unusual condition is osteonecrosis, also known as vascular necrosis. This occurs when bones in the shoulders, arms, knees or sometimes thighs are not receiving a sufficient supply of blood, resulting in destruction and collapse of bone tissue. The cause varies but can include HIV infection, cancer, lupus or perhaps certain medications. The correct medicines or surgery are among the treatment options.

While it is not often highlighted as a common complication, bone issues can occur in people with type 1 diabetes. This form of diabetes usually begins in childhood, when the bones are still growing. As type 1 diabetes affects insulin production, bones may not grow so well and may not reach peak density, as outlined above.

There is a wide range of lesser-known bone conditions and the list above is not exhaustive.

OVER-THE-COUNTER SUPPLEMENTS

Pharmacies and their trained staff are the most accessible source of healthcare guidance in the community and customers at the counter who have concerns about their bone health can be given guidance on the above self-care measures. However, for a variety of reasons, some customers may not be able to achieve sufficient intake of certain nutrients important for bone health and therefore can be recommended to take certain supplements, a few of which are listed below.

The Mylan Vitamin D3 range is made in Ireland and contributes to maintaining normal bones, normal function of the immune system, and maintenance of normal muscle function. One tablet per day. 60 Tablets — two-month supply.

Pharma Nord's BioActive D Pearls are soft gelatin capsules with a choice of 38ug,

SIGNS AND SYMPTOMS OF POSSIBLE UNDIAGNOSED OSTEOPOROSIS

1. A broken bone from a trip fall, or less: Even if you fall on cement or ice.

2. Loss of height or change in your body shape or size: Rounded shoulders and/or pot belly developing.

3. Your head protruding forward from your body: You cannot stand in the 'military position'.

4. A hump developing on your upper back: It is urgent you get a DXA scan with an LVA done ASAP.

5. Back pain: 75% with broken bones in their back have intermittent back pain, only 25% have constant pain.

6. Unexpected broken bones: Anyone with undiagnosed osteoporosis can cough, sneeze, stand up from a chair, or roll over in bed and break bones.

at the pharmacy counter to treat and prevent vitamin D/calcium deficiency. Adults and elderly can chew or suck two tablets a day, preferably one tablet in the morning and one in the evening. Not recommended for use in children.

Lil Critters Calcium Gummy Bears is suitable for children contain no artificial colours or flavours and come in three natural flavours – orange, strawberry and black cherry. Contains no gluten, eggs, milk, peanuts, soya, celery, mustard, sesame seeds or shellfish.

Pharma Nord Joint Care 60 is a preparation consisting of light blue tablets each containing 500mg of glucosamine sulphate corresponding to 400 mg pure glucosamine, 400mg chondroitin sulphate and 20 mg of vitamin C. One capsule can be taken twice daily, or all three capsules can be taken at one time to help promote joint health.

Vitabiotics osteocare original 30 tablets contain magnesium, zinc & vitamin D3 and helps maintain strong bones and teeth. Contains no drugs or hormones, and is free from artificial colourants.

For vegetarians, Vitamin D3 1000iu vegetarian 30 tablets are suitable for adults and children over three years old and supports the immune system, maintain healthy bones and teeth, and are suitable for daily use. Food supplements should not replace a varied, balanced diet and a healthy lifestyle.

REFERENCES

1. Irish Osteoporosis Society, https://www.irishosteoporosis.ie/ wp-content/uploads/Factsheets-About-Osteoporosis.pdf, accessed April 2021.

2. Increased bone turnover in late postmenopausal women is a major determinant of osteoporosis.

P Garnero, E Sornay-Rendu, M C Chapuy, P D Delmas. J Bone Miner Res, 1996 Mar;11(3):337-49. doi: 10.1002/jbmr.5650110307.

75 ug and soon to be launched 20ug of active Vitamin D3 n the range. The vitamin D is dissolved in cold-pressed olive oil, as vitamin-D is a fat-soluble vitamin.

Calcichew D3 Forte are lemon flavoured chewable tablets containing both calcium and vitamin D3 and can be recommended

3. Short-term bone formation is greatest within high strain regions of the human distal radius: a prospective pilot study. Varun A Bhatia et al, J Biomech Eng 2015 Jan;137(1):0110011-0110015. doi: 10.1115/1.4028847.

4. https://www.healthline.com/nutrition/build-healthy-bones#TOC_ TITLE_HDR_11, accessed May 2021.

5. Dietary approaches for bone health: lessons from the Framingham Osteoporosis Study. Shivani S et al, Curr Osteoporos Rep. 2015 Aug; 13(4): 245–255. doi: 10.1007/s11914-015-0272-1.

Figure 1: Signs of undiagnosed osteoporosis. Source: Irish Osteoporosis Society

Are you looking for a vitamin D supplement that is bioavailable and effective?

Get the proven benefits of sun exposure Without worrying about your skin

As you know, it is important to protect your skin when the sun is most powerful. Still, sun exposure is necessary in order for our skin to synthesize vitamin D, which contributes to a normal immune defense.

If we avoid the sun or somehow prevent the UV rays from reaching our skin, it will reduce our ability to make vitamin D. It is difficult to get your full requirement of Vitamin D from diet alone. Therefore, to maintain a reasonable amount of vitamin D in your system it may be a good idea to consider taking a supplement like BioActive D-Pearls.

BioActive D-Pearls are small, soft gelatin capsules with 38, or 75 micrograms of vitamin D in each. This makes it easy for you to choose the right dose for the time of year and for your personal level of sun exposure.

• the vitamin D in BioActive D-Pearls is dissolved in cold-pressed olive oil for better absorption

• small capsules that are easy to swallow – or chew

WOUND CARE

From simple cuts and scrapes to the most serious types of chronic wounds, wounds are an everyday, but important, part of life.

As any parent will testify to, children will invariably scrape their knees and elbows and seek comfort. Fortunately, there is a range of over the counter products to help.

Sudocrem is an iconic product, trusted by generations of people to provide gentle yet effective relief. Sudocrem Antiseptic Healing Cream can be used to treat a number of skin conditions including cuts, grazes, minor burns, eczema, nappy rash and even sunburn.

It is applied to the affected area using light, circular movements. The cream helps to reduce the risk of infection and contains a mild local anaesthetic to ease pain. Gentle on skin, it is also unlikely to sting when applied.

In terms of treating eczema, Sudocrem's emollient soothes and softens skin, while its zinc oxide helps to reduce the loss of fluid from the skin. Its water-repellent excipient base, which includes paraffin and other waxes, creates a protective seal around the affected area.

Another trusted product to treat minor wounds and skin reactions is Savlon Antiseptic Cream. It helps cleanse and protect minor wounds from infection and is a first aid treatment of superficial burns, scalds, and insect bites. It also helps prevent infection on shaving cuts, blisters and sores and can be used to clean and treat minor skin problems.

Bepantiseptic First Aid Cream is also available. It has an antiseptic action to help prevent infections, plus a soothing local anaesthetic effect to numb pain.

TCP Antiseptic Liquid is another very famous staple of the first aid box. Dual action TCP soothes pain, and fights infection. It can also be used for sore throats, mouth ulcers, cuts, grazes, bites, stings and spots.

CHRONIC WOUNDS

The importance of chronic wound care cannot be overstated. Ulcers, sores, and surgical wounds, to name a few, can be debilitating, painful and can have a significant impact on a person’s life. They can also lead to unnecessary admissions to hospital.

The HSE says that an estimated 1.5 per cent of the population are affected by a wound at any one point in time and they can have a major personal, social, and economic impact.

“Studies in the UK indicate that up to 4 per cent of total health care expenditure is spent on the provision of wound management, while in Ireland it is estimated that two-thirds of community nursing time is spent on the provision of wound management,” the HSE's National Guidelines for Wound Management said.

The HSE also indicated that as the population ages, the prevalence of chronic wounds is expected to grow.

“Consequently, the prevalence and incidence of wounds is likely to continue to increase due to the ageing population

and the ongoing increase in prevalence of obesity, diabetes and lower extremity arterial disease,” the HSE's Guidelines said.

Fortunately, there are also a range of wound care products to help manage and treat chronic wounds.

Fleming Medical is a family-owned provider of high-quality healthcare devices and consumables. It is also a trusted partner to pharmacy, community health and healthcare professionals and operates successfully in more than 20 countries worldwide.

There are a range of wound care products available from Fleming Medical including URGO Algoplaque. This is a sterile, highperformance dressing for use in treating pressure sores or leg ulcers.

The dressings in the Algoplaque range are made up of a semi-permeable polyurethane backing combined with an adhesive mass consisting of carboxymethylcellulose hydrocolloid particles exclusively dispersed in an adhesive elastomer matrix. Due to the dressing’s impermeability to water and bacteria, it provides superior protection to the wound. The hydrocolloid dressings absorb wound exudate and forms a colloid gel which creates the conditions favourable to the healing process.

Another Fleming Medical product is Medistrip Wound Closure Strips. They are flexible, breathable and are used for wound support post-operatively, skin tears or following early suture or clip removal. The strips stay firmly in place, allowing the skin to breathe and the wound to heal.

The strips provide secure wound closure, while allowing maximum porosity and vapour transmission to encourage rapid healing. The adhesive strips are used to secure, close and support small cuts and wounds.

The wound closure strips will protect the wound from contamination and infection whilst

AN OVERVIEW OF WOUND CARE AND HOW TO PICK THE RIGHT PRODUCT FOR THE RIGHT WOUND TO PROMOTE THE BEST HEALING POSSIBLE

allowing it to breathe and heal quickly. The strong adhesive ensures that the wound stays dry and clean while it heals.

For foam dressings, there is Medifoam Non-Adhesive Foam Dressing from Fleming Medical. A hydrocellular sterile foam dressing, it absorbs and retains exudate whilst maintaining a moist wound environment.

It is composed of a thick, soft, absorbent polyurethane foam back by a dual layer of breathable polyurethane film. It is designed for a wide range of exuding wounds such as leg ulcers, foot ulcers, pressure ulcers, skin tears.

Medifoam dressings are a range of hydrocellular sterile foam dressings. Designed for moderate to highly-exuding wounds such as pressure ulcers, leg ulcers, skin tears and abrasions, skin graft donor sites and under compression bandage systems for venous ulcer treatment. Thick, soft, absorbent polyurethane foam backed by a dual layer of breathable polyurethane film, which effectively absorbs and retains exudates whilst maintaining a moist wound environment.

Other trusted products include the Medicare Alcohol-Free Natural Sanitiser range, which safely sanitises skin and surfaces and is effective against SARS-CoV-2. It is also suitable to use from birth, kills 99.9 per cent of viruses and bacteria, and is hypoallergenic and naturally moisturising. It is available in 750ml, 500ml, 150ml and 60ml bottles and is is a waterless, alcohol-based sanitising gel that is specially formulated to promote skin health and reduce the spread of infections. It has a 70 per cent concentration of alcohol that denaturises the micro-organisms cellular protein and kills 99.9 per cent of germs, including Covid-19, MRSA, E.Coli, Salmonella, HSV, HIV, influenza virus, RSV, HBV, adeno, rota and rhinoviruses and listeria. The Medicare range is also approved as a sanitiser by the Irish Department of Agriculture, Food and the Marine.

There are also a range of transparent dressings from Fleming, including the Medisite Transparent Thin Film Dressing. It is a sterile, transparent, thin polyurethane, bacteria-proof and waterproof film, coated with hypoallergenic adhesive. Versatile, it can be used as a preventative dressing, for securing IVs and cannulae or to

secure an absorbent dressing underneath. It has a waterproof film so patients can shower with the dressing in place. It is also made of polyurethane film, which allows wounds to breathe and water vapour to escape, protecting the skin against maceration.

Furthermore, it is a bacterial barrier, helping protect the site against extrinsic contamination, reducing the risk of infection by bacteria. The transparent film also allows the healing process to be observed without removing the dressing. Another Fleming Medical product, Mediflex Bordered Silicone Dressing, is also suitable for use on a wide variety of moderate to highly-exuding wounds, ulcers, second-degree burns and traumatic wounds.

correlates with pressure ulcer severity and protracted healing,” the HSE stated.

“Nutrition in woundhealing must provide adequate support for an increased energy demand during the wound-healing process...Several vitamins and minerals are known to have an important role in wound healing. The literature supports a positive effect of supplementation of vitamin A in acute wounds and healing of fractures, burns and radiation-induced injury.”

Fresenius Kabi is a global healthcare company that specialises in clinical nutrition and life-saving medicines. Among its products are oral nutritional supplements. This includes Fresubin, a high energy, high protein oral nutritional supplement. It is a protein blend, that is low in fibre, high in vitamin D, and lactose- and gluten-free.

The dressing is air-permeable, making it a comfortable way to keep wounds clean and protected. The absorbent pad with the adhesive border on this dressing ensures that the wound is well protected from any irritants. It is particularly suitable for those with fragile skin.

Medicel Super Absorbent Pad is a super-absorbent dressing for moderate to highly-exuding wounds, ulcers, second degree burns and traumatic wounds. It has outstanding absorption and retention properties. The dressing remains dry and comfortable for the patient.

NUTRITION

Good nutrition plays a key role in the management of wounds. A body needs increased amounts of energy, protein and specific vitamins and minerals to heal well. The HSE in its wound management guidelines indicated that nutrition plays a pivotal role in the wound-healing process.

“Studies have shown that both inadequate dietary intake and poor nutritional status

There is also Calshake, an oral nutritional supplement powder which is reconstituted with milk to provide a high caloric shake. It is easy to mix, fibre- and gluten-free and comes in five different flavours.

The company Nutricia also believes in the power of nutrition to make a positive difference to health. Included in its range of products is Complan Shake. It is a food for special medical purposes for use under medical supervision. Complan Shake is a high-energy nutritional supplement based on skimmed milk powder, carbohydrate and fat, for the dietary management of disease related malnutrition. It can be used to supplement the diet of patients unable to meet their nutritional requirements from regular dietary intake. Complan Shake can be made up with whole milk or added to foods as a fortifier.

Another product, Nutricia Calogen, is suitable for patients requiring electrolyte restrictions. It can be used to replace milk in protein-restricted diets and can be used as an energy enhancer in tube feeds and oral nutritional supplements.

The importance of chronic wound care cannot be overstated

These FEET were made for walking…

WITH SUMMER UPON US, CUSTOMERS WILL BE KEEN TO GIVE THEIR FEET A LITTLE OPEN-AIR FREEDOM. WE PROVIDE AN OVERVIEW OF SOME OF THE MORE COMMON FOOT CONDITIONS THAT CAN BE TREATED OVER-THE-COUNTER

With better weather approaching, customers at the pharmacy counter will be thinking of getting their shoes off for a walk on the beach or in the park or, hopefully soon, a trip abroad for a holiday and an opportunity to dust-off their flip-flops.

However, some people may have foot conditions that are not only painful or uncomfortable, but also socially embarrassing. These customers may arrive at the counter looking for a specific product, or they may be open to advice and recommendations on the best therapies to suit their foot problem.

Foot complaints may also develop as a result of other conditions, such as diabetes, which can also cause foot

disorders such as corns, bunions, calluses, ‘hammer-toes’, fungal infections, dryness, and ingrown toenails. These problems occur more commonly in people with diabetes due to the nerve and vascular damage caused by the condition.

In a study published in the Pharmaceutical Journal , the authors noted that the worldwide ageing population means an increase in foot conditions, however they can affect people of all ages due to a variety of reasons, including participation in sports, hygiene and lifestyle.

The authors wrote: “Reviews of international foot surveys conducted in the UK and worldwide demonstrate that 20-to-78 per cent of people suffer from corns, calluses and bunions; 20-to-49

per cent have lesser toe deformities; and 28-to-56 per cent have conditions affecting their toenails.

“Further systematic reviews found that one-in-five people in middle and old age suffered from foot and/or ankle pain. The toes and forefoot are the most commonly affected sites, with pain experienced more frequently in females than males. Two-thirds of patients report that their daily life was affected because of this pain, indicating the high impact that foot conditions have on patients.”

Therefore, while a foot condition can cause embarrassment, it is important

for people to know how common foot conditions actually are. The list below is not exhaustive, but covers some of the more common foot issues that present in the pharmacy, most of which can be treated with over-the-counter remedies.

DRY/CRACKED SKIN

Dry and/or cracked skin on feet can be due to a number of causes. As the feet bear all the body’s weight, when that pressure is applied, the skin expands outwards and if the skin is too dry, it can become dry and cracked under pressure. The causes of dry/cracked skin on feet

are numerous and include athlete's foot, flat feet, heel spurs, or standing for long periods of time. Dry/cracked skin can also be caused by medical conditions such as diabetes, eczema, hypothyroidism, Sjögren's syndrome, juvenile plantar dermatosis and obesity. If dry/cracked skin on the feet is due to a fungal infection such as athlete’s foot, if it is left untreated, it can spread and infect the nails, causing discolouration and a fungal nail infection.

fragrance-free and non-allergenic.

GOUT

TREATMENT

The Flexitol foot care range includes Flexitol Heel Balm, Flexitol Moisturising Foot Cream, Flexitol Heel Magic, and Flexitol Heel Balm Platinum. The active ingredient in these products, urea, is also produced naturally in the skin and helps to increase the amount of moisture that the skin contains and reduces the amount of water that is lost from the skin's surface. It is recommended that Flexitol Heel Balm be used twice a day for 14 days, for the maximum benefit, after which the condition should be reassessed. However, depending on the condition of the skin, it may only need to be used once daily. It may be necessary to re-treat for a further 14 days, or switch to an ongoing maintenance regimen with Flexitol Moisturising Foot Cream.

Another product that can help with dry/cracked skin is CeraVe Renewing SA Foot Cream . This product moisturises and helps to restore the protective skin barrier on the feet and contains three essential ceramides and hyaluronic acid to exfoliate and moisturise dry, rough feet. It is also

Gout was in the past referred to as the ‘disease of kings’ because of its association with consuming wine and foods that are rich in protein. Now, more is understood about the condition and it is now known that it is caused by a build-up of uric acid in the blood, which then forms crystals and is deposited in the joints. This causes painful inflammation and ‘attacks’ of gout that can worsen over the following 12 hours and begin to improve over the following 10 days. Men are three-to-four times more likely to develop gout than women because their uric acid levels spike during puberty. However, during menopause, women experience a similar but less serious increase in their uric acid levels. This means the onset of symptoms usually occurs later in women than it does in men. In chronic gout, attacks occur frequently and can cause permanent joint damage and constant pain.

TREATMENT

A GP may prescribe two types of medication to treat gout — the first helps reduce the inflammation and pain associated with gout attacks, while the second prevents complications by lowering the amount of uric acid in the blood.

Canespro Fungal Nail Treatment

Set can be used to treat nails if an infection has spread to that area. Visible results are usually achieved within twoto-three weeks and it can also be used on fungal fingernails. It contains urea, which softens the parts of the nail infected by fungus, leaving the healthy parts intact. Includes medicated plasters and a scraper. Lifestyle changes, such as a modest alcohol intake, smoking cessation and weight loss can also be recommended to prevent future attacks.

BLISTERS

Blisters on the feet can occur for a variety of reasons, including walking or standing for several hours a day, which

Dry/cracked skin can also be caused by medical conditions

puts pressure on the heels, soles, and toes. Many frontline workers, for example those at the pharmacy counter, may have experience of blisters for this very reason. However, shoes that are too tight or too loose can cause friction against the skin on the feet and also result in blisters.

As the weather gets warmer this summer, there may be more presentations at the pharmacy counter with foot blisters, as they can also be caused by excessive moisture from perspiration, particularly in people who run for exercise. Blisters can also result from a bad case of sunburn. Other potential causes include an allergic reaction, exposure to cosmetics or detergents, chickenpox, bacterial infection, herpes, and certain types of eczema. If the symptoms do not improve following over-the-counter treatment, the customer should be advised to see their GP for assessment.

TREATMENT

Compeed Blister Plasters are specially designed for foot blisters. They absorb moisture and form a protective cushion to provide instant pain relief and optimum healing conditions. The Compeed range also includes treatment for blisters on specific locations, such as Compeed Anti Blister Stick, Compeed Underfoot Blister 5 Plasters, and Compeed Blister Plasters 20% Extra Cushioning Medium X 5.

WARTS AND VERRUCAS

Plantar warts are extremely common and affect the bottom of the feet. They are caused by types 1, 2, 4, 60, and 63 of the human papillomavirus (HPV), which flourishes in moist, warm places, such as swimming pools (particularly in the small puddles found around pools) and locker room floors. A wart that develops on the sole of the foot is known as a verruca or plantar wart, and these occur more frequently in children and teenagers than in adults.

The virus is more easily caught if there is a crack in the skin, and these warts can

become quite painful when pressure is applied to them. Effective treatment can take several weeks but the most important thing to get across to the customer is that the treatment must be consistent. Feet should be covered in public places to prevent spread of the virus and shoes and socks should be changed daily, and hands should be washed regularly.

A GP may freeze a wart off using liquid nitrogen (cryotherapy). However, many people find an over-the-counter treatment in the pharmacy to be a more costeffective and convenient option.

be used if the customer has diabetes or impaired peripheral blood circulation.

Carnation Footcare Vericap Verruca

Treatment is used to treat veruccas. This treatment includes smooth felt pads that help to ease pressure on the foot associated with verrucas and an active medicated centre that helps remove the verucca. Treatment is usually for a period of eight days, changing them every second day.

ATHLETE’S FOOT

TREATMENT

Duofilm is a wart treatment that contains salicylic acid and lactic acid, which softens the wart until it falls off or can be peeled off. It is important to advise the customer not to break the skin before it is applied, and before application, the top of the wart should be brushed carefully with an emery board or pumice stone. Salactol Collodion 10ml is another effective treatment that is a ‘wart paint’ for treating warts, verrucas, corns and calluses. Its quick and effective formula restores the feet back to its natural healthy state. Again, use should be consistent for best results. Should not be used on the face, neck, breasts, anal region, genitals or armpits or on moles, and should not

This is a very common fungal infection that often recurs, even after successful treatment. It can affect the soles or sides of the feet and if left untreated, can spread and cause fungal nail infections. People with sweaty feet are susceptible and similar to warts, it is easily spread by walking barefoot in changing rooms and showers, or by touching the affected skin of someone with athlete's foot. The HSE advises that rather than seeking medical treatment, people should seek help in their pharmacy, and treatments can be used continually to stop it coming back. It is also advisable to keep the feet clean and dry. To prevent infection and prevent it recurring, customers should be advised to change socks every day (cotton socks are best) and dry the feet after washing, especially between the toes (dab-dry rather than rubbing them). A separate towel should be used for the feet after showers, etc. People should be advised not to scratch an athlete’s foot infection, as this can spread it.

TREATMENT

Desenex Athlete’s Foot Ointment 30G soothes the itching and burning feelings associated with athlete’s foot. It should be used twice-daily and continued for two weeks after the symptoms have disappeared.

Daktarin Cream 30g is another effective treatment that can be used to treat athlete’s foot, as well as to treat fungal infections in places such as the hands, feet, outer ear, trunk and groin, and can even be used for nappy rash. It should be used along with Daktarin powder to help soothe cracked and red skin.

References on request

The virus is more easily caught if there is a crack in the skin, and these warts can become quite painful when pressure is applied to them

ELECTRIC LOVE – E-BIKES

DR ALAN MORAN LOOKS AT THE INCREASINGLY POPULAR WORLD OF E-BIKES

About four years ago, I wrote an article on e-bikes that made me a big fish in a small pond. Normally I write about cars, and have been doing so for over 20 years. But I decided I’d write about the latest upcoming trend, mainly because my wife had bought one and to say she loved it was an understatement. By the way, I have one car, two motorbikes, and four bikes, plus one tandem. So we are a cycling family in a way. At the time, e-bikes were sensible,

which means heavy. Bike batteries remain heavy, which any electric car manufacturer will tell you as they spend sleepless nights worrying about the weight of their cars.

With heavy batteries, the bike needs a heavier frame, heavier tyres and heavier brakes. But over the last few years they’ve been using different aluminium alloys and the bikes have become lighter. So much so, it is possible to have one that would be hard to tell from a conventional bike.

HOW THEY WORK

Anyway, e-bikes essentially are bicycles that come with motors in three different places: The front hub, the rear hub, and the centre. The centre works out best for weight distribution as it is best to have the centre of gravity in the, em, centre. Batteries can be in the back on a carrier, or attached to, (or within, better again) one of the down tubes. Again, the down tubes are best but it means batteries are not as easily interchangeable. Disc brakes, preferably hydraulic, are best. Gears

can be derailleur, like a racing bike, or hub. Rohloff are the best (and cost about an extra €1,000), but Shimano make a very good second best, for a significantly reduced cost. With hub gears, it is possible to get an e-bike with a belt drive, a bit like the fan belt of a car. These can last up to 25,000km before they need replacing, unlike chains. And they don’t need chain oil, hence they don’t get messy and greasy, leaving stains on your clothes.

Range is dependent on the size of the battery and how you use it. It is possible to have a battery that will last 80km, but using it on hilly terrain (they don’t recharge going downhill) with max assistance will see it run flat in 30-40km, and then you’ll have a heavy bike to pedal home.

BICYCLE OR MPV?

Which brings me to an important point. Generally, what is available in Ireland is ‘pedal assist’. When you’re pedalling, it assists. Stop pedalling and the help disappears. E-bikes are also available that assist by twisting a throttle, rather like a motorbike. Some members of An Garda Síochána will argue that a pedal assist bike is a mechanically propelled vehicle (MPV) and hence needs a licence and insurance. Whenever I looked for insurance for a motorbike, I was always asked for the registration. So until the day I can register the bike, and get a registration plate, I would suggest to the gardaí that if they could tell me where I could register the bike, then I’d be happy to comply.

In February, the Government confirmed that, under current Irish law, e-bikes are not classed as MPVs or as pedal bicycles, but announced its approval to draft legislation on e-scooters and e-bikes in the forthcoming Road Traffic (Miscellaneous Provisions) Bill. This, the Government says, will allow for the introduction of appropriate regulations for these types of vehicles. E-bikes will be legislated for using EU standards as a reference point and will be treated mainly in the same way as pedal cycles, while the more powerful models of e-bikes will be treated as light mopeds.

WHAT’S ON THE MARKET

With all that in mind, let’s have a look at some of the e-bike brands currently on the market. To my mind, one of the best-looking bikes is the Van Moof. It has a 250 watt (powerful enough) front motor, with four power levels, and a range of 60120km. It can get to a 50 per cent charge in 80 minutes with its integrated battery, with full charge in four hours, and looks brilliant. Only problem is, you’ll probably have to go to the Netherlands, Germany or the US to buy one.

If you thought these were expensive, there’s the Trek Madone SLR eTap. Not just electric pedal assist, it has electric gear changes. Priced at around €12,000, these could easily be mistaken for a proper road racing bike. Don’t worry, Trek has bikes from €2,000 upwards too. The best description of their range of e-bikes is ‘vast’.

Raleigh has made great bikes over the years. Their current e-bikes tick a lot of the boxes as above, with a central motor and comfortable ride. We, as in ‘the Royal We’, rented one during our summer holidays (staycation) in Ireland last year (when the lockdown eased) and I have to say, I was not impressed by the motor. Maybe there was some tidying-up to do with the pedal sensors. As with all e-bikes, try before you buy.

WHERE TO BUY

Available in Ireland, Cannondale (called the Cannondale Quick Neo) would be known for their quality frames in the racing fraternity, but not for their value for money. The battery is hidden in the down tube, and hence is small. Range is described as up to 75km.

Also at the upper end of the price spectrum is the Gocycle GXi. Designed by an ex car designer, it features many ‘why didn’t we think of those before’ features. It can vary the amount of assistance given, so you can configure it that unless you’re hitting 200 watts, it sits and watches you do the work. Once you’ve reached your limit, it gently kicks-in. For those living in apartments who don’t want to leave an expensive e-bike in the bike park or shed, it folds up neatly. (By the way, for a seriously good folding bike, not an e-bike, look no further than the Brompton... Another day’s work.)

Now, I cannot leave this article without mentioning two sources from which to buy your bikes. One is recently established in Dublin; Decathlon. They seem to have bikes when no-one else does, and they have a range of e-bikes now for sale. The range of their lowest cost model is 2035kms, with the higher cost model having a range of 50-90kms.

The other source is Easy Motion, a Dublin-based e-bike specialist. I am a great believer in supporting locally-based businesses, especially what is known in the sport as the LBS, or the local bike shop, who always appear to have a friendly face with a greasy rag and a spanner to help out in emergencies.

SO IN CONCLUSION...

E-bikes are a great addition to a family’s transport needs. We need more cyclists on the road to increase our cardiovascular health, reduce pollution, and, dare I say it, take my beloved cars from our cities. Our lungs need it, our cities need it, as does our planet. And the more people we have cycling, the more people we have who understand the needs of cyclists, who will convince selfish motorists that we need to share our roads as well as our atmosphere.

... e-bikes essentially are bicycles that come with motors in three different places: The front hub, the rear hub, and the centre

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1. Quartarone & Hasler-Nguyen 2014; GSK data on file 2. Seefried et al. Ther Adv Musculoskel Dis (2020) Vol. 12: 1-13. 3. GSK data on file, IQVIA value sales data MAT w/c 28/02/2021

Product Information: Please consult the Summary of Product Characteristics for full product information. Voltarol Emulgel Extra Strength 2% w/w Gel (diclofenac). Indications: For the local symptomatic relief of pain and inflammation in trauma of tendons, ligaments, muscles and joints, localised forms of soft tissue rheumatism. Dosage: Adults and adolescents 14 years and over: 2g to 4g of gel, applied topically 2 times daily – morning and evening. Maximum recommended treatment duration is 14 days. Patients should consult their doctor if the condition does not improve within 7 days or worsens. Contraindications: Patients with or without chronic asthma in whom asthma, angioedema, urticaria or acute rhinitis are precipitated by aspirin or other nonsteroidal anti-inflammatory agents. Hypersensitivity to diclofenac, acetylsalicylic acid or other non-steroidal anti-inflammatory drugs. Hypersensitivity to any other ingredient of the gel. Use in third trimester of pregnancy. Use in children and adolescents aged less than 14 years. Warnings and precautions: Apply only to intact, non-diseased skin and not to skin wounds or open injuries. It should not be used with occlusion. It should not be allowed to come into contact with the eyes or mucous membranes and should never be taken by mouth. Application over extensive areas for prolonged periods or application in excess of recommended dosage may give rise to systemic effects. These include gastrointestinal disturbances and bleeding, irritability, fluid retention, rash, hepatitis, renal dysfunction, anaphylaxis and rarely blood dyscrasias, bronchospasm and erythema multiforme. Discontinue if rash develops. Use with caution in patients with a history of peptic ulcers, gastrointestinal bleeding, hepatic or renal insufficiency, or bleeding diathesis, or intestinal inflammation. Pregnancy and lactation: The systemic concentration of diclofenac is lower after topical administration, compared to oral formulations. During the first and second trimester of pregnancy, diclofenac should not be given unless clearly necessary. Only use during lactation on the advice of a health professional. Contraindicated during the third trimester of pregnancy. Should not be applied on the breasts of nursing mothers, nor elsewhere on large areas of skin or for a prolonged period of time. Side effects: Very rare: rash pustular, hypersensitivity (including urticaria), angioedema, asthma, photosensitivity reaction. Rare: Dermatitis bullous.

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