PAI Diary 2021

PAI

PHARMACY ASSIST IRELAND 2021

E D U C AT I O N T R A I N I N G D I R E C T O RY

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3. European 3. European Directorate Directorate forfor thethe Quality Quality of Medicines of Medicines (EDQM), (EDQM), Strasbourg.

Strasbourg.

[URL: [URL: http://www.edqm.eu]. http://www.edqm.eu].

4. CEGEDIM, 4. CEGEDIM, ePharma ePharma Market, Market, INTELLIX, INTELLIX, IQVIA, IQVIA, MEDICUBE, MEDICUBE, PHARMAZOOM, PHARMAZOOM, PHARMSTANDART PHARMSTANDART 2019.

2019.

July July

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Sat Sat 22.22.

09.09.

2020 202014:57:15 14:57:15

96301-2020_Valsartan-Krka-HCTZ_Ad-A4_IE(en).indd 96301-2020_Valsartan-Krka-HCTZ_Ad-A4_IE(en).indd2 2

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2

WWHAM

As a member of the pharmacy team, counter and pharmacy assistants will deal with many different situations which call for effective communication. These will always include responding to OTC requests for information, and counselling patients on their medications.

WWHAM is one of the many mnemonics that allow you to do that effectively and it is included in every article within this booklet. It is the most basic method of questioning used

by Pharmacy teams, but it is direct, and asks most of the necessary questions.

It is used as follows: WWHAM • Who is the presenting complaint about? (patient or other) • What are the symptoms present?

• How long have the symptoms been present?

• Action already taken?

• Medication being taken?

In order for WWHAM to work effectively, the pharmacy team do need to work on the communication process between health professionals and patients.

An effective relationship forms the base that allows a patient to meet professional responsibilities in patient care.

In addition to creating an atmosphere of trust, it further facilitates the exchange of information necessary to assess the patient’s health condition, implement treatment of medical problems and evaluate the effects of treatment on a patient’s quality of life.

Effective communication allows for WWHAM to work in that it is also involves a number of basic processes which include: • Initiating a conversation: In many situations patients can be uneasy, concerned or embarrassed when they come to speak to the pharmacy team. When beginning the conversation it is important to focus on the patient in front of you, greet the customer and introduce yourself and be conscious of how the patient may be feeling. Similarly, establish immediately who the patient is: are they there for themselves or for someone else?

• Obtaining information: Obtaining information is a complex process including the acts of listening, questioning, checking your understanding and reading non-verbal signals. Stop talking and allow the patient to explain why they are here. Look at the other person to help you concentrate and show the other person that you are indeed listening. Similarly, react to ideas, not to the person.

• Action already taken: Any action taken by the patient should be established, including the use of any medication to treat the symptoms. About 50% of patients will have tried at least one remedy before seeking a pharmacist’s advice. Treatment may have consisted of OTC medicines bought from a pharmacy or elsewhere, other medicines prescribed by a doctor on this or a previous occasion, or medicines ‘borrowed’ from a friend or neighbour or ‘found’ in the medicine cabinet. Homoeopathic or herbal remedies may have been used. The cultural traditions of people from different ethnic backgrounds include the use of various remedies that may not be considered as ‘medicines’.

• The identity of any medicines taken regularly by the patient is important for two reasons: possible interactions and potential adverse reactions. Such medicines will usually be those prescribed by the doctor, but may also include OTC products.

Pharmacies have an increasingly important role in detecting adverse drug reactions and consideration should be given to the possibility that the patient’s symptoms might be an adverse effect caused by medication. Where you suspect an adverse drug reaction to a prescribed medicine, you should discuss with the doctor what action should be taken.

Notes to the Pharmacist: The views and opinions expressed within this Pharmacy Assist directory are those of the authors and it is provided to you only as guidance. All of the information is published in good faith and for general information purposes only. Please share with your supervising pharmacist for his/her review in order to tailor it to the specific needs and practices of your individual pharmacy. It can be shared with counter staff at your discretion for training purposes.

PUBLISHER IPN Communications Ireland Ltd. Clifton House, Lower Fitzwilliam Street, Dublin 2 00353 (01) 6690562 ADVERTISING SALES - Amy Evans 00353 (0) 87 062 2025 | amy@ipn.ie www.pharmacynewsireland.com

All rights reserved by IPN Communication Ltd. All material published in Pharmacy Assist is copyright and no part of this document may be reproduced, stored in a retrieval system or transmitted in any form without prior written permission. IPN Communications Ltd have taken every care in compiling Pharmacy Assist to ensure that it is correct at the time of going to print, however the publishers assume no responsibility for any effects from omissions or errors.

CONTENTS

WWHAM Explained 2

Dry Eye 25

Adult Incontinence 7

Dry Skin 27

Allergies 9

Foot Care 29

Age-Related Macular Degeneration 11

Haemorrhoids 31

Blepharitis 13 Congestion in Children 15

Hair, Skin and Beauty 33 Hair Loss 35

Mild to Moderate Pain 45 Mind your Back 46 Nappy Rash 49 Omega 3 51 Oral Care 53 Osteoarthritis 55 Pain 57

Cold & Flu 17

Head Pain 37

Contraception 19

Hygiene 39

Cough 21

Immunity 41

Pregnancy & Fertility 61

Cow’s Milk Allergy 23

Indigestion 43

Reflux 63

Pain in Children 59

3

Sexual Health 65 Smoking Cessation 67 Sports Injuries 69 Supplements in Children 71 Targeted Pain Relief 73 Urinary Tracts Infections 75 Vaginal Dryness 77 Vitamin D 79

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ADULT INCONTINENCE

7

ADULT INCONTINENCE Urinary Incontinence (UI) can have a hugely negative impact on a person’s quality of life, mood and confidence with some sufferers becoming virtual prisoners in their own homes. Incontinence is a condition that most people are too embarrassed to talk about, yet one that affects one in three women and one in nine men, and costs the HSE ¤100 million every year.

Prevalence increases with age, with an estimated 46% of women and 34% of men aged 80-plus affected. What’s more concerning is that up to 80% of sufferers have never sought medical advice and 35% view it as simply part of the ageing process. In most cases these conditions can be easily treated or significantly improved via straightforward interventions.

The local pharmacy has the advantage of being a familiar environment but one with experienced and specially trained staff whom customers trust.

WHAT IS INCONTINENCE? Urinary incontinence is loss of control of the bladder. It can affect anyone, regardless of age. It is a condition which ranges from mild to uncontrollable and embarrassing wetting.

Incontinence can often be caused by an illness, such as a urinary tract infection, and often when the infection gets better the incontinence improves.

Bladder control problems have a significant effect on the quality of life of sufferers on a physical, emotional and social level.

Continence is a necessity for comfortable social adjustment and conversely, urinary incontinence frequently causes profound psychological and social consequences and restricts social activities, causing sexual issues, lack of sleep due to nocturia, constipation from limiting fluid intake and falls and fractures in older people who have to rush to the toilet.

Urinary incontinence can occur when the normal process of storing and passing urine is disrupted. This can happen for a number of reasons, with certain factors increasing the likelihood of incontinence developing; advancing age is the biggest risk factor.

Stress incontinence occurs when the pressure inside the bladder as it fills becomes greater than the strength of the urethra to stay closed. Additional pressure to the bladder such laughing or sneezing can then cause urine to leak. Weak or damaged pelvic floor muscles or an inadequate urethral sphincter can result in the urethra opening when it shouldn’t. These problems can be caused by: • Damage during childbirth, particularly a vaginal delivery.

• Increased pressure on the abdomen, for example during pregnancy or if obese.

• Surgical damage to the bladder or nearby area caused, for example, during a hysterectomy or removal of the prostate gland in men (prostatectomy).

• Birth defects such as a defective bladder or sphincter.

• Menopause, where the reduction in oestrogen results in the bladder becoming lax.

• Some medicines.

Urge incontinence is the urgent and frequent need to pass urine, which can be caused by a problem with the detrusor muscles in the walls of the bladder. These muscles relax to allow the bladder to fill with urine and contract when going to the toilet to let urine out. If these muscles contract too often then this creates an urgent need to go to the toilet – this is known as an overactive bladder.

Overflow incontinence (also called chronic urinary retention) is often caused by a blockage or obstruction of the bladder. The bladder fills as normal but cannot empty completely because of an obstruction causing pressure to build up behind it, causing leaking around the blockage. An obstruction can be the result of an enlarged prostate gland in men, bladder stones and constipation.

Total incontinence occurs when the bladder cannot store any urine at all. This results in large amounts of urine being passed constantly or passed occasionally with frequent leaking. It can be caused by birth defects, spinal cord injury and bladder fistulas.

ASSISTING AND ADVISING Since urinary incontinence is a very common problem, pharmacists and their teams have many opportunities to support and help their customers.

Consider moving to the consultation room starting any conversation with “we have a more private area for consultations, would this be preferable?”

If an individual raises their incontinence with you, then acknowledge that this is a difficult subject for them but avoid telling them how they should feel.

Consider asking open questions to allow the patient to tell you more about what is happening to them, how they feel and what they are doing to manage the issue themselves.

Even though incontinence has a significant impact on people’s lives, many sufferers write it off as getting older. It can be a difficult topic to raise and yet there is much that can be done to manage the condition.

TREATMENTS Lifestyle Advice Frequent contraction of the detrusor muscles can be caused by: • Drinking too much alcohol or caffeine.

• Poor fluid intake, which causes strong, concentrated urine to collect, irritating the bladder.

• Constipation.

• Conditions such as urinary tract infections (UTIs) and bladder tumours.

Incontinence Products While incontinence products aren’t a treatment for urinary incontinence, they are useful for managing the condition while a person is waiting to be assessed or for treatment to take effect.

Absorbent products, such as incontinence pants or pads. Liners, pads, disposable underwear, and reusable underwear absorb moisture. Products made for incontinence control catch the leaks and pull moisture away from the skin. That allows sufferers to go longer between changes. Many disposable pads, liners, and undergarments have a waterproof backing. This helps prevent overflow from reaching clothes.

W

Who? Anyone, regardless of age Women are more prone to stress incontinence than men.

W

What are the symptoms? Depends on the type of incontinence, but generally wetting oneself or dribbling.

H

How long have they had the symptoms? Medical advice should be sought when symptoms present.

A M

Action already taken? Lifestyle changes or pelvic exercises may help.

Medication? A range of products to manage the condition are available.

How often should I use Stérimar?

We recommend using Stérimar Isotonic and Stérimar Baby two to six times a day (or more) in each nostril for as long as you need it or as long as and as often as your doctor recommends.

Stérimar Hypertonic is recommended for a short period. Use two to four times a day in each nostril for light congestion and up to six times a day for severe congestion.

Can Stérimar be used with other medication?

Yes. Stérimar is drug-free and doesn’t contain preservatives so there is no known risk of interaction with any other medication. However, in all cases it is best to check with your doctor.

Am I likely to experience any irritation from using Stérimar?

Stérimar Isotonic and Stérimar Baby are purified sea water solutions with the same concentration of salts as the cells in the human body. As such, irritation is highly unlikely. Stérimar Hypertonic has a higher salt content than Stérimar Isotonic but the solution is still less salty than sea water. A sensation of dryness may occur and should disappear within a few days.

Always follow instructions and/or doctor’s recommendations.

Can I use Stérimar if I am pregnant, diabetic or suffer from high blood pressure?

Yes, Stérimar is completely safe to use with these conditions, but it is always a good idea to check with your doctor.

Can I use Stérimar for my three year old?

Yes, Stérimar Isotonic is suitable for the whole of the family, even babies from 3 months old. Stérimar Hypertonic is suitable for all adults and children over three years of age and Stérimar Baby can be used with babies from birth to 3 years old.

Is the nozzle safe to use?

Yes. The Stérimar nozzle has been specifically designed to fit any shape and size of nostrils.

Stérimar Baby has a specific nozzle with a protective flange. The nozzle cannot be pushed too far into the nose to avoid any risks of injury.

How long will Stérimar keep?

Stérimar products can be kept for a maximum of three years after manufacture or until all solution has been used. The expiry date can be found at the bottom of the can and carton. Each

Please contact your Pemberton Rep to place your order on 01 4632424

dose of Stérimar delivered is aseptic.

The valve on top of the can prevents air from entering. Also, because the solution is kept in a sterilised pouch it never comes into contact with either the aluminium can or the non-flammable nitrogen gas within.

Why is it important to clean the nozzle after each use?

You must clean the nozzle in soapy water to remove any microorganisms left after use to help avoid any cross-contamination.

What does micro-diffusion mean?

The unique Stérimar micro-diffusion system produces a fine spray of sea water. As the droplets produced by Stérimar are microfine, they remain in contact with the walls of the nasal passages for longer, making Stérimar even more effective.

Why are the copper and manganese in Stérimar Hypertonic important?

Copper and manganese are found in very small amounts in the human body.

They stimulate the body’s self defense mechanisms and help keep it healthy.

ALLERGIES

9

ALLERGIES Despite a significant rise in awareness of allergies in recent years, plenty of confusion still surrounds them. The mechanism behind allergy is complex but is best described as the negative reaction that the body has to a particular substance.

Allergies are either seasonal (eg, caused by tree and plant pollen) or nonseasonal (eg, caused by dust). Mold, animal dander, dust, and pollen are the most common allergens.

Very often these substances are foods, although a person can be allergic to pretty much anything. Common allergens other than food include Latex, bee and wasp stings, and a number of medicines (e.g. antibiotics, NSAIDs, aspirin, chemotherapy drugs).

SYMPTOMS Like an unwelcome guest, many allergens arrive with little warning. Their most common effects are all too familiar to the millions suffering from allergies. Symptoms are broad and depend on which part of the body is affected. For example, hay fever (also known as seasonal allergic rhinitis, because it is mainly triggered by pollen) affects the eyes and nose, causing sneezing, a runny nose, and, sometimes, a stuffy, blocked nose.

Respiratory Symptoms Sneezing/ Runny Nose - Perennial allergic rhinitis (a condition that causes symptoms all year round) often causes a stuffy, blocked nose.

Asthma - Asthma affects the respiratory system causing wheezing (a whistling sound in the chest), breathlessness, chest tightness and a cough.

Dermatological Symptoms Eczema - (also called dermatitis) can affect the skin causing itchy, red rashes.

Allergic contact dermatitis - (a condition which is caused by the skin coming into contact with an allergen, such as nickel) is characterised by red, scaly skin that itches where it has made contact with the allergen.

Allergies to some foods, bites or stings can cause urticaria (itchy blisters and red patches on the skin).

REVIEW There are various theories as to why allergy incidence is increasing so rapidly.

These include: • Hygiene hypothesis. This argues that, if we are not exposed to bacteria and endotoxins in early childhood, our immune systems don’t develop as they should and therefore overreact when exposed to allergen challenges • Excessive use of antibiotics • Air pollution • Eating more processed food • Increase in stress

• Insulation and double-glazing, which have created more of an allergy challenge within people’s homes.

Although patients may attempt to avoid allergens’ triggers, they may be unaware of exacerbating environmental conditions, including aerosol sprays, air pollution, cold temperatures, humidity, irritating fumes (including perfume), tobacco and wood smoke, and poor housekeeping

DIAGNOSIS Although most people are aware of seasonal allergies, many cannot pinpoint the culprit.

Keeping a log regarding symptom onset, time of day, and environmental surroundings helps narrow the list. Patients’ symptoms often vary in intensity from day to day, further complicating assessment. Patients with ongoing allergies should see a specialist, even if symptoms are mild. The intensity of current allergic reactions does not necessarily predict the intensity of future attacks.

FOOD TOLERANCE AND FOOD ALLERGIES Many people confuse food allergies with more common food intolerances. Allergies involve an immune reaction; food intolerances stem from the inability to digest certain foods. Symptoms are similar, but milder: gastrointestinal problems, hives, itching, or eczema. Although avoiding specific foods is the recommended strategy, patients should be evaluated by an allergist.

Symptom recognition in food allergy is an important aspect of patient education, so the patient knows when to use an adrenaline auto-injector. This is as important as knowing how to use it.

Discuss anaphylaxis Those with severe reactions have increased risk for anaphylaxis. Inform patients they need to go to A&E if: • acute symptoms occur within minutes or hours involving respiratory compromise, tongue swelling, or hypotension • skin tone is flushed or pale (almost always present with anaphylaxis)

• nausea, vomiting, or diarrhea begins • dizziness or fainting, or a weak or rapid pulse, occurs.

Certain medications (especially penicillin); foods like peanuts, fish, shellfish, milk, and eggs; and insect stings are common triggers for anaphylaxis.

TREATMENTS The choice for treating allergic rhinitis can be confusing. Pharmacists are well placed to recommend a product that is matched to symptoms and their severity. It is beneficial to start treatment before symptoms begin.

Eye Drops - Eye symptoms are common in allergic rhinitis, with patients reporting red, watery and itchy eyes in addition to nasal symptoms. If this is the case, eye drops may be required.

Antihistamines - These products are the first line of defence for many allergic conditions. When helping patients choose an antihistamine, it is important to be aware of the sedative effect of first-generation drugs, as well as the short duration of action. The benefit of second-generation antihistamines is the rapid onset, which is good for compliance, as is the daily dosing and the fact that they are non-sedating.

On occasion, patients may require high doses of antihistamines to manage allergic or potentially non-allergic symptoms – eg in chronic spontaneous urticaria. Although these doses should be prescribed, it is important to provide reassurance that they are safe and within national guidelines.

W

Who? Sensitivity to indoor allergens is very common and occurs at every age.

W H

What are the symptoms? Itchy, congested nose, clear nasal discharge, irritated eyes, sneezing, tickly throat, coughing or wheezing.

A M

Action already taken? Patients may have tried antihistamines but not be aware of the benefits of nasal hygiene.

How long have they had the symptoms? Indoor allergies tend to be at their worst in the late summer, when dust mites are at most prevalent.

Medication? Saline nasal rinses and sprays are drug free and do not contain preservatives, so will not interact with other medication.

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AGE RELATED MACULAR DEGENERATION

11

AGE RELATED MACULAR DEGENERATION Age-related macular degeneration (AMD) is a chronic disease leading to progressive central vision loss. The symptom of central vision loss is due to the fact that the damaged macula is in the center of the retina. Patients with AMD may be unable to recognise faces, read, or drive a vehicle.

AMD is the most common cause of sight loss in people over the age of 50 in Ireland and it’s estimated that 7% of Irish people over 50 years of age are living with AMD. On account of our ageing population, the number of people in Ireland affected by this condition is expected to increase.

CAUSES The exact cause of AMD is unknown.

However, extensive research efforts over the last decade are playing an important role in uncovering some of the clues as to what may be causing the disease.

Researchers know that certain genes can cause AMD, but they don’t know what triggers the gene. While AMD can be inherited, many lifestyle choices can make progression of the disease worse.

Some risk factors that are believed to increase the chances of developing AMD include being over the age of 50 and having a family history of AMD. Having high blood pressure, a poor diet lacking carotenoids, or being overweight are also thought to be risk factors for this condition.

Because the exact causes of AMD are not yet known, some people may develop AMD even in the absence of these risk factors.

SYMPTOMS Symptoms of AMD include decreased central vision, central scotoma, and metamorphopsia.

Scotoma is an area of partially diminished vision surrounded by a field of normal or well-preserved vision. Metamorphopsia is a visual defect that causes people to see objects in a distorted manner; straight objects appear wavy or curvy. Patients will complain of distorted vision, lack of bright colours, or blurred vision.

What are the symptoms?

• Gaps or dark spots (like a smudge on glasses) may appear in their vision, especially first thing in the morning. Objects in front of them might change shape, size or colour or seem to move or disappear.

• Colours can fade.

• Sufferers may find bright light glaring and uncomfortable or find it difficult to adapt when moving from dark to light environments.

• Words might disappear when they are reading.

• Straight lines such as door frames and lampposts may appear distorted or bent.

TYPES OF AMD There are 2 types of macular degeneration: dry and wet. Dry macular degeneration, also known as the nonexudative form, is more common and found in approximately 90% of AMD patients. The onset of dry AMD is subacute. Management of dry AMD includes attempts to prevent progression to and frequent monitoring for the development of wet macular degeneration Wet (also known as exudative or neovascular) macular degeneration occurs in about 10% of AMD patients. It is the more acute form and more likely to cause vision loss.

Wet age-related macular degeneration develops when abnormal blood vessels grow into the macula. These leak blood or fluid which leads to scarring of the macula and rapid loss of central vision. Wet AMD can develop very suddenly but it can now be treated if caught quickly.

TREATMENT Injection Treatment for Wet AMD is most often through a series of injections into the eye using a drug called anti-VEGF (anti-vascular endothelial growth factor). This treatment works by reducing the growth of new blood vessels.

Response to this treatment is usually better in the early stages of Wet AMD, although even later stages can be stabilised. In some cases, individuals may notice improvements in their vision.

Supplements Age-Related Studies (AREDS1 and AREDS2) have shown that a combination of vitamins and antioxidants may help reduce the risk of progression of Early AMD to late-stage AMD. The recommendations include supplements containing vitamins C and E, zinc, copper, lutein and zeaxanthin.

Scientists from the Nutrition Research Centre Ireland (NRCI) at Waterford Institute of Technology (WIT) have proven that our eyes need the specific combination of 10mg Lutein,

W W H A M

10mg Meso-Zeaxanthin and 2mg Zeaxanthin to successfully rebuild the macular pigment in our eyes, protect against AMD and improve vision. By increasing the macular pigment density in the eye, you can improve real world visual function and performance by reducing glare sensitivity, improving contrast sensitivity and improving a person’s dark/light adaptation as well as reducing light scatter.

Irish clinical studies have found that MesoZeaxanthin has the strongest antioxidant action of all three of the carotenoids present in macular pigment (Lutein, Meso-Zeaxanthin and Zeaxanthin). Most importantly, it was also found that when all three carotenoids (L, M & Z) are combined together, they provide the most potent antioxidant effect on the macula, over and above any carotenoid on its own.

ASSISTING AND ADVISING It is important to remind patients at risk for AMD to have regular eye exams, even when they are symptom-free. Patients complaining of a recent or chronic loss or change of vision should be urged to see an ophthalmologist immediately. A healthy lifestyle may help prevent AMD. This includes not smoking, eating a healthy diet, and being physically active. Following the recommended guidelines and the use of appropriate pharmacologic agents may help patients with AMD slow vision loss progression, improve visual performance, and experience a greater quality of life.

Who? Anyone over 50 years of age is at risk of developing AMD. What are the symptoms? Gaps or dark spots in vision, faded colours, discomfort in bright light, straight lines may appear wavy and distorted.

How long have they had the symptoms? Everyone over the age of 50 should get their eyes tested every year. If they have any of the above symptoms they should see an Ophthalmologist immediately.

Action already taken? Patients may have already seen an eye doctor and have been recommended to take an eye health supplement.

Medication? Recommend a patient to start taking a triple carotenoid supplement to start rebuilding their macular pigment and start protecting their macula from further damage.

DAILY EYELID CLEANSING

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BLEPHARITIS

MANAGING AND TREATING BLEPHARITIS Blepharitis is a common condition, accounting for an estimated 1 in 20 eye problems reported to GPs. Eye irritation is among the most common, and most annoying, conditions for patients. Itchy, swollen eyelids and a sensation of something in the eyes make patients miserable.

Blepharitis can develop at any age, but is more common in people over 40.

Most people with dry eye syndrome also have blepharitis, which is a common and usually mild condition where the edges of the eyelids become inflamed, red and swollen.

Blepharitis can also be acute; this type usually originates from allergen or irritant exposure.

WHAT IS BLEPHARITIS? Blepharitis, an overarching term, is a family of inflammatory eyelid diseases. Most often blepharitis is a waxing and waning chronic condition exacerbated by seborrheic dermatitis or meibomian gland dysfunction.

Approximately 15% of patients have symptoms about half the time. Blepharitis is frequently associated with systemic diseases.

ASSISTING AND ADVISING Pharmacists should keep certain tips in mind when helping patients who have blepharitis.

First, pharmaceutical preparations like ointments and gels will stay in contact with the lid margin longer than solutions. These are usually preferred for blepharitis, but drops are preferred for corneal disease because they spread evenly.

Pharmacists need to repeat one message to patients at every visit: when applying any ointment to lid margins, using a clean application device, such as a cotton swab or a clean fingertip, is critical, as is gentle eyelid handling.

A warmed wet towel or eyelid-warming mask can help to improve gland function. This is usually recommended for 10 minutes twice daily, but manufacturers’ instructions for eyelid-warming masks may vary.

Ensure that patients are aware that continued treatment is important. Even if

13

the patient’s condition improves, continued management is important to ensure that any improvement is maintained.

Advise patients using antibiotic drops or ointment to avoid wearing contact lenses. The drops may build up behind the contact lenses and cause irritation. The contact lenses may also be damaged by the medicines.

EYELID HYGIENE FOR BLEPHARITIS For 5 minutes once or twice daily, apply a wet washcloth, soaked gauze pads, or flax-filled mask, that has been warmed.

This step softens gland secretions and promotes evacuation and cleansing of secretory passages.

Gently wash the eyelid margins while avoiding the lids or eye surface to remove adherent scurf (dead epidermal cells), collarettes (rims of thickened epidermis), and crusting. This also cleanses glandular orifices. Although many clinicians recommend washing with water, some suggest adding a few drops of baby shampoo.

Apply an antibiotic ointment like erythromycin or sulfacetamide, but only for short courses of treatment (chronic use is contraindicated).

Generally, ointments are applied at bedtime so blurry vision is not a problem.

Anterior blepharitis usually subdivided into staphylococcal and seborrheic variants, generally present with inflammation primarily around the eyelashes and follicles.

Posterior blepharitis have meibomian gland involvement and dilation of capillaries of the eyelid margin. Posterior blepharitis is usually less observable to the casual bystander as a cosmetic issue, but has more pronounced physical symptoms for the patient.

SYMPTOMS Patients with blepharitis may present with eyelash changes, watering, crusting and mattering around the lashes and canthus, photophobia, pain, and vision changes. The symptoms are usually worse in the morning, after a night of closed eyes has kept eyelids in contact with the ocular surface.

Patients’ visual function may decline pursuant to corneal damage and inflammation, scar formation, loss of surface smoothness, and clouded corneas. If severe inflammation develops, corneal perforation can occur.

The normal progression may include eyelid damage to the lids with trichiasis, or entropion and ectropion (respectively, inward or outward turning lids that cannot close properly).

Ophthalmologists and opticians encourage blepharitis sufferers to establish a systematic, long-term commitment to eyelid hygiene (e.g Wipes), because management will require lifelong vigilance. The exact process varies.

Antibiotic drops or ointments, or low-dose antibiotic courses should be considered if hygiene changes are ineffective.

W W H A M

Who: Most common in those aged over 40.

What are the symptoms? Eyelash changes, watering and crusting around the lashes, pain and vision changes.

How long have they had the symptoms? Symptoms are usually worse in the morning.

Action already taken? Sufferers may already be adhering to eyelid hygiene practices.

Medication? Antibiotic drops, ointments or low dose antibiotic courses.

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Lets Kids be Kids MAH: Johnson & Johnson (Ireland) ltd. Airton Road, Tallaght, Dublin 24. Products not subject to medical prescription. Full prescribing information available upon request. Calpol® Vapour Plug & Nightlight is an electrical device and non-medicine. CALPOL® Saline Nasal Spray, CALPOL® Saline Nasal Drops and CALPOL® Blocked Nose Spray are medical devices for congestion relief. *IMS May MAT Units 2020 (For Calpol® Infant and Calpol® Six Plus medicinal products)

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CONGESTION IN CHILDREN

15

CONGESTION IN CHILDREN Clearing congestion in children can be a challenge. For starters, it’s not always obvious what’s causing a stuffy nose.

Infants and toddlers, as they begin to build their immunity to common viruses that exist in their environment, are naturally very susceptible to colds and congestion.

Mild infections, such as cold or flu, are generally the root cause - but it is worth initially checking to ensure the child hasn’t accidentally blocked a nostril themselves.

Mucus production is the body’s natural response to infection and irritation; it is not generally a cause for concern, but can lead to discomfort.

SYMPTOMS Nasal congestion occurs when excess fluid accumulates within the nose, nasal cavity and airways. If untreated, it can lead to problems like sinus infections (sinusitis). Whilst small children may not be able to communicate their symptoms, they will generally present with noisy or quickened breathing, coughing, sniffling or grunting. A baby may also have trouble sleeping and feeding if he or she is congested.

Tips for using a nasal spray

There are some tell-tale signs that can help you tell the difference between viral and bacterial infections. For example, if a child has a runny nose, the colour of the discharge is an important clue. Clear and watery discharge at first are usually the result of a virus, though the mucus may turn white, green, or yellow for a few days before it turns clear again.

2. It’s sometimes helpful to lay them on a pillow, so you can tilt their head back slightly.

Causes

If they’re over 2:

Some of the causes of nasal congestion include:

1. Put the nozzle into one nostril, holding the bottle vertically.

• Infections: the common cold and other respiratory tract infections, including influenza (flu) and sinusitis.

2. Press the other nostril closed.

It is important to get the timing right. It’s hard to use a nasal spray when a baby’s feeling wriggly, so try dosing them when they are nice and relaxed, like after a bath or a feed.

If a child is under 2: 1. Lay the child down and turn their head to one side.

3. Put the nozzle into a nostril and press the spray head once.

4. Then repeat in the other nostril.

• Allergies, including hay fever.

3. Press the spray head once and spray deeply, asking your child to breathe in at the same time.

• Persistent rhinitis.

4. Then repeat in the other nostril.

When temperatures begin to drop, and kids are inside and interacting with each other in greater numbers, cold and flu season inevitably follows. Children under the age of 6, and particularly under age 2, are at an especially high risk during cold and flu season.

Babies and children who are exposed to irritants, such as smoke, dust or aerosols are also at a higher risk of congestion.

Don’t worry about misfires If a little spray gets in their eye, don’t panic. It may surprise them a little but saline solution is very gentle and shouldn’t cause any harm.

TREATMENTS A gentle option is to wash away the mucus that’s causing the blockage, so the child can breathe more easily. Medicated nasal sprays aren’t recommended for young children.

Fortunately, gentle saline sprays and drops are readily available to help clear up a stuffy nose. These will thin the mucus, which can then be easily dispersed or removed with a bulb syringe.

W W H A M

If it is tricky to use a nasal spray with a young baby, try using nasal drops instead, as some people find these easier.

Advice for Parents Advise on keeping the child hydrated to help reduce cold and flu symptoms and alleviate discomfort. Fevers can result in dehydration; children suffering with the cold or flu may not feel as thirsty as they normally would, and they may be uncomfortable when drinking, so it’s important to encourage them to drink plenty of fluids Moisture and warmth can help too. Try advising a parent to take the child into the bathroom while they run a steamy shower or bath.

Advise the parent to make sure their little one gets plenty of restful sleep – this will really help give them the strength they need to recover.

If the child is older than one, advise the parent to prop up the child’s pillow. It can help the child breathe more easily while they sleep.

Use a cool-mist humidifier in the child’s room. A range of plug-in products which release vaporised oils into the child’s room, in addition to topical vapour rubs, are also available for young children.

Who? All children are prone to congestion and colds.

What are the symptoms? Stuffy nose, irritability.

How long have they had the symptoms? An infant will have difficulty communicating their symptoms.

Action already taken? Steam, moisture and warmth can help to alleviate symptoms.

Medication? Decongestants for adults or older children should not be used on young children.

COLD & FLU

17

COLD & FLU The number of people turning to over-thecounter cold remedies continues to increase year-on-year. Sales of decongestants, lozenges and cough mixtures are also rising.

With increasing encouragement from GPs not to attend practices for common seasonal symptoms, it is more important than ever for pharmacists to stock a wide range of products, including. Consumers can then treat cold and flu symptoms at home rather than visiting their GP. During this time of year, many patients are likely to seek advice regarding the proper selection to treat and manage the symptoms generally associated with the common cold and the seasonal flu. For many patients, especially those taking prescription medications and those with other medical conditions, the selection of OTC products is overwhelming. Pharmacists can be an indispensable resource when it comes to aiding patients in the selection and proper use of these products and can also refer patients to seek further medical care from their GP when warranted.

or pharmacy staff. Echinacea and Zinc may also benefit patients during the cough and cold season.

FLU In the majority of healthy people, the flu is unpleasant. Symptoms such as fever, headaches, coughs, muscle aches and pains can suddenly occur and last up to seven days or a fortnight in some cases.

Other groups are at-risk of harmful or even life-threatening complications from the flu, particularly those with compromised or developing immune systems, including pregnant women, the elderly, and young children.

Table one Symptoms

Flu

Cold

Runny nose or nasal congestion

Rare

Common

Sneezing

Rare

Common

Sore throat

Common

Common

Fever

Common Temperatures between 38°C and 40°C Sudden onset

Rare

Cough

Common Sudden onset

Common Mild or moderate

Headache

Common Sometimes intense

Rare

Aches and pains

Common Sometimes intense

Rare Mild

Distinctive symptoms means that people often diagnose and treat themselves through a combination of self-care and OTC products, without needing to go to the doctor. If there is no improvement then an appointment with a doctor should be arranged. A GP can do an investigation to rule out whether the symptoms are being caused by a more serious infection, such as pneumonia or glandular fever.

Fatigue

Common Intense Duration: a few days, sometimes longer

Common Mild

Nausea and vomiting

Common in children Rare in adults Often accompanied by diarrhoea and abdominal pain in children

Rare Mild

All members of staff should be trained up on when to refer a patient for further medical attention, especially if they present with cold or flu-like symptoms that are accompanied by any of the following: high fever, vomiting, a non-blanching rash, photophobia, severe headache and/or confusion. Children presenting with high-pitched screaming, floppiness, bulging fontanelle, convulsions or stiff neck should go straight to A&E.

W

When speaking to customers, pharmacists may also be able to help patients in distinguishing between cold and flu symptoms (Table 1), and they should always seize this opportunity to remind patients about the safety and efficacy of the annual flu vaccination.

COMMON COLD The term “common cold” is widely used to describe an upper respiratory tract infection of viral origin. Adults in general suffer from cold approximately two to four times annually while children can contract the virus three to eight times as their immune systems aren’t as developed.

There is no cure for a cold, but certain measures can be taken to improve comfort levels while the virus dissipates: decongestants, antihistamines and pain relievers might offer some relief from symptoms however they won’t stop a cold from developing and will not shorten its duration. Vitamin C is useful for people in high risk groups who are at high risk of colds due to frequent exposure — for example, nurses

W H A M

Who? Anyone – the young and elderly are more susceptible to winter illness.

What are the symptoms? Cold, congestion, sore throat and cough.

How long have they had the symptoms? Symptoms of a cold generally only last a few days, flu symptoms can make people feel very unwell often leaving them unable to leave the house or go to work.

Action already taken? People may have tried pain relief – but may not be aware of combination products, for example ones containing combinations of antihistamine, analgesic and stimulant.

Medication? Pseudoephedrine is contraindicated in patients with diabetes mellitus, cardiovascular disease, severe or uncontrolled hypertension, severe coronary artery disease, prostatic hypertrophy, hyperthyroidism, closed angle glaucoma, and pregnant women.

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No other emergency hormonal contraception (EHC) is more effective than ellaOne®.1 REFERENCES: 1. Glasier A et al. Lancet 2010; 375 (9714): 555-62 PRODUCT INFORMATION ellaOne® 30 mg film-coated tablet (ulipristal acetate). Refer to the SmPC for further information. INDICATION: Emergency contraception (EC) within 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure. DOSAGE: one 30mg tablet taken orally as soon as possible, but no later than 120 hours (5 days) after unprotected intercourse or contraceptive failure. Another tablet should be taken if vomiting occurs within 3 hours of intake. Can be taken at any time during the menstrual cycle. Not recommended for women with severe hepatic impairment.

CONTRAINDICATIONS: Hypersensitivity to the active substance or excipients. SPECIAL WARNINGS AND PRECAUTIONS: Occasional use only. Use reliable barrier method after use until next menstrual period. If next menstrual period is delayed >7 days or is abnormal or suggestive symptoms occur then perform pregnancy test. Consider ectopic pregnancy. If pregnancy confirmed, woman should contact their doctor. Concomitant use with EC containing levonorgestrel not recommended. Does not contraindicate the continued use of regular hormonal contraception but reliable barrier method should be used until next menstrual period. Not recommended in severe asthma treated by oral corticosteroids. Concomitant use of CYP3A4 inducers [e.g. barbiturates (including primidone and phenobarbital), phenytoin, fosphenytoin, carbamazepine, oxcarbazepine, herbal medicines containing Hypericum perforatum (St. John’s wort), rifampicin, rifabutin, griseofulvin, efavirenz, nevirapine] not recommended (may decrease efficacy of ellaOne). Long term use of ritonavir not recommended. Not recommended for women who have used enzyme-inducing drugs in the past 4 weeks. Nonhormonal emergency contraception (i.e. a copper intrauterine device (Cu-IUD)) should be considered. Contains lactose. FERTILITY, PREGNANCY AND LACTATION: Not intended for use during existing or suspected pregnancy. Limited human data does not suggest safety concern. Does not interrupt existing pregnancy. No teratogenic potential was observed; animal data insufficient with regard to reproduction toxicity. Marketing Authorisation Holder maintains a pregnancy registry (www.hra-pregnancy-registry.com) to monitor outcomes of pregnancy in women exposed to ellaOne®. Patients and health care providers are encouraged to report any exposure. Ulipristal acetate is excreted in human breast milk; breastfeeding is not recommended for one week after intake. Breast milk should be expressed and discarded. A rapid return of fertility is likely following ellaOne use; regular contraception should be continued or initiated as soon as possible; subsequent acts of intercourse should be protected by reliable barrier method until next menstrual period. UNDESIRABLE EFFECTS: Always consult the SmPC before prescribing. Only the most common side effects and those which are rare but may be serious are listed below. Most commonly reported adverse reactions: headache, nausea, abdominal pain and dysmenorrhea. Common (≥1/100 to <1/10): mood disorders, dizziness, vomiting, abdominal discomfort, myalgia, back pain, pelvic pain, breast tenderness and fatigue. Rare (≥1/10,000 to <1/1,000): ruptured ovarian cyst. RETAIL PRICE: ellaOne 30 mg single film-coated tablet blister pack; € 35.

MARKETING AUTHORISATION HOLDER Laboratoire HRA Pharma, 200 avenue de Paris, 92329 Châtillon, France. Marketed in Ireland by: HRA Pharma UK & Ireland Limited, Haines House, 21 John Street, Bloomsbury, London, WC1N 2BF MARKETING AUTHORISATION NUMBER(S): EU/1/09/522/003. LEGAL CATEGORY: Medicinal product not subject to medical prescription.

Date of last revision of text: May 2019 Unique ID: IE/ELLA/0112

30 mg

film-coated tablet. Ulipristal acetate

Adverse events should be reported. Reporting forms can be found at www.hpra.ie or email: medsafety@hpra.ie.

Adverse events should also be reported to HRA Pharma UK & Ireland limited on Freephone: 1800 812 984 or email med.info.ie@hra-pharma.com IE/ELLA/0200 Date of preparation: November 2020

EMERGENCY CONTRACEPTION

19

EMERGENCY CONTRACEPTION Emergency contraception is a safe, effective and responsible method of preventing pregnancy when regular contraception has failed, no contraception was used, and/or in the case of sexual assault. For those who act quickly, emergency contraception will usually prevent pregnancy.

Emergency contraception will not prevent someone from getting a sexually transmitted infection (STI).

It is important for pharmacy teams to understand that many customers will often find it embarrassing to talk about sexual health and would prefer to do this in an informal, but confidential and private manner, with someone they trust.

It is also best not to assume anything about the patient when they approach the pharmacy for advice on sexual health. A person who is asking for information may not be sexually active and just want to be better informed.

A person may not already know all the facts.

Being prepared to go back to basics and giving information in stages ensures you give a patient time to ask questions about what you have said and clarify any areas of misunderstanding.

It can be hard to reduce a whole conversation about sexual health into a 30-secondover-the-counter chat. It is much more beneficial if consultations can take place in an appropriately confidential space if possible.

This helps to build up a trusting relationship with the patient as confidentiality is a priority when accessing sexual health services in any setting.

Use visual tools to tell young customers that contraception is available, such as leaflets about STI prevention methods, contraception and sexual health at the counter and posters around the pharmacy. Information slips about safe sex could be included in prescription bags, especially when issuing scripts for contraceptives and STI treatments.

When teenagers are approaching the pharmacy for EHC, this may provide an ideal opportunity for pharmacy staff to refer them to the pharmacist to discuss wider aspects of contraception and sexual health, including protection from sexually transmitted infections (STIs).

• Be professional but have a warm and approachable manner.

routinely used today and either of them may be purchased over the counter. They are:

The risk of becoming pregnant after unprotected sexual intercourse (UPSI) depends on the age and relative fertility of the lady and timing of the intercourse. The highest risk part of a cycle starts approximately 5 days before ovulation to approximately 2 days after ovulation but when those days occur may be hard to predict. When studies are done looking at all women who present for Emergency Contraception (EC) advice regardless of their age or when in the cycle they had the UPSI- the pregnancy risk is sometimes quoted as about a 5% overall.

1. The high dose (1500microgram (1.5mg)), progestin-only levonorgestrel (LNG) tablet – marketed under the names ‘Norlevo’ or ‘Prevonelle’.

According to the Faculty of Sexual and Reproductive Healthcare, EC should be indicated when: - Women who do not wish to conceive should be offered EC after unprotected sexual intercourse (UPSI) that has taken place on any day of a natural menstrual cycle.

- Women who do not wish to conceive should be offered EC after: - UPSI from Day 21 after childbirth (unless the criteria for lactational amenorrhoea are met).

- UPSI from Day 5 after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease (GTD).

- Women who do not wish to conceive should be offered EC after UPSI if their regular contraception has been compromised or has been used incorrectly.

There are two hormonal methods of EC

W W

DISCUSSING CONTRACEPTION

H

• Reassure them they have done the right thing.

A

• Offer them the use of a private consultation room, so that they may talk more freely.

• Talk to them in consumer language, for example mention ‘morning-after pill’ rather than EHC.

M

or 2. The high dose (30mg), progesterone receptor modulator ulipristal acetate (UPA) tablet- marketed under the name ‘ellaOne’ Women with medical cards can get the EHC pill free-of-charge directly from a pharmacist without the need for a prescription from their GP. This is an important public health measure and will remove any barrier to women getting timely treatment from their local pharmacy.

When it comes to which EC should be supplied, according to the IPU Emergency Hormonal Contraception (EHC) Protocol, Ulipristal acetate (ellaOne) has been demonstrated to be more effective than levonorgestrel from 0-120 hours after unprotected sexual intercourse (UPSI) so it should be considered first-line oral emergency contraception unless contraindicated. The main reasons to give levonorgestrel instead of ulipristal acetate would be if the patient was taking liver enzyme-inducing drugs or was breastfeeding or was taking a progestogencontaining oral contraceptive or had severe asthma treated by oral glucocorticoids.

Always refer to the pharmacist, anyone seeking EC who is taking medications that may interact with it. These include medicines used to treat HIV, tuberculosis, epilepsy and those taking St John’s Wort.

Who? Sexually active women for whom regular contraception has failed/no contraception was used, and/or in the case of sexual assault.

What are the symptoms? Unprotected sexual intercourse/failed contraception method. Many will be embarrassed so ensure to offer private consultation space.

How long has the patient had the symptoms? EC is most effective as soon after sexual intercourse as possible.

Action already taken? Routine contraception may have been used/ some may have taken the opportunity to discuss with friends/family members for advice before visiting the pharmacy.

Medication: Medicines which can interact with EC include those for epilepsy, tuberculosis and HIV.

4

3

Based on combined MAT sales data. To verify contact: verify@perrigo.com 2Associated with a cold.

Bronchostop Junior is a medical device according to Directive 93/42/EEC, used to relieve any cough (dry & chesty) associated with a cold for children from 1 year. Children under 3 years of age should consult with a doctor to exclude more serious diseases being present. Use in children under 1 year of age is not recommended. Children aged 1 year and above 5ml up to 3 times daily. Children 2 to 3 years: 5ml up to 4 times daily. Children 4 to 5 years: 7.5ml up to 4 times daily. Children 6 to 11 years: 15ml up to 4 times daily. Always read the leaflet.

4 Buttercup Bronchostop Cough Syrup contains thyme herb extract and marshmallow root extract. A traditional herbal medicinal product for the relief of coughs, such as chesty, dry, tickly, irritating coughs and catarrh, exclusively based upon long-standing use. Adults and children over 12 years: 15ml every 4 hours. Max dose 90ml per day. Not recommended for children under 12 years. Seek medical advice if symptoms persist after 7 days or if dyspnoea, fever or purulent sputum occurs. Contraindications: Known hypersensitivity to ingredients, rare hereditary intolerance to some sugars. Caution: Not recommended for use in Pregnancy and lactation. Contains methyl parahydroxybenzoate and propyl parahydroxybenzoate, which may cause allergic reactions. Side effects: Hypersensitivity reactions and stomach disorders. TR 2006/1/1. TR Holder: Kwizda Pharma GmbH, Effingergasse 21, A-1160 Vienna, Austria.

SPC: https://www.medicines.ie/medicines/buttercup-bronchostop-cough-syrup-31510/spc IRE BRO 2020 18 1 3

COUGH

21

COPING WITH COUGH Cold and flu season is the time of the year when pharmacists are more likely to see patients scanning the pharmacy shelves in search of the perfect remedy to manage a cough. Patients may be overwhelmed by the numerous OTC cough products, but pharmacists are in an ideal position to evaluate and aid patients in selecting a cough product for self-treatment, as well as to encourage patients to seek further medical care when warranted.

During winter, most coughs are caused by viruses such as colds and flu and can be safely managed at home using OTC remedies. Coughs are classified as “acute” or “chronic”. An acute cough is most common and lasts up to three weeks. It’s usually caused by a cold or flu virus and most improve after one to two weeks.

SYMPTOMS Chronic cough lasts for eight or more weeks.

The most common causes include acid reflux, asthma, TB, COPD, bronchitis and smoker’s cough. Red-flag signs include: • Coughing up blood • Unexplained weight loss • Night sweats • Cough worsening after three weeks • Shortness of breath • Voice changes • Lumps/swellings in neck • Chest pain Dry or chesty cough?

A dry cough is caused by inflamed airways due to a viral infection such as a cold or flu.

A chesty cough produces phlegm. This is caused by the lungs producing extra fluid due to an infection.

It is important to get a detailed overview of the patient’s symptoms. Is their cough productive? How long have they had the cough and what action has been taken?

Pharmacists should ask if a patient has any medical conditions that may affect any treatment or product you recommend.

Coughs can be described by: Behavior or experience. When and why does the cough happen? Is it at night, after eating, or while exercising?

Characteristics. How does your cough sound or feel? Hacking, wet, or dry?

Duration. Does your cough last less than 2 weeks, 6 weeks, or more than 8 weeks?

Effects. Does your cough cause related symptoms such as urinary incontinence, vomiting, or sleeplessness?

Grade. How bad is it? Is it annoying, persistent, or debilitating?

TREATMENT The role of cough medicine is to ease symptoms while the body heals. There are many brands of OTC cough medicines.

Expectorants help thin mucus, making it easier to cough up. The ingredient is guaifenesin.

Suppressants help cut the number of times someone coughs. The active ingredient listed is usually dextromethorphan (DM).

Other cough suppressants include camphor, eucalyptus oil, and menthol.

Combination cough products have more than one active ingredient. They have both guaifenesin and dextromethorphan. Cough medicines may also contain ingredients to help coat and soothe the throat.

Combination products may have medicines to ease other symptoms, that may include decongestants for stuffy nose, antihistamines for allergies or a runny nose, or painkillers.

Cough drops can also help relieve a cough and may ease a sore throat.

COUGH IN CHILDREN When temperatures start turning colder and kids are inside and interacting with each other in greater numbers, cold and flu season inevitably follows.

Children under the age of 6, and particularly under age 2, are at an especially high risk during cold and flu season. Whilst it is known that antibiotics won’t help when it comes to clearing up an infection, there are steps pharmacists can advise parents to take to help their child feel better while their immune system battles the virus.

When to refer Children with a cough should be seen by a doctor if they:

W W H A M

• have a cough for more than 3 weeks • have a fever above 102°F (38.89°C) or any fever in children ages 2 months and younger • become so out of breath that they can’t talk or walk • turn bluish or pale • are dehydrated or unable to swallow food • are extremely fatigued • make a “whoop” noise during violent coughing attacks • are wheezing in addition to coughing

Who? Anyone can be affected.

What are the symptoms? Depend on type of cough to suggest if it is allergic or viral.

How long have they had the symptoms? Coughs should clear after 3 weeks, is it short or persistent?

Action already taken? Customers may already have purchased cough medicines.

Medication? Some of the ingredients in cough medicines should not be given to children such as opioids. Antacids may interfere with other medicines.

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Neocate LCP, Aptamil Pepti 1 and Pepti 2 are Foods for Special Medical Purposes for the dietary management of cow’s milk allergy. In addition, Neocate LCP is also indicated for the dietary management of multiple food protein allergies and for infants who require an amino acid-based formula from birth.They must be used under medical supervision after consideration of all feeding options, including breastfeeding.

Accurate at time of publication: September 2020

References

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

COWS’ MILK ALLERGY

23

COWS’ MILK ALLERGY Cows’ milk allergy (CMA), also called cows’ milk protein allergy, is one of the most common childhood food allergies. It is estimated to affect between 2% and 7.5% of babies under one, though most children grow out of it by the age of five.

CMA typically develops when cows’ milk is first introduced into a baby’s diet either in formula or when a baby starts eating solids.

More rarely, it can affect babies who are exclusively breastfed because of cows’ milk from the mother’s diet passing to the baby through breast milk.

Babies can either be allergic or intolerant to milk. Because some of the symptoms of milk allergy and milk intolerance are similar, they are difficult to diagnose. A milk allergy involves an immune reaction to one or more of the proteins present in milk, whereas an intolerance does not involve the immune system.

An intolerance is caused by an inability to deal with certain substances in milk, such as lactose. Lactose intolerance is when some individuals don’t produce any or enough of the enzyme lactase which breaks down lactose. Undigested lactose causes symptoms like diarrhoea, bloating and wind.

TYPES There are two main types of CMA: • immediate CMA – where symptoms typically begin within minutes of having cows’ milk • delayed CMA – where symptoms typically begin several hours, or even days, after having cows’ milk

a combination of tests and a series of elimination and reintroduction diets are often necessary.

Giving the doctor as much detail about the baby’s symptoms as possible can help speed up the diagnosis process. By keeping a diary of their symptoms, including when they occur and how long they last for, can help the doctor identify or rule out cows’ milk allergy. Taking photos of any skin reactions, such as a rash, can be helpful too. They should advise the doctor if there is a history of allergy in the family.

FEEDING AND MILK ALLERGIES Managing a cows’ milk allergy involves removing all cows’ milk from the baby’s diet, so parents should always read ingredients on food labels. Common allergens, like milk, must be declared on pre-packaged foods.

If a baby is being formula fed and has been diagnosed with cows’ milk allergy, The doctor may prescribe an extensively hydrolysed formula. The protein in these formulae has been broken down into smaller pieces so that the baby’s immune system does not recognise it as an allergen – a process which does not affect the nutritional value of the formula.

Soya formulae are not recommended before six months as they contain phytoestrogens (plant-based compounds with oestrogen-like properties), and infants who react to cows’ milk-based formulae often also react to soyabased formulae.

RECOGNISING MILK ALLERGY

In rare cases, the baby may be reacting to the milk proteins passing from the mothers’

If a baby is allergic to milk, they will react to infant formula which is based on cows’ milk and sometimes, but very rarely, to breast milk the mother recently consumed dairy products. Symptoms include stomach cramps, vomiting, diarrhoea, rashes, hives, eczema, and difficulty breathing. Individual symptoms can sometimes be related to a bug, but if the baby is affected in two separate areas of the body – for example, the stomach (vomiting) and skin (hives), parents should ask their health visitor or doctor for advice.

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It’s common for babies who are allergic to cows’ milk to be allergic to goats’ milk and sheeps’ milk too, as they contain similar proteins. Unfortunately, there is no single diagnostic test for cows’ milk allergy and

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diet into breast milk. If a breastfeeding mothers’ baby is diagnosed with cows’ milk allergy, she may have to change her diet but this is quite rare.

IDENTIFYING LACTOSE INTOLERANCE A baby with lactose intolerance usually experiences less severe reactions than one with an allergy. As with a milk allergy, symptoms of lactose intolerance can include diarrhoea, vomiting, and stomach cramps but not usually hives or breathing difficulties.

Another difference is that lactose intolerance will not show up in a blood or skin-prick test. However, the baby’s reaction will be noticeable, if not as severe as that of an allergy.

There are two main types of lactose intolerance. The first is primary lactose intolerance, and is caused by a deficiency in the enzyme lactase. It normally affects Hispanic, Asian and American Indian populations, but is uncommon in Europeans.

Primary lactose intolerance doesn’t mean that lactose must be removed from the diet entirely: depending on the individual, those with primary lactose intolerance can often tolerate a certain amount of lactose.

Secondary lactose intolerance is usually caused by damage to the gut, after a severe stomach bug, for example. But this form of the condition is usually temporary, until the gut heals. In very severe cases, lactose may need to be removed from the diet for a few weeks.

Who? Babies and infants.

What are the symptoms? Stomach cramps, vomiting, diarrhoea, rashes, hives, eczema, and difficulty breathing.

How long has the patient had the symptoms? Only around 2–7.5% of babies under one year old are allergic to cows’ milk. By the age of three most children will have grown out of cows’ milk allergies.

Action already taken? If a baby is being formula fed and has been diagnosed with cows’ milk allergy, the doctor may have prescribed an extensively hydrolysed formula.

Medication? Parents may be using creams or emollients to treat the symptoms affecting their baby’s skin.

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DRY EYE DISEASE

DRY EYE DISEASE Dry Eye Disease (DED) which is also sometimes referred to as dry eye syndrome or keratoconjunctivitis sicca, is considered th most prevalent ophthalmic disorder that affects the anterior eye and is most often associated with the aging process, especially in postmenopausal women.

An estimated 10% to 30% of the population older than 40 years suffers from some degree of dry DED. The condition tends to affect people above 60, and it is more common in women than men.

Around one in 13 people who are in their fifties experience dry eye syndrome, and the condition becomes more common with age.

Up to a third of people age 65 or older may have dry eye syndrome.

WHAT IS DRY EYE DISEASE? DED is a multifactorial disease of the tears and ocular surface that results in discomfort, tear film instability, and visual disturbance, with potential for damage to the ocular surface. DED can be classified as chronic or temporary.

Causes Dry eyes can be caused by ordinary things that increase tear evaporation, such as looking at a computer screen too long; being outside in windy, dry conditions; or just being tired. Cigarette smoke may also cause dry eyes. Common causes of dry eye include: • Gender. A deficiency of tears is more common in women, especially with hormonal changes caused by pregnancy, the use of birth control pills, or menopause.

• feelings of dryness, grittiness or soreness, which get worse throughout the day • redness of the eyes • watering eyes, particularly when exposed to wind • eyelids that stick together when waking up

ASSISTING & ADVISING When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors.

Briefly, this should include details of the signs and symptoms, duration of symptoms and exacerbating factors, such as the environment, changes in humidity or computer use.

substitute depending on the severity of the condition. Pharmacological interventions in all forms of dry eye conditions range in formulation, such as drops, sprays, gels and ointments.

It should also record details of topical and systemic medicines taken by the patient, whether the patient wears contact lenses and if the patient has any dermatological, inflammatory or other systemic diseases.

Pharmacologic agents that have anticholinergic properties—including antihistamines, decongestants, and antihypertensives such as antidepressants, beta-blockers, and diuretics—are common causes of DED.

For occasional or mild dry eye symptoms, OTC eyedrops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces. An indoor air cleaner to filter dust and other particles can help prevent dry eyes, as can a humidifier by adding moisture to the air, avoiding dry conditions, and allowing the eyes to rest when performing activities that require someone to use their eyes for long periods of time.

A differential diagnosis for other eye conditions (such as conjunctivitis, allergy and acute red eye) should be established because initial presentation may be similar.

Once dry eye syndrome develops, some people have recurring episodes for the rest of their lives. There is no cure for dry eye syndrome, but a range of treatments can control the symptoms. In rare cases, more severe cases of dry eye syndrome may require surgery.

TREATMENTS

• Wearing contact lenses.

The ultimate goal of dry eye treatment focuses on symptomatic relief, usually using tear supplements. It is thought that increased tear volume, improved tear stabilisation, reduced tear osmolarity or a dilution of inflammatory biomarkers or a combination of these factors play a vital role.

• An eye injury or other problem with your eyes or eyelids.

Topical ocular lubricants are the mainstay of dry eye treatment, with the choice of tear

• The use of cold or allergy medicines, antidepressants, and drugs for high blood pressure; acne; birth control; and Parkinson’s disease.

WHEN TO REFER Dry eye syndrome can cause complications, such as: • scarring of the cornea • conjunctivitis - inflammation (swelling and redness) of the conjunctiva Such complications can produce more severe symptoms, for example: • extreme sensitivity to light (photophobia) • very red eyes • very painful eyes • a deterioration in vision Anyone presenting with these symptoms should be immediately referred to their GP.

• Thyroid disorders.

• Vitamin A deficiency.

• Laser eye surgery may also cause temporary dry eye.

• Allergens Other medical conditions associated with DED include diabetes, lupus, and scleroderma. Bell palsy, collagen disorders such as rheumatoid arthritis, Sjögren syndrome.

Symptoms The symptoms of dry eye syndrome usually affect both eyes and may include:

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Who? Can affect all but mainly women and those over age 60.

What are the symptoms? Feelings of dryness, grittiness, soreness, redness, watering of the eyes.

How long has the patient had the symptoms? Symptoms can be recurring.

Action already taken? The patient may already be using eye drops, reducing computer screen time and avoiding exacerbating factors.

Medication? Topical ocular lubricants, OTC eye drops, glasses and wraparound sunglasses can help.

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DRY SKIN

DRY SKIN Dry skin (xerosis) occurs when the epidermis does not hold on to sufficient moisture, so skin can feel tight, rough, flaky and itchy. A number of things can contribute to its development, for example; too frequent bathing, use of harsh drying soaps, the ageing process (the production of natural oils in the skin slows as we age) and sun damage or certain conditions such as eczema or psoriasis.

The average skincare category accounts for 5 per cent of total OTC shelf space. It is important that this space works hard for you and the range stocked provides maximum return in terms of profitability as well as offering customers the right range of specialist skincare treatments to meet their needs.

SYMPTOMS Dry skin will manifest initially in skin colour and texture, becoming red and rough. It may also result in flaking, gray or ashy skin, and itching (pruritus). In worst case scenarios, sufferers of dry skin might present with very severe peeling, or deep cracks that may bleed. At this point, they should be advised to consult a dermatologist in order to avoid scarring or infection.

Causes Whilst genetics have a role to play in dry skin, there are a number of environmental factors that contribute to the condition.

Temperature: As temperatures and humidity levels drop in the winter, skin is likely to dry out.

Indoor conditions will have a similar impact - a very warm home will lead to decreased moisture in the air which also dries the skin.

Cleansing habits: Skin can dry out if it is exposed to any harsh products, skincare or detergents, designed to wash away natural oils. Additionally, taking very long, hot baths or showers will reduce moisture in the skin.

Skin conditions: There are many skin conditions which can lead to dry skin, the most common being eczema or psoriasis.

Atopic dermatitis can be activated by incessantly dry skin left untreated.

TREATMENTS Moisturisers People suffering from dry skin should avoid harsh, alcohol-based products, as these can irritate skin and dry it out. People who have oily skin should avoid oil-based products and choose water-based ones instead. A good moisturiser is not necessarily an expensive one. Deciding what is best for skin depends on ingredients. There are various ingredients that provide different functions including: • Ceramides. Ceramides help the skin hold water and soothe dry skin. Synthetic ceramides may mimic the natural substances in the outermost layer of skin that help keep moisture in.

• Dimethicone and glycerin. These draw water to the skin and keep it there.

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• Hyaluronic acid. Like ceramides, hyaluronic acid helps skin hold water.

• Lanolin, mineral oil, and petroleum jelly (petrolatum). These help skin hold on to water absorbed during bathing.

Advise and Assist Here are 5 tips pharmacists and pharmacy staff can advise sufferers on as efficient selfcare management: 1: More moisturiser Emollients are moisturisers that are used in two ways: applied directly to the skin as a leave-on moisturiser, and as a soap substitute instead of soap and shower gel. Dry skin itches. Moisturising rehydrates the epidermis, seals in moisture, and soothes dry, itchy skin.

In winter, sufferers may need to moisturise more frequently and/or use a ‘heavier’ moisturiser such as an ointment rather than a cream or lotion; ointments tend to work better when the skin is very dry.

Applying moisturiser: • Apply a 50p piece-sized amount of moisturiser to the face and neck, from the chest upwards.

• Application should be even, across the whole area, especially when using a day cream with in-built sun protection.

Moisturisers can be applied immediately after a serum or, if not using a serum, directly after cleansing, to help trap essential moisture inside the skin.

• Moisturise while skin is still moist. Patt skin with a towel after a shower or washing the face or hands, leaving it damp. Apply a moisturiser within three to five minutes of washing to lock moisture in.

Use emollient wash products (soap substitutes) when hand-washing, bathing or showering, which leave the skin coated with a protective film afterwards.

After bathing or showering, gently pat the skin dry. This is a great time to apply emollient all over as it helps to seal in moisture while skin is still damp.

3: One quick daily dip!

• Advise customers not to apply face cream to the eye area, as this requires a specific eye cream. Many moisturisers may be too rich in oils for the eye area and cause puffiness, or contain high levels of hydroxy acids, which may cause irritation.

Staying in the bath or shower too long can be dehydrating- anyone suffering from dry skin should limit themselves to a single 5or 10-minute warm shower or bath a day.

Additionally, water temperature should be lukewarm rather than hot, as hot water strips oils from the skin faster than warm water.

2: Keep it simple - avoid harsh products

4: Wear sunscreen

The best products to prevent flare ups of dry skin will be bland, unfragranced and preservative-free.

Sun damage is cumulative, so a lifetime of sun exposure and sun damage can result in thinner skin that doesn’t retain moisture well. This can also reduce the appearance of premature ageing.

Ordinary soaps and bubble baths can dry out the skin by stripping away its natural oils.

Skin pH is a measure of acidity and alkalinity, ranging on a scale form 0 (most acidic) to 14 (the most alkaline). Healthy skin is naturally acidic, with a pH of around 5.5. This acidity plays an important role in skin barrier function and skin health. Soaps and detergents raise skin pH which disrupts this delicate balance.

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5: Consider using a humidifier Humidifiers moisten the air to increase the level of humidity. To combat the drying effects of central heating and lower humidity during winter, some may want to consider using a humidifier indoors when the heating is on.

Who? Anyone.

What are the symptoms? Red and inflamed skin.

How long has the patient had the symptoms? Dry skin is particularly prevalent in the winter months.

Action already taken? Patients may already be using moisturisers.

Medication: If the patient has other skin conditions refer them to a GP so they can provide the appropriate topical cream.

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FOOT CARE

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FOOT CARE Every day, feet are abused and bruised, which is why so many experience heel pain, blisters, corns and calluses. However, despite a high prevalence of foot care conditions, few people actually opt to treat them.

A major part of the problem surrounding reluctance to treat is confusion. With over 15 different ailments in foot care, this is a category that spans a hugely diverse number of consumer needs. There are also issues with daily foot comfort and posture.

An overarching lack of awareness about available solutions is the key reason why people are not doing enough about general discomfort.

COMMON PROBLEMS AND TREATMENTS Corns and calluses - are a build-up of hard dead skin caused by pressure when bony parts of the feet rub against the shoes.

Wearing shoes that fit better or using special pads may solve the problem. If corns or calluses become painful, patients should be advised to visit the chiropodist or doctor.

Over-the-counter treatments for corns, such as corn plasters, are available. Corn plasters may not be suitable for certain people, such as those with diabetes, circulation problems, or fragile skin.

Bunions - develop when the joints of the big toe no longer fit together. This causes a painful swelling which makes walking difficult.

Wearing shoes made of soft leather or fabric uppers, or bunion shields may help to ease the discomfort. A chiropodist or doctor will advise on how to treat the condition.

Athlete’s Foot - is a fungal infection and is very contagious. It causes dry skin, an itchy rash, splitting of the skin between the toes and blisters on the skin under the toes. To prevent infection advise patient to keep feet – especially the area between toes – clean and dry. Change shoes, socks, tights or stockings often. Over-the-counter antifungal creams are sufficient for treating most cases of athlete’s foot. If the condition does not get better within two weeks, advise a visit to chiropodist or GP.

Verrucas are highly contagious and spread easily through contact with contaminated changing room floors or swimming pool areas. They usually disappear on their own, but this can take up to two years. Several treatment options are available OTC, including salicylic acid gels, creams, plasters and paints, and cryotherapy products.

Cracked heels - often caused by openbacked shoes, such as sandals or flip-flops rubbing the skin. Applying a moisturising cream or specially formulated foot cream, twice daily, will keep feet smooth and soft.

Any hard skin can be removed with a pumice stone or non-metal foot file; these are most effective when used during a bath or shower.

Blisters - can be painful and are more likely to occur in hot weather, when sandals or flipflops rub against the skin. Anti-blister sticks and blister plasters can provide instant relief and prevent further damage. Customers should be advised not to pop blisters, as this increases the risk of infections – instead, they should cover them with a protective gel dressing.

Fungal nail infections - most common in people who wear shoes in hot sweaty weather, regularly damage their nail or skin, or have certain health conditions such as

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In-growing toenails - can be very painful and are usually caused by cutting the toenail too short or by wearing shoes that are too tight. A chiropodist or GP will advise on how to treat the condition. OTC soaks are available to help relieve pain or swelling and pain-relieving medication can also be recommended.

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Verrucas - Most verrucas, which develop on the soles of the feet, are harmless. They don’t cause any pain, unless they are on a weight-bearing part of the foot. The affected skin is usually white and may have a black spot in the centre.

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diabetes or psoriasis. The infection usually develops slowly and causes the nail to become thickened and discoloured. The nail may turn white, black, yellow or green, but isn’t usually painful.

Mild fungal nail infections usually clear up on their own, although a GP may check for any underlying conditions. Antifungal nail paint may be effective if only the end of the nail is infected, but this needs to be used for up to six months or even a year.

Antifungal tablets are up to 80 per cent effective, but again need to be taken for several months. Most treatment failure occurs because people stop using the medicines too early. In severe or painful cases, the nail may be removed with surgery.

Feet odours - teenagers and pregnant women are particularly prone to sweaty feet, because hormonal changes make them sweat more often. Ideally, customers should wash their feet every morning and night with warm soapy water and change their socks at least once a day. An antibacterial wash, followed by a wipe with cotton wool soaked in surgical spirit, can help to combat any odour. Medicated insoles and ‘feet fresh’ socks have a deodorising effect.

Who? Everyone is prone to foot problems, particularly those who are on their feet for most of the day.

What are the symptoms? There are a wide range of common foot problems with a wide range of symptoms.

How long has the patient had the symptoms? Many patients are confused about the range of foot ailments so do not tackle discomfort early.

Action already taken? Using appropriate footwear for the conditions can alleviate or prevent many foot ailments.

Medication? A wide range of OTC products are available.

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For the symptomatic treatment of internal and external (ointment only) haemorrhoids and pruritus ani. MA holder. Church & Dwight UK Ltd., Premier House, Shearway Business Park, Pent Road, Folkestone, Kent, CT19 4RJ. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found at: Anusol cream: https://www.medicines.org.uk/emc/product/1486/smpc; Anusol Suppositories: https://www.medicines.org.uk/emc/product/1488/smpc; Anusol Plus-HC Ointment: https://www.medicines.org.uk/emc/product/1470/smpc. Latest revision of SmPCs: April 2018.

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HAEMORRHOIDS

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HAEMORRHOIDS Haemorrhoids are one of the most common ano-rectal ailments. Also known as piles, these are swellings that contain enlarged blood vessels that are found inside or around the bottom (the rectum and anus).

• Persistent cough or repeated vomiting

More than half of people will develop haemorrhoids, usually after the age of 30. Half the Irish population experience symptomatic haemorrhoid disease at some point in their lives, with the peak incidence of symptomatic disease between the ages of 45 and 65 years.

Supportive care strategies may include lifestyle changes, such as adopting a highfibre diet, increasing fluid intake, avoiding straining during defecation, and using topical products for symptom relief.

SYMPTOMS Most haemorrhoids are mild and sometimes don’t even cause symptoms. When there are symptoms, these usually include: • bleeding after passing a stool (the blood will be bright red) • itchy bottom • a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool Symptoms may include rectal bleeding resulting from irritation of internal haemorrhoids, with bleeding usually occurring immediately after defecation. Other symptoms may include perianal discomfort and soiling.

Constipation, pregnancy, heavy lifting, or strenuous exercise may exacerbate these symptoms. Prolonged sitting, obesity, and low-fibre diets are other possible contributing factors.

CAUSES The exact cause of haemorrhoids is unclear, but they’re associated with increased pressure in the blood vessels in and around the anus.

This pressure can cause the blood vessels in the back passage to become swollen and inflamed.

Many cases are thought to be caused by too much straining on the toilet, due to prolonged constipation – this is often due to a lack of fibre in a person’s diet. Chronic (long-term) diarrhoea can also make sufferers more vulnerable to getting haemorrhoids.

Other factors that might increase the risk of developing haemorrhoids include: • Being overweight or obese • Age, as a person get older, the body’s supporting tissues get weaker, increasing the risk of haemorrhoids • Pregnancy– which can place increased pressure on your pelvic blood vessels, causing them to enlarge • Having a family history of haemorrhoids • Regularly lifting heavy objects

• Sitting down for long periods of time

TREATMENT

As haemorrhoidal tissues are inflamed, topical vasoconstrictors are commonly used to shrink blood vessels in the anorectal area and temporarily relieve swelling. Topical analgesics may also be used to relieve pain, itch, and irritation.

OTC treatments - various creams, ointments and suppositories are available from pharmacies without a prescription.

They can be used to relieve any swelling and discomfort. These medicines should only be used for five to seven days at a time. They may irritate the sensitive skin around your anus if you use them longer than this.

Corticosteroid cream - a GP may prescribe corticosteroid cream, which contains steroids, if there is severe inflammation in and around the back passage.

Painkillers - common painkilling medication, such as paracetamol, can help relieve the pain of haemorrhoids. But if a sufferer has excessive bleeding, they should avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, as they can make rectal bleeding worse. They should also avoid using codeine painkillers as they can cause constipation.

Banding - carried out as a day procedure, this involves placing a very tight elastic band around the base of the haemorrhoids to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment. Banding is usually a day procedure that doesn’t need an anaesthetic,

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and most people can get back to their normal activities the next day.

Sclerotherapy - may be used as an alternative to banding. During sclerotherapy, a chemical solution is injected into the blood vessels in the back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so a scar is formed. After about four to six weeks, the haemorrhoid should decrease in size or shrivel up.

Surgery - although most haemorrhoids can be treated using the methods described above, around one in every 10 people will eventually need surgery. Surgery is particularly useful for haemorrhoids that have developed below the dentate line – unlike non-surgical treatments, anaesthetic is used to ensure sufferers don’t feel any pain.

Any medication should be combined with the diet and self-care advice discussed above.

Pharmacists can advise about which product is most suitable.

Who? The risk of haemorrhoids increases as a person gets older.

What are the symptoms? Pain or discomfort, especially when sitting, pain during bowel movements, itching or irritation around the anal region, bright red blood on stools, swelling around the anus.

How long have they had the symptoms? If OTC products have not helped the symptoms within a week they sufferer should be referred to a doctor.

Action already taken? Sufferer can be advised of a number of lifestyle changes which can lessen the symptoms or reduce the risk of haemorrhoids returning.

Medication? A number of OTC treatments are available. Sufferers should avoid ibuprofen and codeine.

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HAIR, SKIN & BEAUTY

33

HAIR, SKIN & BEAUTY Skin, hair and beauty within the pharmacy environment often relates to cosmetic products such topical creams, makeup, and hair cleansing and styling products. However, there is a lot more to this category than people may initially assume.

Whilst a healthy and balanced diet, including plenty of essential vitamins and minerals, is required for healthy hair and skin, more and more people are using beauty supplements – sometimes known as nutraceuticals - to help add further benefit. Studies have shown that women are more likely to take these supplements than men.

Some nutraceuticals contain vitamins such as A, C, B2, B3 and B7, and minerals like iodine and zinc – all of which are known to contribute to healthy skin, nails and hair.

As they are intimately connected, many supplements which treat one will also benefit the others.

Those who take nutraceuticals should always be advised that they should be taken to boost, rather than as a substitute for diet.

It is useful to provide customers with clear guidance on a variety of different products, what they are for and their various benefits, including natural healthcare options.

A number of factors contribute to the slowing of hair growth over time, including poor diet, stressful lifestyle, hormonal imbalances and genetics. We can lose as many as 50-150 hairs a day. Many people note hair thinning and dulling as they age - supplements may help to curb this process by stimulating blood flow and follicle activity.

As people age, the most important proteins in their skin— collagen and elastin— begin to break down. Making matters worse, the body doesn’t produce these proteins as easily as a person grows older. While different supplements work in slightly different ways, the overall effects are similar. Skin supportive supplements are designed to help revitalise and rejuvenate skin by improving the health of skin cells and helping to produce more crucial proteins like collagen.

POPULAR SUPPLEMENTS Zinc and calcium - both are necessary for health in general, but they’re also critical for the health of hair and skin. Zinc is essential for cell structure and tissue strength, which helps fight wrinkles and keep skin tight. It also helps keep the oil glands around hair follicles working properly.

Hair loss is a common symptom of zinc deficiency. Meanwhile, calcium helps with cell regeneration and cell growth, thus keeping your skin youthful and your hair healthy.

Fish oil supplements - are loaded with Omega-3 fatty acids. These fatty acids have a number of proven health benefits. They support collagen growth and promote skin moisture, both of which help to keep skin healthy. Fish oil promotes circulation Selenium - a mineral found in fish oil

amongst other foods, can be taken as a supplement. Selenium plays a vital role within the body in stimulating follicles and promoting healthy hair growth.

Fern extract - sometimes referred to as PolypodiumLeucotomos Extract, or PLE extract, as that chemical compound is the primary active ingredient. Designed to offer protection from the sun. The sun’s harmful UV rays are a leading cause of collagen degradation, so extra protection does a lot to keep skin healthy.

GLA oils - also known as gamma-Linolenic acid oils, GLA oils are Omega-6 fatty acids.

Like their cousin, the Omega-3 fatty acids, Omega-6s are also intended to keep skin healthy. While they’re important for healthy skin, the body doesn’t produce them. GLA oils are found in vegetable oils. The most common GLA supplements are evening primrose oil (EPO), borage oil, and black currant seed oil. All these varieties of GLA oil can be found in tablet form.

Vitamins (A, C& E) - it’s widely known that vitamins are good for general health. But it’s worth stressing how important these Vitamins A, C, and E are for hair, skin and nail health.

• Vitamin A increases cell reproduction - this relates to hair, the fasting growing tissue in the human body.

• Vitamin C helps prevent damage to cells, thus facilitating the production of elastin and collagen.

• Vitamin E is an antioxidant that protects skin cells and helps maintain moisture.

Phytonutrients - these are antioxidants found in fruits, veggies, and nuts. There are a number of different phytonutrients, including Lycopene, Ellagic Acid, and Resveratrol, among others. Phytonutrients are useful supplements for healthy skin because they

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expel toxins and harmful chemicals from skin cells. This allows for healthy cell regeneration and maximum collagen production.

Coenzyme Q10 - commonly referred to as CoQ10, this antioxidant helps get rid of free radicals and other toxins in the body. Thus, it has the effect of promoting healthy skin and collagen production, whilst also stimulating circulation to the hair follicles to prevent hair loss.

Biotin - an essential B vitamin, also known as vitamin B7, that helps promote healthy skin, as well as healthy nails and hair.

Researchers also think that Biotin works to reduce the death of skin cells. Biotin is found in foods like cheese, beans, eggs, and leafy greens. People can add more of these foods to their diet to ensure they’re getting plenty of Biotin, or can take a tablet as a supplement.

Hyaluronic acid - also known as sodium hyaluronate, has strong moisture-retaining properties, which benefits healthy skin, hair and nails. While this compound is an ingredient in many creams and serums, there’s little evidence to suggest hyaluronic acid is effective when applied topically.

It’s best to ingest an oral tablet to receive maximum benefits from this skin supplement.

Curcumin - is not produced by the body, but it does occur naturally in turmeric, the bright yellow spice often used in Indian food.

Curcumin acts as an antioxidant and has been shown to have a number of health benefits. Available as a supplement tablet to reduce hair loss.

Copper - is an essential trace mineral necessary for survival. It is found in all body tissues and plays a role in making red blood cells and maintaining nerve cells and the immune system. It also helps the body form collagen and absorb iron, and plays a role in energy production. Most copper in the body is found in the liver, brain, heart, kidneys, and skeletal muscle.

Who? Both males and females, although studies show women are more likely to take supplements.

What are the symptoms? As a person ages the collagen and elastin in their skin begins to break down.

How long have they had the symptoms? Part of the natural ageing process.

Action already taken. A balanced diet is recommended to achieve necessary vitamins and minerals.

Medication? N/A

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HAIR LOSS

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HAIR LOSS Hair-loss, for both men and women, can be distressing, and is a subject which needs careful and sensitive handling by pharmacists and pharmacy staff. It is important you are educated in the types of hair-loss, what causes it and that you understand which treatments are available.

Hair Growth Cycle A hair growth cycle consists of three phases.

• Anagen phase - Hair grows actively. This phase may last for years.

• Catagen phase- Hair stops growing and separates from its follicle, which is the structure beneath the skin that holds the hair in place. The catagen phase lasts about 10 days.

• Telologen phase, the follicle rests for two or three months, and then the hair falls out.

The next anagen phase begins as a new hair grows in the same follicle. Most people lose 50 to 100 hairs per day as part of this natural cycle.

If this cycle is disrupted, or if a hair follicle is damaged, hair may begin to fall out more quickly than it is regenerated, leading to symptoms such as a receding hairline, hair falling out in patches, or overall thinning.

CAUSES Hair-loss is mainly genetic but can be caused by some other factors like sedentary lifestyle, unhealthy diets, ageing and hormonal imbalance and increasing chronic disease like arthritis, cancer, hypertension and depression.

Androgenetic alopecia is the most common form of hair loss for both men and women.

It can be caused by either hormonal or hereditary factors.

Androgenetic alopecia is an androgendependent hereditary disorder in which dihydrotestosterone is a significant contributing factor. The condition affects Caucasian men more than men of other ethnicities. It can start at any age, but approximately 30% of men will experience some hair loss by the age of 30 years, 50% by the age of 50 years, and 80% by the age of 70 years.

TYPES OF HAIR LOSS Male Pattern Hair Loss In men, hair loss can begin any time after puberty and progress over the course of years or decades. It starts above the temples and continues around the perimeter and the top of the head, often leaving a ring of hair along the bottom of the scalp. Many men with male pattern hair loss eventually become bald.

Female Pattern Hair Loss In women, hair slowly thins all over the scalp, but the hairline usually doesn’t recede. Many women experience this type of hair loss as a natural part of aging, although hair loss may begin any time after puberty. Female pattern hair loss can cause hair to thin dramatically, but only rarely does it lead to baldness.

Telogen Effluvium Telogen effluvium, a type of hair loss, occurs when large numbers of follicles on the scalp enter the resting phase of the hair growth cycle, called telogen, but the next growth phase doesn’t begin. This causes hair to fall out all over the scalp without new hair growth.

Telogen effluvium does not generally lead to complete baldness, although some may lose 300 to 500 hairs per day, and hair may appear thin, especially at the crown and temples.

A medical event or condition, such as a thyroid imbalance, childbirth, surgery, or a fever, typically triggers this type of hair loss. Telogen effluvium may also occur as a result of a vitamin or mineral deficiency - iron deficiency is a common cause of hair loss in women - or the use of certain medications, such as isotretinoin, prescribed for acne, or warfarin, a blood thinner.

Starting or stopping oral contraceptives (birth control pills) may also cause this type of hair loss.

Anagen Effluvium Anagen effluvium is rapid hair loss resulting from medical treatment, such as chemotherapy.

These potent and fast-acting medications kill cancer cells, but they may also shut down hair follicle production in the scalp and other parts of the body. After chemotherapy ends, hair usually grows back on its own.

Alopecia Areata Alopecia areata is an autoimmune condition, which means the body’s immune system attacks healthy tissues, including the hair follicles. This causes hair to fall out and prevents new hair from growing.

This condition can affect adults and children, and hair loss can begin suddenly and without warning. Hair from the scalp typically falls out in small patches and is not painful. Hair in other parts of the body, including the eyebrows and eyelashes, may also fall out.

Tinea Capitis Tinea capitis, also called scalp ringworm, is a fungal infection of the scalp that’s a common cause of hair loss in children. This condition causes hair to fall out in patches, sometimes circular, leading to bald spots that may get

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bigger over time. The affected areas often look red or scaly, and the scalp may be itchy. Sores or blisters that ooze pus can also develop on the scalp.

TREATMENTS There are ranges available from pharmacy that encompass a full system for consumers to use that includes supplements, fibres and densifying shampoo, conditioner and elixir. The haircare products help to ensure the scalp is healthy and nourished, while helping the hair to look thicker and fuller.

Minoxidil increases blood flow which stimulates hair follicles, promoting hair re-growth in 4 ways: • Reverses miniaturisation of follicles • Increases blood flow around follicles • Stimulates follicle movement from resting to hair growth phase • Extends each follicle’s growth phase Tinea capitis needs to be treated with oral antifungal medication and a medicated antifungal shampoo to reduce spread of the fungus to other people.

Supplements containing biotin may assist in regrowth. There’s some research to suggest that increased biotin intake can improve overall hair quality, including thickness and shine.

Who? Both men and women can be affected by thinning hair due to a number of factors.Androgenetic alopecia will affect 30% of men will by the age of 30 years, 50% by the age of 50 years, and 80% by the age of 70 years. In addition, up to 13% of premenopausal women experience some degree of androgenetic alopecia.

What are the symptoms? Most people will lose some hair every day.

Patients with androgenetic alopecia experience hair loss with no signs of inflammation or scarring.

How long has the patient had the symptoms? If a patient develops sudden hair loss they should be referred to a GP. Action already taken? Eating a balanced diet can aid hair health.

Medications? Finasteride is only licensed in Ireland for BPH.

HEADACHE AND PAIN

HEADACHE AND PAIN Headache is a universal experience; most people will suffer with one at some point in their lives. Community pharmacy is ideally placed to support people with chronic health conditions such as headaches. Most headaches, including migraine which is very distressing, can be correctly diagnosed with appropriate over the counter remedies and/ or self-care advice provided in a community pharmacy by the community pharmacist and the wider team.

Research has shown that migraine is underdiagnosed and under treated in at least half of patients and that one-third of sufferers can experience significant disability as a result of their migraines at some stage of their lives.

TYPES OF HEADACHE Chronic Daily Headache Chronic Daily headache (CDH) is a descriptive term rather than a specific diagnosis. It can evolve from any primary headache disorder or can be de novo. Studies in the US and Europe indicate that 4-5% of the general population are affected by CDH. It is becoming more frequent and is a major reason for consultation in Headache/Migraine clinics.

Much like migraine, CDH can significantly affect someone’s ability to function within the family, in society and in the workplace.

In general, headaches occurring more often than fifteen days per month, over at least six months and lasting for four hours a day can be considered CDH. People with chronic tension-type headache (CTTH) usually have a history of episodic tension-type headache but may also have no history of migraine. Many people use excessive amounts of analgesics and they may also have concomitant depression.

The overuse of analgesics may convert episodic tension-type headaches into CTTH. Tension-Type Headache Tension-type headache is the most common type of primary headache with a lifetime prevalence of up to 78%. However, episodic tension-type headache requires little intervention from medical professionals as it rarely produces significant disability. It usually presents as a low impact, mild to moderate band-like featureless headache.

Patients with frequent episodic tension-type headache (1-15 days of TTH per month) often have co-existing Migraine without aura.

Patients should be educated to differentiate between the two disorders and encouraged to use a Headache Diary to record individual episodes so that treatment can be maximised and medication-overuse headache avoided.

Tension-type headache (TTH) is usually described as a pain that feels like a tight band round the head or a weight on top of it. The

37

neck or shoulder muscles may also hurt along with the headache. The pain can last from 30 minutes to several days, or may be continuous.

Cluster headache The symptoms of cluster headache are characterised by unilateral (one sided) pain, although for some people the side can vary from time to time. The pain is usually centred over one eye, one temple or the forehead. It can spread to a larger area making diagnosis harder.

During a bout of cluster headache the pain is often experienced at a similar time each day.

The headache often starts at night waking people one to two hours after they have gone to sleep. The pain usually reaches its full intensity within 5 to 10 minutes and lasts at this agonising level for between 30 and 60 minutes. For some people the pain can last for 15 minutes, for others 3 hours has been known. It then stops, usually fairly abruptly.

Sufferers may experience the head pain every other day during a bout, or up to 8 times per day during a bad cluster.

In about 80% of people with cluster headache the bouts (or “clusters”) of head pain last for 4 to 12 weeks once a year often at the same time and often in the Spring or Autumn. It may then disappear for several months or even years. This is known as episodic cluster headache. The reason for this seasonal timing is not completely known, although it is one of the key aspects of diagnosis and may involve a brain area called the hypothalamus.

The remaining 20% of people do not have these pain free intervals and are said to have “chronic cluster headache.”

People who use acute pain-relief medicine more than two or three times a week or more than 10 days out of the month can set off a cycle called ‘medication-overuse headaches’ (MOH).

As each dose of medicine wears off, the pain comes back, leading them to take even more.

MOH can occur with both over-the-counter and prescription pain-relief medicines. They can also occur whether taken for headache or for another type of pain.

It is characteristic of migraine that people have episodic attacks of multiple symptoms (pain, nausea, vomiting, sensitivity to light and sound) but they go back to their usual state of health in between attacks. Medicationoveruse headache, in contrast, is a dull

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constant headache which is often worse in the morning. It is present on most days or part of every day. It is possible to have medication headaches most days with episodic migraine pain superimposed on the ‘headache’.

TREATMENT Painkillers such as paracetamol, NSAIDs (aspirin, ibuprofen and diclofenac) and combined analgesics containing paracetamol can be used as first-line treatment to relieve pain from all headaches. There are also treatments that can be combined with paracetamol, such as buclizine and prochlorperazine to treat the nausea especially associated with migraine headaches.

If the patient is nauseous a soluble painkiller may be recommended as these are absorbed quicker from the stomach.

All over the counter treatments have legal licence specifications which the pharmacy must adhere to. This may sometimes be different from that which applies when the same medication is written on a prescription.

Who? Headache pain is universal.

What are the symptoms? Pain that feels like tightness around the head; nausea, vomiting, sensitivity to light/sound.

How long have they had the symptoms? Can be daily, often occurring more in the morning, for medication-overuse headache pain can present most days; cluster headache bouts of pain can last 4-12 weeks; Migraines are best controlled as soon as the warning signs appear. After-effects can last up to 24 hours.

Action already taken? Paracetamol, aspirin or ibuprofen can be effective.

Medication? Codeine is a major cause of rebound headache.

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HYGIENE AND SANITATION

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HYGIENE AND SANITATION During the current uncertain times, as we fight Covid-19 many people are relying on community pharmacy more than ever before.

Whilst many people are working from home, both GP surgeries and pharmacies continue to be busy and their staff are continuing to help those that are in need.

INFORM BOTH STAFF AND CUSTOMERS One of the most important things to do is inform both your team and also any customers of the procedures you are putting in place to manage hygiene during this time.

We would recommend that you use multiple sign holders and display stands throughout the store and also outside the store to inform people of how the pharmacy will be running and what they need to do during their visit.

Hopefully, with the correct signage, you won’t need to worry about having to continually remind people about rules that you’ve put in place in relation to hygiene.

stickers to visibly display the distancing required. Often, people are more likely to abide by the distancing if they have visible instructions to follow.

ENFORCE RULES TO MINIMISE THE SPREAD OF GERMS

Pharmacy teams who are accustomed to working in close confines, for example in a small pharmacy, may need to reconsider how they work. If the store has a small dispensary, but a larger shop area, it may be appropriate to expand the dispensary into the store. This would allow more space between employees. Although this may not be an ideal working environment, it is important to consider if appropriate social distancing is to be maintained. This temporary measure also prevents the number of customers who could enter the store.

The biggest thing to try and focus on at this time is the spread of germs in the pharmacy.

Often the people coming in will be high risk or even potentially poorly themselves so, you must put rules in place to protect everyone.

Even simple things like avoiding using cash and encouraging contactless card payments can make a big difference.

The majority of contact in a pharmacy is when prescriptions are collected or advice is being given regarding medication so, you should focus on protection at these times.

ENSURE YOU’RE FOLLOWING SOCIAL DISTANCING RULES There is no avoiding the social distancing rules that have been put in place by the government and it is imperative that you ensure everyone in the store is following them.

We would advise you to use sign holders to remind customers of these rules and also restrict the number of people in the pharmacy at one time, especially if your store is quite small.

To help you ensure that people are following these rules, you may also want to use floor

ABUSE FROM PATIENTS AND THE PUBLIC Sadly, some pharmacies have reported abuse from patients. Whether this is a result of panic or anxiety, it is not acceptable. As such, pharmacies should place signs in their window indicating that patients will not be served if they behave inappropriately.

The following should be considered as abuse: • Using inappropriate language or swearing at staff; • Any physical violence towards any member of the team or other patients, such as pushing or shoving; • Verbal abuse towards the staff in any form;

• Racial abuse; • Sexual harassment; • Persistent or unrealistic demands that cause stress to staff.

HYGIENE AND INFECTION CONTROL MEASURES Remind staff of the rules relating to basic handwashing. This may seem like an assumed skill, but it is important to ensure everyone is following the guidance. To reinforce this message, it may be appropriate to have them observe your handwashing technique; although this may appear condescending, it helps emphasise how hands should be washed to prevent the spread of infection.

Consider implementing policies in the pharmacy relating to uniforms, such as whether staff need to wash their uniforms daily. You could also consider whether you can provide more uniforms for staff.

Although the provision of PPE is sporadic, consideration should be given to what the team are wearing. For example all staff should: • Wear short sleeves (or rolled-up sleeves); • Refrain from wearing ties; • Remove wristwatches or jewellery when in the pharmacy — this not only helps prevent the transmission of Covid-19, but will also help with handwashing that encourages inclusion of the wrist.

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For further information on the Kelkin Vitamin range, For more information on promotions and POS, contact your Valeo Healthcare Manager or Sales Rep please contact your Valeo Healthcare salesAccount representative David Keane 087 279 2860 Fintan Byrne 087 647 0764 Eamonn Connolly 087 238 5648

david.keane@valeofoods.ie Moloney 087 699 9344 Fintan Byrne Stephen Eamonn Connolly fintan.byrne@valeofoods.ie Julie Webster 086 462 1723 087 647 0764 087 238 5648 eamonn.connolly@valeofoods.ie

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IMMUNITY BOOSTING SUPPLEMENTS

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IMMUNITY BOOSTING SUPPLEMENTS It is well known that many consumers struggle to ensure they are eating a healthy, balanced diet - the result can be low immunity, and a general lack of energy which will leave them prone to picking up viruses and infections.

Vitamin

EU RDA

Vitamin A

800 mcg

Vitamin B1

1.1 mg

Millions take vitamins and dietary supplements hoping to achieve good health, ease illnesses or defy ageing. Recent years have seen a massive boom in supplement use as products that were once the preserve of specialist health food stores have become more widely available, especially in pharmacy. However, the huge range of dietary supplements now available makes the area something of a minefield for consumers.

Vitamin B2

1.4 mg

Vitamin B6

1.4 mg

Vitamin B12

2.5 mcg

Vitamin C

80 mg

Vitamin D

5 mcg

Vitamin E

10 mg

There are 13 essential vitamins (A, B, C, D, E & K, with 8 vitamins within the B complex).

It should be explained that vitamins and minerals are two completely things.

Folic acid

200 mcg

Mineral

EU RDA

Pharmacy staff should understand the evidence regarding the efficacy of supplements and be able to explain this to patients. They must also be up-to-date on any new products and formulations and be familiar with the benefits of each item.

It is essential that customers feel that they are being recommended the correct VMS for them, not just whichever product is on special offer that particular day.

Calcium

800 mg

Iodine

150 mcg

Iron

14 mg

Magnesium

375 mg

Phosphorus

700 mg

Zinc

10 mg

BUYER CATEGORIES Supplements are products that contain vitamins, minerals, herbs or plant material and come in pill, capsule, tablet or liquid form.

is recommended for women at low risk of conceiving a child with neural tube defects and 5mg daily for those at high risk. Some pregnant women might require additional calcium or iron.

Women are more likely to purchase VMS products than men, as will older people with poor health. Over 50% of children are given vitamins regularly and/or a mineral supplement.

Vitamin C

The Department of Health & Children recommend specific vitamins for specific groups of people, and the EU has daily recommended allowances for vitamins and minerals these are shown in the table.

All of these have been found to have antiviral properties in animal or laboratory studies.

Researchers have been interested in using

Certain vitamins are important for certain people, these are: Vitamin D Vitamin D is recommended for all pregnant and breastfeeding women. Older people also require additional vitamin D and it is recommended for children aged from six months to five years, together with vitamins A and C. Vitamin B9 More commonly known as folic acid, vitamin B9 is recommended for women who are trying to conceive and who are in the first 12 weeks of pregnancy – 400mcg daily

Vitamin C is the most popular single vitamin supplement. Other supplements that people often turn to when they have a cold include zinc and echinacea.

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vitamin C to prevent and treat colds for more than 60 years. Some animal studies have found that vitamin C strengthens resistance to infections. One theory for this is that the vitamin protects cells against oxidative stress.

Vitamin C is not suitable for everyone. It can cause dangerous rises in the blood sugar levels of people with diabetes. It can also be dangerous for people with genetic conditions that cause an excessive build-up of iron in their body, such as haemochromatosis.

Large doses may cause nausea, diarrhoea and stomach cramps.

Refer to the pharmacist anyone with any medically significant conditions.

Zinc Zinc is a trace element that is essential for normal growth. The mineral has been promoted for many years as being able to boost the immune system. Customers purchasing zinc must keep to the recommended dosages. The correct dose is important and there may be side effects including nausea and an unpleasant taste in the mouth, or more serious events such as vomiting, diarrhoea and abdominal pain.

Combination Products Combination products are also growing in popularity, such as combined fish oils and garlic for heart health. In fact, along with multivitamin formulations, products containing fish oils are amongst the highest top-selling supplements in recent years in Ireland.

Who? Certain vitamins are recommended for specific patient groups.

Keep educated on their target populations.

What are the symptoms? Take a full symptom and medical history in order to direct the customer to the most appropriate vitamin/ supplement.

How long have they had the symptoms? N/A Action already taken? Some customers may have already commenced a more balanced and healthy approach to diet and lifestyle, recommend continuation of this to include exercise.

Medication: A full medication history is essential to ensure the right product is selected for the right customer as many vitamins and supplements can cause side effects if used inappropriately.

INDIGESTION AND DYSPEPSIA

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INDIGESTION AND DYSPEPSIA Indigestion or dyspepsia refers to pain or discomfort in the upper abdominal area after eating, while heartburn refers to the burning pain felt behind the sternum associated with acid reflux, which is often accompanied by nausea, water brash or regurgitation of acid or bile.

Giving up smoking may also help, as smoking can exacerbate GORD symptoms by relaxing the lower oesophageal sphincter. Losing weight, if overweight or obese, should also help to control symptoms, but sufferers should avoid over-exertion and exercises like sit-ups, as these can provoke acid reflux.

Dyspepsia usually occurs when stomach acid irritates the stomach lining, oesophagus or top part of the bowel, perhaps after a heavy meal, whereas most cases of acid reflux or gastro-oesophageal reflux disease (GORD) occur due to weakening of the lower oesophageal sphincter.

The symptoms of GORD are often worse at night, especially for overweight individuals, but raising the head of the bed by 20cm by placing blocks underneath it may help.

For anyone experiencing the discomfort associated with heartburn and dyspepsia, finding rapid relief is a top priority. Heartburn and dyspepsia are common gastrointestinal (GI) complaints that, if left unresolved, may negatively affect an individual’s overall quality of life and restrict or limit activities or ingestion of certain foods.

GASTROOESOPHAGEAL REFLUX DISEASE GORD is caused by acid leaking up from the stomach and coming into contact with the oesophagus. While the stomach is able to withstand litres of acid without pain, the gullet is not. GORD has a significant impact on quality of life and productivity, with sufferers reporting impaired sleep and interference with social activities and work.

Incidence of GORD is certainly rising as obesity rates accelerate. People are also binge drinking and eating more fatty or calorific food, which increases acidity levels and contributes to poorer digestive health.

Heartburn, or pyrosis, is characterised as a burning sensation arising from the substernal area and moving toward the neck or throat.

There are 2 main types: postprandial heartburn occurs within 2 hours after a meal, when bending over, or when lying down, and nocturnal heartburn occurs during sleep and often is responsible for interrupting it.

Dyspepsia is pain that manifests in the gastroduodenal region. Symptoms may include postprandial fullness, epigastric pain, and burning.

LIFESTYLE ISSUES Lifestyle modifications can help to ease the severity of symptoms of GORD and dyspepsia, although many patients will also need to take medication. For example, eating smaller, more frequent meals can help to control reflux and indigestion by reducing pressure on the abdomen, as can avoiding dietary triggers, such as coffee, alcohol, citrus fruits, chocolate and fatty foods. These may relax the lower oesophageal sphincter and/or delay gastric emptying.

TREATMENT Antacids are alkali liquids or tablets that provide immediate relief by neutralising excess stomach acid, although the effects are often short-lived so extra doses may be needed. Care should be taken to avoid taking antacids alongside other medicines, as they can interfere with absorption or damage the coating of certain tablets.

Alginates protect the oesophagus by forming a barrier or ‘raft’ over the top of the stomach contents, helping to suppress the backflow of acid.

Antacids and alginates are available in combination to provide dual action relief against both heartburn and indigestion.

For patients with persistent symptoms that are not relieved by antacids or alginates, acid suppressants are available, including histamine H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs).

H2 blockers, such as cimetidine and famotidine, prevent the parietal cells in the stomach from responding to histamine by releasing acid.

PPIs, such as lansoprazole and omeprazole are more commonly prescribed or recommended for managing GORD than H2 antagonists, and are also used to treat

H. pylori infections. They work by reducing the production of stomach acid by inhibiting the hydrogen-potassium adenosine triphosphatase enzyme system, otherwise known as the ‘proton pump’. This reduction in acid reduces reflux symptoms, helping to heal the oesophagus as well as ulcers in the stomach or duodenum.

DYSPEPSIA IN PREGNANCY Most people are affected by indigestion from time to time, but women are often affected by it while they are pregnant. As many as 8 out of 10 women experience indigestion at some point during their pregnancy. Indigestion tends to become more common as the baby develops.

Indigestion during pregnancy is mainly due to changes that occur in the body, such as rising levels of hormones and increased pressure on the abdomen.

These changes can often result in acid reflux, the most common cause of indigestion.

Some women may find that their indigestion gets worse as their pregnancy progresses.

However, in most cases, after giving birth, the symptoms disappear. Indigestion during pregnancy rarely causes complications.

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Who? 73% of people can experience indigestion and heartburn interchangeably. As many as eight out of 10 women experience indigestion at some point during their pregnancy.

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What are the symptoms? Pain in the lower chest, abdomen or top of the stomach, feeling bloated, needing to burp or pass wind, nausea or vomiting and loss of appetite.

H

How long have they had the symptoms? The symptoms are usually experienced after eating or drinking, but there can sometimes be a delay between eating a meal and developing indigestion. Women may experience indigestion at any point during their pregnancy.

Symptoms may be more frequent and severe during the third trimester.

A

Action already taken? People may have taken antacids but not be aware how to eliminate triggers until they start to keep a food diary.

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Medication? Antacids can be taken safely during pregnancy to treat indigestion.

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References: 1. Merry A, et al. AFT-MX-1, a prospective parallel group, double-blind comparison of the analgesic effect of a combination inhibiting drug, an anti-inflammatory drug and thiazide diuretic at the same time increases the risk of renal impairment. Blood of paracetamol and ibuprofen, paracetamol alone, or ibuprofen alone in patients with post-operative pain. Department of Anaesthesiology, dyscrasias have been rarely reported. Patients on long-term therapy with ibuprofen should have regular haematological monitoring.

University of Auckland, New Zealand 2008. *compared with the same daily dose of standard paracetamol or ibuprofen alone.

Like other NSAIDs, ibuprofen can inhibit platelet aggregation. GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at anytime during treatment. Combination therapy with protective agents (e.g. misoprostol or proton pump Easolief Duo 500 mg/150 mg film-coated tablets Each tablet contains paracetamol 500 mg and ibuprofen 150 mg. inhibitors) should be considered. Use with concomitant NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided.

Presentation: A White, capsule shaped tablet with breakline on one side and plain on the other side. Indications: Short-term NSAIDs may lead to onset of new hypertension or worsening of pre-existing hypertension and patients taking antihypertensive symptomatic treatment of mild to moderate pain. Dosage: Adults/elderly: The usual dosage is one to two tablets taken every medicines with NSAIDs may have an impaired anti-hypertensive response. Fluid retention and oedema have been observed in six hours up to a maximum of six tablets in 24 hours. Children: Easolief Duo is contraindicated in children under 18 years. some patients taking NSAIDs. NSAIDs may very rarely cause serious cutaneous adverse events such as exfoliative dermatitis, toxic Contraindications: Severe heart failure, known hypersensitivity to paracetamol, ibuprofen, other NSAIDs or to any of the epidermal necrolysis and Stevens-Johnson syndrome. Products containing ibuprofen should not be administered to patients with excipients, active alcoholism, asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid or other NSAIDs, history acetylsalicylic acid sensitive asthma and should be used with caution in patients with pre-existing asthma. Adverse ophthalmological of gastrointestinal bleeding or perforation related to previous NSAID therapy, active or history of recurrent peptic ulceration/ effects have been observed with NSAIDs. For products containing ibuprofen aseptic meningitis has been reported only rarely. NSAIDs haemorrhage, severe hepatic failure or severe renal failure, cerebrovascular or other active bleeding, blood-formation disturbances, may mask symptoms of infection and fever. Interactions: Warfarin, medicines to treat epilepsy, chloramphenicol, probenecid, during the third trimester of pregnancy. Warnings and precautions: This medicine is for short term use and is not recommended zidovudine, medicines used to treat tuberculosis such as isoniazid, acetylsalicylic acid, other NSAIDs, medicines to treat high blood for use beyond 3 days. Clinical studies suggest that use of ibuprofen, particularly at a high dose may be associated with a small pressure or other heart conditions, diuretics, lithium, methotrexate, corticosteroids. Refer to summary of product characteristics for increased risk of arterial thrombotic events. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic other interactions. Fertility, pregnancy and lactation: Easolief Duo is contraindicated during the third trimester of pregnancy. heart disease, peripheral arterial disease and/or cerebrovascular disease should only be treated with ibuprofen after careful Driving and operation of machinery: Dizziness, drowsiness, fatigue and visual disturbances are possible after taking NSAIDs. consideration and high doses should be avoided. Careful consideration should be exercised before initiating long-term treatment If affected patients should not drive or operate machinery. Undesirable effects: Dizziness, headache, nervousness, tinnitus, of patients with risk factors for cardiovascular events. The use of paracetamol at higher than recommended doses can lead to oedema, fluid retention, abdominal pain, diarrhoea, dyspepsia, nausea, stomach discomfort, vomiting, flatulence, constipation, slight hepatotoxicity, hepatic failure and death. Patients with impaired liver function or a history of liver disease or who are on long term gastrointestinal blood loss, rash, pruritus, alanine aminotransferase increased, gamma-glutamyltransferase increased, abnormal liver ibuprofen or paracetamol therapy should have hepatic function monitored at regular intervals. Severe hepatic reactions, including function tests, blood creatinine increased and blood urea increased. Refer to Summary of Product Characteristics for other adverse jaundice and cases of fatal hepatitis, though rare, have been reported with ibuprofen. Paracetamol can be used in patients with effects. Pack size: 24 tablets. Marketing authorisation holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Marketing chronic renal disease without dosage adjustment. There is minimal risk of paracetamol toxicity in patients with moderate to severe authorisation number: PA0126/294/1. Medicinal product not subject to medical prescription. For retail sale through pharmacy only. renal failure. Caution should be used when initiating treatment with ibuprofen in patients with dehydration. The use of an ACE A copy of the summary of product characteristics is available upon request. Date prepared: October 2019. 2019/ADV/EAS/120H.

MILD TO MODERATE PAIN

45

MILD TO MODERATE PAIN The management of pain places a huge burden on health resources, with the number of patients seeking help for chronic pain increasing due to Ireland’s ageing population.

Oral analgesics are commonly used for relieving pain such as headache, menstrual pain, toothache, back pain and arthritis. Some analgesics work on the body’s peripheral and central nervous systems to block or decrease sensitivity to pain. Others act by inhibiting the formation of certain chemicals in the body that mediate pain. Oral forms include capsules, syrups, suspensions and powders.

Over the counter (OTC) analgesics containing codeine or dihydrocodeine in combination with other analgesics, such as paracetamol or ibuprofen, are intended for short-term use (no longer than three days) to minimise dependence and addiction. Concerns that codeine or dihydrocodeine containing analgesics are being taken regularly should be discussed with the patient and the patient should be encouraged to seek medical advice and access appropriate services.

The biggest problem areas are the lower back, knee, back, shoulder and hip. But it can also involve living with pain in the foot, abdomen, head or ankle.

TYPES OF PAIN Acute or short-term pain usually has a sudden onset and a clearly identifiable cause, such as sustaining a burn while cooking, and lasts no longer than a few days.

While unpleasant, it often serves a useful purpose in triggering reparative action, eg taking a baking tray out of the oven with bare hands causes pain that results in the individual dropping the tray, thereby minimising further damage. Addressing the cause usually resolves the problem, eg taking heat out of the burned area by applying a towel soaked in cold water.

• Recurrent or intermittent pain is acute pain that comes and goes, for example, toothache. Again, addressing the issue usually eases the pain, though the exact cause may be difficult to pinpoint and some conditions – period pain, for instance – require regular management, though usually not for long on each occurrence.

• Chronic pain differs from recurrent pain in that it is unrelenting, though there will be times when it feels more severe than others, and it lasts three months or longer. The cause is usually a long-term condition such as arthritis, though it may be less specific, for example a painful back.

Chronic pain can have a huge effect on quality of life, causing problems with mobility, dexterity, sleep and concentration. It often results in the sufferer changing how they live in order to cope. This, in turn, can have a huge bearing on emotional wellbeing, causing anxiety, helplessness and depression.

Approaches to Management In terms of management, a good approach is the ‘analgesic ladder’ advocated by the World Health Organisation. Originally developed to help improve the management of cancer pain, the stepwise tactic is equally applicable to many painful conditions:

• Step 1 (mild pain): non-opioid, eg aspirin, paracetamol or an NSAID, with an adjuvant if appropriate. If the pain persists or worsens, move to step 2.

• Step 2 (mild to moderate pain): weak opioid, eg codeine, with or without a nonopioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 1. If it persists or worsens, move to step 3.

• Step 3 (moderate to severe pain): strong opioid, eg morphine, with or without a non-opioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 2.

TREATMENT OPTIONS Various formulations and dosage forms are available for the self-treatment of pain, and pharmacists can help patients choose the one that meets their needs. Helping customers choose the right topical analgesic for their individual needs is key if they are to gain optimum benefit.

Musculoskeletal pain Topical analgesics are recommended for targeted relief where pain is localised to a

W W H A M

small area. This may also help with adherence.

Improved adherence may also depend on the site of pain. For superficial joints with easy access, such as the hand, adherence may be easier than for larger, deeper joints, such as the hip.

Patient confusion regarding the wide array of topical products and formats available can also hinder usage. Consumers want help and reassurance when it comes to self-treating.

For the treatment and management of musculoskeletal injuries and disorders, many patients commonly use non-prescription topical analgesics. Available in several different formulations, including gels, ointments, creams, lotions, sprays, and patches, and as single entity or combination formulations, these products may have local analgesic, anesthetic, antipruritic and/or counterirritant effects.

Topical OTC treatments broadly divide into those with active ingredients and those that are drug-free. OTC options are suitable for treating acute musculoskeletal problems, such as soft tissue injuries (e.g. sprains, which are an injury to the ligament, or strains – an injury to the muscle fibres).

OTC treatments can also be used in chronic conditions such as persistent back pain and osteoarthritis (OA).

Who? Anyone.

What are the symptoms? Pain in one or more sites in the body.

How long have they had the symptoms? If the pain lasts longer than three months it is considered chronic.

Action already taken? The patient may have already used OTC pain relief.

Medication? Opioids to be used sparingly due to addictive properties.

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For topical use only. Cleanse and dry the affected area before applying. A copy of the summary of product characteristics is available upon request. The active ingredient in Caldesene Medicated Powder is Calcium Undecylenate 10% w/w, 20g, 55g, 100g pack size. For supply through general sale. PA 126/152/1 PA Holder: Clonmel Healthcare Ltd., Waterford Road, Clonmel, Co. Tipperary. Date Prepared: October 2019. 2019/ADV/CAL/112H

NAPPY RASH

49

NAPPY RASH Ireland now has the highest birth rate in Europe and the baby retail market has shown positive growth. Pharmacies have significant advantages over supermarkets, mainly because pharmacy staff can offer advice and expertise that the supermarkets do not offer.

Nappy rash is one of the most common skin conditions in babies and it is also the most common skin problem in early childhood.

Most children aged 0-3 years old develop nappy rash in some way and it is usually presents in babies from 6-8 months.

WHAT IS NAPPY RASH Nappy rash can be caused by a number of factors including a combination of excess moisture, warmth, urine, faeces and friction in a baby’s nappy. It is a difficult environment for baby skin.

The nappy creates an enclosed area around the bottom and this increases warmth, moisture and encourages the growth of microorganisms that can cause infection. Chafing, due either to skin rubbing against the nappy, or from skin folds, can damage and irritate the skin and ongoing contact of the skin with urine, faeces or both, can lead to a formation of ammonia which can irritate a baby’s skin.

There is also a common link made between nappy rash and teething, as well as the transition to solid foods.

CAUSES AND TYPES There are various causes of a nappy rash.

Examine the rash and explain what type it is and how to treat it most effectively.

Nappy rash can occur a baby soils or wets itself and the nappy is left on for a longer time than usual, the urine and faeces can encourage the production of the chemical ammonia, which can irritate the baby’s skin, causing it to become sore and inflamed.

Where there has been close contact with the nappy, the baby’s skin will look red and inflamed. Most affected will be the genitals, the outer skin on the folds of thighs, and the bottom. The affected areas can appear either dry or moist, and look shiny or pimply.

The best way to treat this is to keep the bottom as clean and dry as possible and change nappies often. It’s also a good idea to apply a barrier ointment/cream or medicated powder after every change.

Fungal Nappy Rash Fungal nappy rash is often a complication

of initial nappy rashand looks different. If the baby’s skin is warm and damp for long periods of time, it can cause the fungus ‘candida’, to grow. Like ammonia, candida can irritate the baby’s skin. The area of skin will be inflamed, with spots around the edges.

The infection will be bright red and also present in the folds of the skin.

There are a number of treatments for severe nappy rash.

• Corticosteroids help to reduce the inflammation of the skin and relieve any itching and redness.

Severe Nappy Rash

• Hydrocortisone cream, which should only be applied once a day should not be used for more than seven days

If a patient’s baby has severe or reoccurring nappy rash, they should be advised to visit their GP as it will usually require prescribed medication. Nappy rash should clear up within a few days of over the counter treatment.

• An anticandidal medicine helps to treat any fungal infection that may cause a rash.

Some commonly prescribed anticandidal medicines include: Clotrimazole, econazole, ketoconazole, miconazole and nystatin.

W W H A M

Who? Predominantly newborn babies up to one year of age.

What are the symptoms? Nappy rash can affect the genitals, the outer skin on the folds of the thighs and the buttocks. The affected areas can appear either dry or moist and may sometimes look shiny or pimply.

How long has the patient had the symptoms? Severe nappy rash or recurring nappy rash should be referred.

Action already taken? Parents may already be following self-care tips such as leaving baby’s nappy off and changing regularly.

Medication? If baby’s rash is caused by thrush, don’t use a barrier cream or ointment, as this can make the rash worse.

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OMEGA 3

51

OMEGA 3 Fish oils are sometimes called the beauty and brains supplement. The DHA ingredient in fish oils is known to be a building block for brain and nerve formation.

Fish oils are a type of polyunsaturated fatty acids (PUFAs). They are the omega-3 and omega-6 fatty acids. Regarding heart health, the active ingredients in fish oils are DHA and EPA. The hypothesis is that omega-3s offer protection from cardiovascular disease by reducing the heart’s susceptibility to arrhythmias, decreasing platelet aggregation and lowering blood pressure and triglyceride levels.

Fish oil’s popularity has soared in recent years, propelled by research that suggests consuming omega-3 fatty acids can ward off heart disease. It is added to baby formulas to support brain and nerve development.

Community pharmacists play an important role in helping patients make informed decisions about fish oil and omega-3 supplementation.

But with hundreds of OTC options available (and labels claiming that the supplements treat everything from bipolar disorder to menstrual cramps) how can pharmacists distinguish between them to help patients make the best choice?

IMPORTANCE OF FISH OILS Sold by pharmacists since the early years of the 20th century, cod liver oil is one of the oldest and most well-known food supplements. The oil first gained its reputation as an effective preventative against rickets because of its high vitamin D content and it was taken by generations of children, decreasing in popularity only when, in the 1960s, the British government decided to phase it out as a welfare food.

There is little doubt that n-3 fatty acids have an important role in nutrition. They are significant structural components of the phospholipid membranes of tissues throughout the body, particularly in the brain and retina. Because of their role in cell membranes, n-3 fatty acids are essential for the formation of new tissue and are therefore important for development and growth (eg, during foetal and infant development).

For optimal foetal health, women can be advised to take a DHA dominant Omega-3 oil from the start of their pregnancy.This is particularly important as fish consumption is usually reduced during pregnancy due to the heavy metals found in fish.

Long chain n-3 fatty acids (and other fatty acids) are present in breast milk and European Union regulations now allow their addition to infant formulas.

THE EXTRACTION PROCESS There are various methods for extracting the Omega 3 oil. The most effective

and environmentally friendly method is ‘Supercritical CO2 Extraction’. Molecular Distillation can also be used - This method heats the oils to over 200 degrees Celsius, affecting the quality of the Omega 3 oil.

Supercritical CO2 Extraction will: • Protect the Omega-3 from oxidation during processing • Provide higher purity Omega-3 • Reduces the odour (fishy aftertaste) • Has a lower environment impact • Removes unnecessary saturated fats and cholestorol

ASSISTING AND ADVISING Pharmacy team should be aware of, and understand, the following key points:

W W H A M

• Those who could benefit from an increased intake of n-3 fatty acids. The typical Irish diet contains relatively low amounts of these.

• Fish oil appears to reduce the risk of CHD. It may help to reduce the risk of thrombosis (by increasing bleeding tendency), reduce blood levels of triacylglycerols, prevent atherosclerosis and arrhythmias and reduce blood pressure.

• Fish oil may have a role in various mental disorders, such as depression, schizophrenia and Alzheimer’s disease, but research in this area is in its infancy.

• Fish oil supplements appear, in general, to be safe. However, patients on anticoagulants or with blood clotting disorders should be monitored.

• Fish oil could have beneficial effects in inflammatory conditions such as rheumatoid arthritis, Crohn’s disease and ulcerative colitis, but evidence of any benefit in asthma and psoriasis is poor.

Who? Certain vitamins are recommended for specific patient groups.

Keep educated on their target populations.

What are the symptoms? Take a full symptom and medical history in order to direct the customer to the most appropriate vitamin/ supplement.

How long have they had the symptoms? N/A Action already taken? Some customers may have already commenced a more balanced and healthy approach to diet and lifestyle, recommend continuation of this to include exercise.

Medication: A full medication history is essential to ensure the right product is selected for the right customer as many vitamins and supplements can cause side effects if used inappropriately.

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Mylan IRE Healthcare Ltd, Newenham Court, Northern Cross, Malahide Road, Dublin 17, Ireland. www.mylan.ie Job code: CB12-2019-0161 Date of preparation: June 2019

ORAL HEALTH

53

ORAL HEALTH Given the recent trend in teeth whitening, oral health has become big business, and pharmacies are usually the first port of call. Patients are in need of more than just toothpaste, however, and improving oral hygiene is paramount and can prevent many illnesses from emerging. In addition to what you recommend, it is good to also provide trips on general oral hygiene. These tips include: • regularly (twice daily) brushing teeth and gums using a fluoride toothpaste • flossing between teeth using dental floss, dental tape, or interdental brushes • keeping the tongue clean (Gently brush the tongue a couple of times to remove bacteria and freshen breath when brushing teeth) In addition to those seeking good oral health, there will be patients who have already developed illnesses related to poor oral hygiene.

The most common are Gingivitis and Halitosis.

GINGIVITIS Gingivitis is a form of periodontal disease. Periodontal disease is the inflammation and infection that destroys the tissues, such as the gums, ligaments and the tooth sockets, which support the teeth. This is caused by a build-up of plaque over periods of time and is caused by poor dental hygiene, undiagnosed diabetes or a poor diet.

Who? Adults are more likely to present to the pharmacy with gingivitis, especially smokers, those with a poor diet and some experts believe women on some of the contraceptive pills may be extra-susceptible.

The disease can often remain silent for many years and will only present itself when the gums become swollen or bleed. Gum disease can result in teeth loss.

Patients who smoke or suffer from diabetes are at a higher risk of developing the disease.

How long has the patient had the symptoms? Gingivitis can be present for years without the patient knowing.

If a patient presents with symptoms of gingivitis, they should have their teeth professionally cleaned and they should also be advised to practice good oral hygiene. In order to prevent a build-up of plaque, toothbrushes or water irrigation devices can be advised, along with anti-bacterial mouthwashes and anti-plaque or anti-tartar toothpastes. Soft bristle brushes should be used and the recommended time for cleaning the teeth is two minutes.

Who? People, who have poor oral hygiene. The problem can affect anyone of any age.

What are the symptoms? Bad breath How long has the patient had the symptoms? If the patient has persistent bad breath that cannot be resolved, it may be a symptom of another condition. A referral should be made to a doctor, dentist or health hygienist.

Medication: Customers who express concern about sensitive teeth should choose a product formulated to reduce this.

What are the symptoms? Swollen or bleeding gums

Actions already taken? Patients may have already attended their dentist and are looking for pharmacy over-the-counter solutions.

Medication: Customers who express concern about sensitive teeth should choose a product formulated to reduce this.

HALITOSIS Halitosis or bad breath can be caused by excessive amounts of volatile sulphur compounds (VSCs) being produced by bacteria in the mouth. This can be influenced by any number of factors, such as eating, drinking, oral hygiene, sleeping and the effect that these activities have on saliva flow. Mouthwashes will reduce halitosis, due to the anti-microbial influences of the products.

MOUTH ULCERS Mouth ulcers are painful sores inside the mouth that are not related to poor oral hygiene. They may occur on the tongue, the lining of the cheeks, the gums, the inside of the lips, or the soft palate on the back of the roof of your mouth. Common symptoms of mouth ulcers include the following: • A burning, tingling, or prickling sensation, up to 24 hours before the sore appears • Crater-like ulcers that are white, grey, or yellow in colour, with a red border • Sores are usually painful • Difficulty speaking, eating, or swallowing Over-the-counter pain medications such as ibuprofen, acetaminophen, or naproxen can be used to help with discomfort from mouth ulcers. Zinc lozenges or vitamins B and C may also help relieve symptoms.

In addition, oral antiseptic rinses may aid in the healing of lesions. Sufferers should be advised to seek care from their GP if symptoms worsen, show no signs of improvement after 7 days of self-treatment, or do not heal in 14 days.

Who? Those suffering from mouth ulcers.

What are the symptoms? Ranging from burning and tingling before sores appear, pain in the mouth.

How long have they had symptoms? Symptoms will usually clear up within 7 days of treatment.

Action already taken?

Sufferers may already be aware of tell-tale signs.

Medication: If using Ibuprofen avoid smoking or drinking large amounts of alcohol.

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OSTEOARTHRITIS

55

OSTEOARTHRITIS Osteoarthritis is caused by wear and tear of cartilage in the joints. It is the most common form of arthritis in Ireland. In osteoarthritis, the surface of a joint becomes damaged and the surrounding bone grows thicker.

Osteoarthritis occurs when there is damage in and around the joints that the body cannot fully repair. It’s not clear exactly why this happens in some people, although the chances of developing the condition can be influenced by a number of factors, such as age and weight.

There are many different types of osteoarthritis, which can affect a number of the body’s joints.

The knees are the most common sites for osteoarthritis. The hips, hands, spine and big toes are also often affected.

The pain and stiffness in the joints can make carrying out everyday activities difficult for some people with the condition.

The condition affects 400,000 people in Ireland. There has been an increase in the number of people with osteoarthritis in Ireland for two reasons; our ageing population and more obese people putting an increased strain on their joints.

Osteoarthritis is more common and often more severe in women, especially in the knees and hands. It often starts after the menopause.

Osteoarthritis usually develops in people over 45 years of age, although younger people can also be affected. It is commonly thought that osteoarthritis is an inevitable part of getting older, but this is not quite true.

People may in fact be able to reduce their chances of developing the condition by doing regular, gentle exercises and maintaining a healthy weight.

Most people with osteoarthritis can carry on with a normal life. Symptoms can peak for a few years, and then subside. For others, one or more joints may worsen, causing pain and disability. Unfortunately, it is difficult to predict the outcome for a person affected with the condition.

TREATMENTS There’s no cure for osteoarthritis, but the condition doesn’t necessarily get any worse over time and a number of OTC treatments are available to help relieve the symptoms.

One of the main treatments for osteoarthritis is changes to lifestyle – such as maintaining a healthy weight and exercising regularly.

SYMPTOMS

Topical gel - pharmacists will be able to advise on the use of topically applied gel to ease joint pain associated with osteoarthritis.

Gels work by delivering lubricating ingredients directly into joints that have become damaged due to osteoarthritis. By improving lubrication within the joints they can relieve pain and reduce joint stiffness. They can be used safely with other medicines.

Stiff and painful joints are the main symptoms.

Symptoms vary from one person to the next.

The level of physical activity can make a difference. The weather (especially damp and low pressure) may affect symptoms.

Painkillers - the type of painkiller (analgesic) you may recommend will depend on the severity of the pain and other conditions or health problems the patient has. Paracetamol is often used in the first instance and sufferers

Pain tends to be worse on exercising the joint and at the end of the day. The joints do not move as freely as normal and may cause a ‘cracking’ sound when moved.

In osteoarthritis of the knee, pain is felt at the front and sides of the knee, and in severe causes it causes the legs to become bent (bow-legged). With hip joints, the pain is usually in the front of the groin, but can radiate around the side and front of the thigh, the buttock and even down to the knee.

Sometimes when osteoarthritis is severe, the affected leg may shorten.

With knee and hip osteoarthritis, daily tasks such as going up or down stairs can become difficult to perform. Mobility can be affected due to pain and walking.

A complication of osteoarthritis, especially knee osteoarthritis, is calcification, which is when chalky deposits of calcium crystals form in the cartilage of joints. This process tends to make the osteoarthritis more severe and painful.

W W H A M

can be advised to take it regularly rather than waiting until the pain becomes unbearable.

Opioids, such as codeine, are another type of painkiller that may ease pain if paracetamol does not work. Opioids can help relieve severe pain, but can also cause side effects such as drowsiness, nausea and constipation.

In some circumstances a non-steroidal antiinflammatory drug (NSAID) may be prescribed as a painkiller by a GP. NSAIDs are painkillers that work by reducing inflammation. Some NSAIDs are available as creams (topical NSAIDs) that you apply directly to the affected joints. Some topical NSAIDs are available without a prescription.

Capsaicin cream - a GP may prescribe capsaicin cream if a patient has osteoarthritis in the hands or knees and topical NSAIDs haven’t been effective in easing the pain.

Capsaicin cream works by blocking the nerves that send pain messages in the treated area.

The patient may have to use it for a while before it has an effect.

Steroid injections - steroids are a type of medication that contain man made versions of the hormone cortisol, and are sometimes used to treat particularly painful musculoskeletal problems. Some people with osteoarthritis may be offered steroid injections when other treatments haven’t worked.

Who? Osteoarthritis usually develops over the age of 45. It is more common and severe in women than men.

What are the symptoms? Pain and stiffness in the joints, joint tenderness, increased pain and stiffness when a person has not moved their joints for a while, joints appearing slightly larger or more ‘knobbly’ than usual, a grating or crackling sound or sensation in the joints, limited range of movement in the joints.

How long have they had the symptoms? Medical help should be sought if a patient has persistent symptoms.

Action already taken? Lifestyle changes, such as exercise and losing weight, can help to relieve symptoms.

Medication? There’s no cure for osteoarthritis, but the condition doesn’t necessarily get any worse over time and a number of treatments are available to help relieve the symptoms.

DON’T LET PAIN HOLD YOU BACK

ESSENTIAL INFORMATION Solpa-Extra 500mg/65mg Soluble Tablets contain paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and children over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Children 12-15 years: 1 tablet disolved in water every 4-6 hours. Max 4 tablets a day. Not suitable for children under 12 years. Contraindications: Hypersensitivity to the ingredients. Precautions: Particular caution needed under certain circumstances, such as renal or hepatic impairment, chronic alcoholism and malnutrition or dehydration. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Patients should be advised not to take other paracetamol containing products concurrently. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions.

Unknown: nervousness, dizziness. Further information is available in the SmPC. PA 1186/017/001. P. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

Date of preparation: July 2020. Not subject to medical prescription.

PAIN

57

PAIN Oral analgesics are used commonly for relieving pain such as headache, menstrual pain, toothache, back pain and arthritis. Some analgesics work on the body’s peripheral and central nervous systems to block or decrease sensitivity to pain. Others act by inhibiting the formation of certain chemicals in the body that mediate pain.

They are available in various oral forms such as tablets, capsules, syrups, suspensions and powders. The analgesics market has experienced its fair share of ups and downs in recent years but is still growing and is likely to continue doing so.

TYPES There are two kinds of analgesics: Non-opioid: Non-opioid analgesics include paracetamol and non-steroid anti-inflammatory drugs (NSAIDs) such as Aspirin and Ibuprofen.Non-opioid analgesics are the first choice analgesics for treating mild to moderate pain and are also used in moderate to severe pain to potentiate the effects of opioids.

Opioid: Opioid analgesics block or decrease sensitivity to pain in the body’s peripheral and central nervous systems. Most of the opioid analgesics are prescription-only medicines and are suitable for moderate to severe pain, particularly of visceral origin.

They can be further classified into two categories: mild and potent opioids. Mild opioid analgesics include codeine and tramadol.

Strong opioid analgesics examples are morphine and methadone.

General Advice when taking Oral Analgesics • Always follow the dosage instructions on the packaging or as instructed by your doctor or pharmacist. Do not take more than the recommended dose as this will increase the risk of serious side effects.

• Painkillers should not be shared with anyone else, as different people may experience pain with different cause and severity.

• Avoid drinking alcohol if you are taking analgesics as it may increase the risk and severity of side effects of the medicines.

WARNINGS FOR ORAL ANALGESICS Paracetamol: Taking excessive amounts can cause Liver damage and less frequently kidney damage following over doses. It should be used with caution for patients with impaired kidney or liver function, alcohol dependence, chronic malnutrition or dehydration NSAIDS: These should always be taken with food or milk.

The medication should be stopped immediately

and the patient referred to a GP if the patient has abnormal or black stools. Those taking NSAIDS should avoid smoking and drinking large amounts of alcohol as these activities can increase the risk of developing a stomach ulcer

ORAL PAIN Oral pain is a big market for analgesics.

Many common conditions cause oral pain or discomfort. Examples of these conditions include cold sores, toothaches; tooth sensitivity; teething; minor oral mucosal injury or irritation; oral mucosal disorders, such as recurrent aphthous stomatitis ([RAS]; and xerostomia (dry mouth).

There are OTC products available for the selftreatment of each of these sources of oral pain and discomfort, including topical analgesics/ anaesthetics, toothpastes formulated for sensitive teeth, artificial saliva products for dry mouth, and oral mucosal protectants, as well as products that provide treatment of and relief from pain due to cold sores. In general, the goals involved in the treatment of minor oral pain are to provide immediate symptomatic relief from discomfort and irritation and to promote healing.

W W H A M

Patients should be assessed for the appropriateness of therapy and educated on the proper use of these products. Pharmacy teams should advise patients to seek medical care if their conditions worsen or show signs of infection. In an effort to self-medicate, some patients may try using analgesics to ward off pain caused by more serious health conditions and pharmacy staff are in an ideal position to monitor such situations without being too intrusive.

DENTAL PAIN Toothache is pain in and around the teeth and jaws that is most often caused by tooth decay.

The pain usually starts suddenly and it can vary from mild discomfort to a severe throbbing, which is often worse at night. The area of the jaw close to the infected tooth may also be sore and tender to the touch. Toothache can either come and go or be constant. Eating or drinking can make the pain worse, particularly if the food or drink is hot or cold. Painkillers such as paracetamol and ibuprofen may help reduce pain and discomfort whilst sufferers are waiting for an appointment.

Who: Those suffering from pain such as dental pain.

What are the symptoms? Pain anywhere in the body.

How long have they had symptoms? Symptoms will usually clear up within 7 days of treatment.

Action already taken? Sufferers may already have tried analgesics. If the pain persists longer than 2 weeks, the patient should be referred to a GP. Medication: Check for underlying conditions before suggesting a specific pain relief, see the warning box above.

PAIN IN CHILDREN

59

PAIN IN CHILDREN It can be a challenge to recognize the symptoms of pain in children. Are they really hurting, or are the parents overreacting? Pain is a highly individual and complex experience.

Here we take a look at reading the symptoms of pain in children.

SYMPTOMS OF PAIN IN CHILDREN AND ADOLESCENTS Chronic or recurrent pain is common in children and adolescents. Research has shown that as many as 30% to 40% complain of pain at least once a week.

Acute abdominal pain. Pain that comes on suddenly can be caused by viral infections or by something more serious like appendicitis. If a child’s pain seems to be localised to the right of the belly button and is accompanied by nausea, vomiting, and desire to stay very still, they should be evaluated for appendicitis.

Recurrent stomach aches and headaches.

A stomach ache that goes away after a bowel movement could signal a problem with constipation or, less often, inflammatory bowel disease. Daily abdominal pain without nausea, vomiting, or diarrhea could be a special form of migraine, or could fall under the category of chronic recurrent abdominal pain, a common but frustrating complaint in children.

SYMPTOMS OF PAIN IN TODDLERS Fortunately, at this age, children in pain can talk.

They will often also clutch the part that hurts.

Pulling or rubbing the ear is common in toddlers and although it can sometimes indicate ear pain, it may be a habit. Suspect an ear infection if the child has had cold symptoms or a fever and begins to tug at the ear suddenly.

SYMPTOMS OF PAIN IN BABIES Unlike with older children, crying isn’t always a reliable pain indicator in babies. That’s because crying is a baby’s way of expressing a whole host of needs. Here are signs that a baby may be in pain.

Changes in crying patterns. A baby’s distressed cry sometimes, but not always, sounds different from ordinary crying. Changes in a baby’s behavior can also be a tip-off. For example, crying that can’t be soothed with a bottle, diaper change, or cuddling could signal pain. Also, a calm baby who becomes unusually fussy could be in pain.

Crying while nursing. The baby who cries while nursing could very well have a painful ear infection.

Prolonged, intense crying, often at the same time each day. This behavior is common with colic. It often starts at the age of 2 weeks, peaks at 6 weeks, and then gradually declines.

Crying and drawing the legs up to the abdomen. The baby could have colic or a serious medical condition.

Withdrawing. Chronic pain can sap a baby’s energy, causing him or her to become still, quiet, and to avoid eye contact.

ASSISTING & ADVISING Communicating with and involving children in taking their medications will have a significant impact on their adherence. Children take responsibility for their medications at different ages. Children are often not present when their parents collect their medications from the pharmacy and, therefore, this prevents them from receiving support and advice from community pharmacists so ensure parents are well educated on the symptoms, medications and side effects.

Communication: • Check parents understand what the medication is for and supplement knowledge if needed; • Ensure parents are aware of the most common adverse effects and what to do if these occur; • Explain what to do if their child misses a dose; • Explain anything relevant to the particular medication (e.g. to take phenoxymethylpenicillin on an empty stomach); • Check parents understand how to administer the medication to their child.

TREATMENT Discomfort during an illness is often due to associated pain; e.g. myalgia, sore throat, headache. Ibuprofen and paracetamol may be considered to improve comfort (with accompanying improvements in feeding activity and irritability), because they may also provide relief from pain and may reduce the risk of dehydration. They should be used to make the child more comfortable and not used routinely

W W H A M

with the sole aim of reducing the temperature.

The use of antipyretic medication and attention to the fever must not detract from monitoring the child’s activity and level of consciousness (as an indicator of worsening illness) and paying attention to adequate hydration.

Both paracetamol and ibuprofen are safe and effective for short-term use in children.

The practices of combining or alternating paracetamol and ibuprofen have limited value and are not recommended. Dose of antipyretic medication in children should be accurately based on body weight and should not merely be estimated. For accurate dosing, liquid medicines should be administered with a syringe. The use of NSAIDs has been associated with an elevated risk of severe skin and soft-tissue infections in patients with varicella zoster virus infection. Therefore, paracetamol is recommended as the antipyretic of choice in children with chicken pox.

Medicines containing combinations of NSAID(s), paracetamol, codeine and/or antihistamines should not be used in children.

Non pharmacological measures can be used as an adjunct therapy in the management of pain in both adults and children.

Nonpharmacological strategies such as physical and psychological comfort measures are useful in conjunction with pharmacological options to help lower levels of anxiety, distress and pain. Some physical comfort measures include the use of massage or heat and/or cold compresses, applying pressure or vibration and repositioning. Psychological comfort measures include use of imagery, distraction and relaxation techniques.

Who? Babies, toddlers and children under 9.

What are the symptoms? Changes in crying patterns, lacking energy, high temperature, discomfort when feeding, touching where they hurt.

How long have they had the symptoms? Colic can start at 2 weeks and peak at 6 weeks, symptoms of other pain can be acute and/or recurrent.

Action already taken? Changing feeds, administering pain relief such as paracetamol and/or ibuprofen, keeping child cool and hydrated.

Medication? Paracetamol and ibuprofen.

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More than just folic acid Most trusted by mums2 Most recommended by midwives 2,3 Helping to make healthy mums and babies for over 25 years, Pregnacare® provides the recommended level of folic acid.4 It also provides a range of micronutrients, and is supported by unique clinical research with mums-to-be.6,7

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Available from leading pharmacies, supermarkets and health food stores nationwide.

For more information, visit www.pregnacare.com 1. Journal of the American College of Nutrition, Vol.18, No.5, 487-489 (1999). 2. For more information on this research, please visit www.pregnacare.com/mostrecommended. 3. Based on a survey of 1000 midwives. 4. Folic acid contributes to maternal tissue growth during pregnancy. Pregnacare® has always contained 400mcg folic acid, the level recommended for all women from the start of trying to conceive until the 12th week of pregnancy. 5. Source: NHS Choices. 6. Agrawal, R. et al. Prospective randomised trial of multiple micronutrients in women undergoing ovulation induction, Reproductive BioMedicine Online December 2011. 7. L Brough et al. Effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a low-income, multi-ethnic population. British Journal of Nutrition (2010), 104, 437-445. *Awarded Number 1 pregnancy supplement by NPPA & Mums and Tots Awards.

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PREGNANCY AND FERTILITY

61

PREGNANCY AND FERTILITY It is a noticeable trend that many people are now starting families older, and this trend is set to continue. More women than ever are deciding to have children later in life, and thus many will turn to their community pharmacy for ovulation and pregnancy self-testing kits, supplements and advice. Because there is such an extensive array of these products available today, selecting the appropriate test or supplement may be overwhelming and confusing to many.

TESTING PRODUCTS A variety of at-home diagnostic tests are available for detecting ovulation and pregnancy.

Pharmacies can be a valuable resource for women electing to use these tests by aiding in both their selection and proper use.

Approximately one in six women in Ireland face fertility problems that interfere with achieving a successful pregnancy. Some women ovulate irregularly, and/or the male’s sperm count may have dropped.

Ovulation tests Devices used for ovulation prediction monitor the natural hormonal changes that occur during a woman’s menstrual cycle. OTC products available for predicting ovulation include thermometers measuring basal body temperature (BBT), urine tests, fertility microscopes, and saliva tests. Factors that may be considered when selecting a method of testing include ease of use, patient preference, and cost.

Urine-based ovulation tests use monoclonal antibodies specific to luteinizing hormone (LH) to detect the surge of LH.These tests should be used 2 to 3 days before estimated ovulation, and once the LH surge has been detected, testing should be discontinued. Ideally, earlymorning collection is recommended because the LH is most concentrated at this time.

readings of “pregnant” or “not pregnant”, which make the interpretation of results easier and more accurate.

Women should be advised that performing a test too early after a missed menstrual cycle may result in a false- negative test result, and it may be best to wait to test at least one week after an expected cycle. Patients obtaining a negative test result should be advised to retest if menstruation does not begin as expected, as well as be advised to seek medical evaluation from their GP for a serum hCG test and physical examination.

Fertility Lubricants Some women may need artificial lubrication due to decreased cervical mucus production that may be caused by conditions such as diabetes and inflammatory bowel disease or by medications such as antihistamines, stimulants, anticholinergics, and antidepressants. Couples may also use lubricants for comfort and to increase sexual satisfaction.

Some lubricants can actually hinder sperm from moving, or even kill them, making it harder to conceive. There are five main types of lubricants: petroleum based, natural oil -based, water based with glycerin, glycerin-free water based, and silicone. While each of these lubricants has respective advantages and disadvantages, they all may impair sperm motility.

Lubricants specifically designed for conception help with sperm viability and mobility, as well as match the body’s internal PH levels, which like many things, change during ovulation.

Folic Acid Current recommendations are that women should take 400mcg folic acid daily from before pregnancy until the end of the first trimester, and 10mcg vitamin D daily throughout pregnancy and while breastfeeding.

Home pregnancy tests

The role of folic acid in reducing the risk of neural tube defects and the value of vitamin D supplements in building bone formation in babies is well supported. Expectant mothers can therefore be reassured that it is not necessary to invest in expensive multivitamin

Home pregnancy tests are designed to detect the presence of human chorionic gonadotropin (hCG) hormone in urine samples. These tests use monoclonal or polyclonal antibodies in an enzyme immunoassay. Early pregnancy tests enable women to confirm a pregnancy and receive early prenatal care.

W W

If the test cannot be performed immediately, the urine sample should be refrigerated for testing later the same day. The sample should be returned to room temperature before testing.

When advising patients about home pregnancy tests, they should be reminded to adhere to the testing protocol provided by the manufacturer, unless otherwise specified, the first morning urine should be used, because levels of hCG are most concentrated at this time. If testing takes place at another time of the day, patients should be advised to restrict fluid intake for 4 to 6 hours before urine collection. Most tests can be performed in an easy, 1-step procedure.

The newest tests are digital and display

H A M

supplements, and that eating a good balanced diet during pregnancy, along with folic acid and vitamin D supplements, should be all that is required to ensure the best possible health outcomes for both themselves and their unborn child.

ASSIST AND ADVISE Pharmacy teams have the unique role as accessible healthcare providers to optimise preconception health, such as in screening tobacco and alcohol use, in counselling on preconception risk factors and current medication use. They are also well placed to offer guidance on the plethora of pregnancy and ovulation self-testing kits now on the market.

Women should be advised to adhere to the testing directions provided by the manufacturer and should read the testing procedure before starting the test. Medical conditions such as polycystic ovarian syndrome (POS) and menopause, which are associated with high levels of LH, may cause false- positive test results. The use of fertility medications, a patient recently discontinuing the use of oral contraceptives, or impaired hepatic and renal function, can cause false-positive results.

The decision on which fertility product to select will ultimately be the customer’s choice and dependent on factors such as cost and convenience so ensure your pharmacy teams are educated and equipped to offer the latest and best advice on all available.

Careful merchandising will help reach with other products such as for those suffering from stress incontinence, iron supplements and haemorrhoid creams.

Who? Sexually active couples trying to conceive/pregnant women.

What are the symptoms? Those unable to conceive within first 6 months.

How long has the patient had the symptoms? N/A Action already taken? Ovulation kits and fertility lubricants may have been tried.

Medication: N/A

30 30

% of infants experience symptoms of regurgitation

1

WHY MEDICATE? TRY NUTRITION FIRST.

For bottle-fed infants with frequent regurgitation

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AVAILABLE IN RETAIL AND PHARMACY OUTLETS * European Society for Pediatric Gastroenterology, Hepatology, and Nutrition 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.

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.

Ireland: www.nutricia.ie FOR HEALTHCARE PROFESSIONAL USE ONLY.

Northern Ireland: www.nutricia.co.uk December 2020

INFANT REFLUX

63

INFANT REFLUX Infant reflux occurs when food backs up (refluxes) from a baby’s stomach, causing the baby to spit up. Sometimes called gastroesophageal reflux (GER), the condition is rarely serious and becomes less common as a baby gets older. It’s unusual for infant reflux to continue after age 18 months.

Reflux occurs in healthy infants multiple times a day. As long as the baby is healthy, content and growing well, reflux is not a cause for concern.

CAUSES The muscle at the bottom of the food pipe acts as a kind of door into the stomach – so when food or milk travels down, the muscle opens allowing the food into the stomach.

However, while this muscle is still developing in the first year, it can open when it shouldn’t (usually when a baby’s tummy is full) allowing some food and stomach acid to travel back up again. Acid in the stomach is normal and a necessary part of the digestion process – it helps break down food.

In most babies, reflux is nothing to worry about (as long as they are healthy and gaining weight as expected). However, in some cases (though very few) reflux can cause a lot of pain when strong acid travels up into the food pipe. When reflux becomes painful and it happens frequently, this is known as ‘gastrooesophageal reflux disease’ (GORD).

periods and usually are cat naps for 10 to 40 minutes with the child waking distressed; Older children with reflux can be restless during sleep and may cry, moan or swallow even when asleep.

ASSISTING AND ADVISING Infant reflux usually clears up by itself. In the meantime, you can recommend the following to worried mums: • Giving the baby smaller, more-frequent feedings.

medications can prevent absorption of calcium and iron, and increase the risk of certain intestinal and respiratory infections.

However, a short-term trial of an acid-blocking medication — such as cimetidine (Tagamet HB) or famotidine (Pepcid AC) for infants ages 1 month to 1 year or omeprazole magnesium (Prilosec) for children ages 1 year or older — might be recommended if a baby: • Has poor weight gain and moreconservative treatments haven’t worked • Refuses to feed • Has evidence of an inflamed esophagus

• Interrupting feedings to burp baby.

• Has chronic asthma and reflux

SYMPTOMS

• Holding baby upright for 20 to 30 minutes after feedings.

When to Refer:

• constant or sudden crying when feeding

• Eliminating dairy products, beef or eggs from mum’s diet if they are breast-feeding, to test if baby has an allergy.

• Isn’t gaining weight

• bringing up milk during or after feeds (regularly) • frequent ear infections • lots of hiccups or coughing • refusing, gagging or choking during feeds • poor weight gain • frequent waking at night Reflux and Sleep It is important that all parents know that night time sleeping problems are very common in refluxing infants. Research shows that 13% of infants over 3 months of age wake their parents three or more times a night, however a study completed on infants with GastroOesophageal Reflux Disease (GORD) found that 50 to 60% of infants over 3 months of age suffering from GORD woke their parents frequently at night.

Sleep issues that can be due to reflux include: • Waking in the middle of the night with a burst of crying • Waking frequently overnight, a child may initially sleep for three or four hours, but then will wake every one or two hours for the rest of the night and be difficult to resettle • Infants and children may be more comfortable in a fully upright position and may object or cry when put to lie down • Day time sleeping tends to be for short

• Switching the type of formula.

• Using a different size of nipple on baby bottles. A nipple that is too large or too small can cause a baby to swallow air.

• Thickening formula or expressed breast milk slightly and in gradual increments with rice cereal. Although recognized as a reasonable strategy, thickening adds potentially unnecessary calories to a baby’s diet.

TREATMENT

If the baby: • Consistently spits up forcefully, causing stomach contents to shoot out of his or her mouth (projectile vomiting) • Spits up green or yellow fluid • Spits up blood or a material that looks like coffee grounds • Refuses food • Has blood in his or her stool • Has difficulty breathing or a chronic cough • Begins spitting up at age 6 months or older • Is unusually irritable after eating

Medication Reflux medications aren’t recommended for children with uncomplicated reflux. These

W W H A M

Who? Newborn babies.

What are the symptoms? Hiccups, coughing, sudden crying, bringing up milk, poor weight gain.

How long has the patient had the symptoms? Can occur up to age 18 months.

Action already taken? Mums may already have tried switching feeds, feeding times, holding baby upright.

Medication: Short-term trial of an acid-blocking medication for infants ages 1 month to 1 year may be recommended in some instances.

SEXUAL HEALTH

65

SEXUAL HEALTH Community pharmacy has, for many years, been involved in providing support for sexual health, selling products ranging from condoms, lubricants, emergency hormonal contraception (EHC), sanitary goods, pregnancy and ovulation tests, herbal supplements for the menopause, treatments for cystitis and thrush and Viagra for erectile dysfunction.

With greater access to contraception now open for consultation by the HSE, and the recent news that PrEP is to be made available through community pharmacy in Ireland, pharmacy teams have a crucial role to play in the area of Sexual Health.

This range of products and services is not available from any other single provider and so community pharmacy is well-placed to position itself as a one-stop shop for sexual health.

PRODUCT RECOMMENDATION Condoms Condoms offer the best protection from both an unplanned pregnancy and sexually transmitted infections (STIs).

Encouraging use of condoms is of utmost importance and can be promoted by listing their advantages: 1. Many contain lubricant 2. 92-98% effective 3. Prevention of STI’s 4. Only contraception males have control of 5. Females can be prepared and carry them also If a customer knows or suspects that a condom has failed, they can access services at their local pharmacy to find out if this has happened and/or what the consequences may be. These (obviously) include the sale of pregnancy tests and similar products.

STI Screening Customers can also access STI screening and detection services at some Irish pharmacies.

Some available products provide simple kits that a customer may use themselves to extract and store a sample. The sample is then sent to a reputable laboratory to be tested for a range of STI types that are prominent in Ireland. These include chlamydia, gonorrhoea, HIV, herpes simplex and hepatitis. A customer can request screening for a combination of these in accordance with their preferences.

The role of the pharmacy team in terms of STI screening, therefore, is mainly on advising on the availability of these kits, and of the potential benefits of screening. If the customer is diagnosed with an STI, the treatment options available from their pharmacy may

depend on a consultation with a GP or other health professional (e.g. staff in a sexual health clinic) and on any prescription they receive as a result.

HAVING THE CONVERSATION As the most accessible healthcare professional, pharmacists are an important resource for STI prevention and control.

The large number of pharmacy outlets, and the trust shared between pharmacists and the public combine to afford a unique opportunity to reach patients and discuss their sexual health.

It can be hard to reduce a whole conversation about sexual health into a 30-secondover-the-counter chat. It is much more beneficial if consultations can take place in an appropriately confidential space if possible.

This helps to build up a trusting relationship with the patient as confidentiality is a priority when accessing sexual health services in any setting.

• Use appropriate body language • Ask open-ended questions • Reassure them that all information remains confidential, as always These factors are fundamental to ensure a patient feels at ease and comfortable in your presence. There are some key opportunities to potentially broach the subject and promote sexual health. One such occasion is when emergency hormonal contraception is required. Advice about long term methods of contraception and information regarding STI’s are standard practice throughout the consultation.

A patient asking about irregular periods, spotting or genital warts is a signal that demonstrates the patient requires more knowledge and is open to any information that can be provided. A patient presenting with their first prescription for a contraceptive is another opportunity to utilise, to counsel on sexual health and how to reduce the risk of contracting STIs.

It is important that you are educated and confident in discussing personal details with patients and giving them advice in a non-judgemental manner. Pharmacy team members need to be confident in discussing topics such as sexual health to develop a level of trust with the patient. Sexual health topics need to be dealt with in a sensitive manner:

Pharmacy staff can aid patients in several ways including:

• Greet the patient

• Supply of EHC where necessary and appropriate

• Bring the patient into the consultation room • Maintain eye contact

W W H A M

• Signposting and referral when necessary • Sale of OTC items (pregnancy tests, condoms, self-care products) • Advice and information on STI’s

• Information on long term contraception options

Who? Sexually active males and females.

What are the symptoms? Advise on appropriate protection measures, unprotected sexual intercourse/failed contraception method, STI screening and advice.

How long has the patient had the symptoms? Advise that suitable methods of contraception are discussed and understood before intercourse, symptoms of STIs may vary based on the infection.

Action already taken? Routine contraception may have been used/ some may have taken the opportunity to discuss with friends/family members for advice before visiting the pharmacy.

Medication: Self-testing kits for STIs are available in the pharmacy, lubricants and EHC.

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Nicorette QuickMist1 mg/spray, oromucosal spray. Composition: One spray delivers 1 mg nicotine in 0.07 ml solution. 1 ml solution contains 13.6 mg nicotine. Excipient with known effect: Ethanol (less than 100 mg of ethanol/spray). Propylene glycol, Butylated hydroxytoluene.

Pharmaceutical form: Oromucosal spray, solution. A clear to weakly opalescent, colourless to yellow solution. Indications: For the treatment of tobacco dependence in adults by relief of nicotine withdrawal symptoms, including cravings, during a quit attempt or to cut down smoking before stopping completely.Permanent cessation of tobacco use is the eventual objective. Nicorette QuickMist should preferably be used in conjunction with a behavioral support program. Dosage: Subjects should stop smoking completely during the course of treatment with Nicorette QuickMist. Adults and Elderly: The following chart lists the recommended usage schedule for the oromucosal spray during full treatment (Step I) and during tapering (Step II and Step III). Up to 4 sprays per hour may be used. Do not exceed 2 sprays per dosing episode and do not exceed 64 sprays (4 sprays per hour, over 16 hours) in any 24-hour period. Step I: Weeks 1-6: Use 1 or 2 sprays when cigarettes normally would have been smoked or if cravings emerge. If after a single spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Step II: Weeks 7-9: Start reducing the number of sprays per day. By the end of week 9 subjects should be using HALF the average number of sprays per day that was used in Step I. Step III: Weeks 10-12: Continue reducing the number of sprays per day so that subjects are not using more than 4 sprays per day during week 12. When subjects have reduced to 2-4 sprays per day, oromucosal spray use should be discontinued. To help stay smoke free after Step III, subjects may continue to use the oromucosal spray in situations when they are strongly tempted to smoke. One spray may be used in situations where there is an urge to smoke, with a second spray if one spray does not help within a few minutes. No more than four sprays per day should be used during this period. Regular use of the oromucosal spray beyond 6 months is generally not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Gradual cessation through progressive reduction in smoking For smokers who are not willing or ready to quit abruptly. The oromucosal spray is used between periods of smoking in order to prolong the smoke-free intervals and with the intention to reduce smoking as much as possible. The patient should be aware that an incorrect use of the spray may enhance adverse effects. A cigarette is replaced with one dose (1-2 sprays) and a quit attempt should be made as soon as the smoker feels ready and no later than 12 weeks after start of treatment. If a reduction in cigarette consumption has not been achieved after 6 weeks of treatment, a healthcare professional should be consulted. After quitting smoking, gradually reduce the number of sprays per day. When subjects have reduced to 2-4 sprays per day, oromucosal spray should be discontinued. Regular use of the oromucosal spray beyond 6 months is not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Paediatric population: Do not administer this medicine to persons under 18 years of age. There is no experience of treating adolescents under the age of 18 with this medicine. Method of administration: After priming, point the spray nozzle as close to the open mouth as possible. Press firmly the top of the dispenser and release one spray into the mouth, avoiding the lips. Subjects should not inhale while spraying to avoid getting spray into the respiratory tract. For best results, do not swallow for a few seconds after spraying. Subjects should not eat or drink when administering the oromucosal spray. Behavioural therapy advice and support will normally improve the success rate. Contraindications: Hypersensitivity to nicotine or to any of the excipients. Children under the age of 18 years. Those who have never smoked. Special warnings and precautions for use: This medicine should not be used by non-smokers. The benefits of quitting smoking outweigh any risks associated with correctly administered nicotine replacement therapy (NRT). A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions: Cardiovascular disease: Dependent smokers with a recent myocardial infarction, unstable or worsening angina including Prinzmetal’s angina, severe cardiac arrhythmias, recent cerebrovascular accident and/or who suffer with uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions (such as counselling). If this fails, the oromucosal spray may be considered but as data on safety in this patient group are limited, initiation should only be under close medical supervision. Diabetes Mellitus. Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when smoking is stopped and NRT is initiated as reduction in nicotine induced catecholamine release can affect carbohydrate metabolism. Allergic reactions: Susceptibility to angioedema and urticaria. Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects. Phaeochromocytoma and uncontrolled hyperthyroidism: Use with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma as nicotine causes release of catecholamines. Gastrointestinal Disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions. Paediatric population: Danger in children: Doses of nicotine tolerated by smokers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be handled or ingested by children. Transferred dependence: Transferred dependence can occur but is both less harmful and easier to break than smoking dependence. Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. The plasma concentration of other medicinal products metabolised in part by CYP1A2 e.g. imipramine, olanzapine, clomipramine and fluvoxamine may also increase on cessation of smoking, although data to support this are lacking and the possible clinical significance of this effect for these drugs is unknown. Limited data indicate that the metabolism of flecainide and pentazocine may also be induced by smoking. Excipients: The oromucosal spray contains small amounts of ethanol (alcohol), less than 100 mg per dose (1 or 2 sprays). This medicinal product contains less than 1 mmol sodium (23 mg) per spray, i.e. essentially ‘sodium- free’. This medicine contains 12 mg propylene glycol in each spray which is equivalent to 157 mg/mL. Due to the presence of butylated hydroxytoluene, Nicorette QuickMist may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes. Care should be taken not to spray the eyes whilst administering the oromucosal spray.Undesirable effects: Effects of smoking cessation: Regardless of the means used, a variety of symptoms are known to be associated with quitting habitual tobacco use. These include emotional or cognitive effects such as dysphoria or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating, and restlessness or impatience. There may also be physical effects such as decreased heart rate; increased appetite or weight gain, dizziness or presyncopal symptoms, cough, constipation, gingival bleeding or apthous ulceration, or nasopharyngitis. In addition, and of clinical significance, nicotine cravings may result in profound urges to smoke. This medicine may cause adverse reactions similar to those associated with nicotine given by other means and these are mainly dose-dependent. Allergic reactions such as angioedema, urticaria or anaphylaxis may occur in susceptible individuals. Local adverse effects of administration are similar to those seen with other orally delivered forms. During the first few days of treatment irritation in the mouth and throat may be experienced, and hiccups are particularly common. Tolerance is normal with continued use. Daily collection of data from trial subjects demonstrated that very commonly occurring adverse events were reported with onset in the first 2-3 weeks of use of the oromucosal spray, and declined thereafter. Adverse reactions with oromucosal nicotine formulations identified from clinical trials and during post-marketing experience are presented below. The frequency category has been estimated from clinical trials for the adverse reactions identified during post-marketing experience. Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1 000 to <1/100); rare (≥1/10 000 to <1/1 000); very rare (<1/10 000); not known (cannot be estimated from the available data). Immune system disorders Common Hypersensitivity Not known Allergic reactions including angioedema and anaphylaxis Psychiatric disorders Uncommon Abnormal dream Nervous system disorders Very common Headache Common Dysgeusia, paraesthesia Eye disorders Not known Blurred vision, lacrimation increased Cardiac disorders Uncommon Palpitations, tachycardia Not known Atrial fibrillation Vascular disorders Uncommon Flushing, hypertension Respiratory, thoracic and mediastinal disorders Very common: Hiccups, throat irritation Uncommon Bronchospasm, rhinorrea, dysphonia, dyspnoea, nasal congestion, oropharyngeal pain, sneezing, throat tightness Common: cough Gastrointestinal disorders Very common Nausea Common Abdominal pain, dry mouth, diarrhoea, dyspepsia, flatulence, salivary hypersecretion, stomatitis, vomiting Uncommon Eructation, gingival bleeding, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral Rare Dysphagia, hypoaesthesia oral, retching Not known Dry throat, gastrointestinal discomfort, lip pain Skin and subcutaneous tissue disorders Uncommon Hyperhidrosis, pruritus, rash, urticaria Not known Erythema General disorders and administration site conditions Common Burning sensation, fatigue Uncommon Asthenia, chest discomfort and pain, malaise. MAH: Johnson & Johnson (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland.

PA Number: PA 330/37/13. Date of revision of text: August 2020. Product not subject to medical prescription. Full prescribing information available upon request..

IE-NI-2000100

SMOKING CESSATION

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SMOKING CESSATION Many who have attempted to kick the smoking habit would probably agree that it is often easier said than done, and that it can be both overwhelming and challenging.

The suggestion that giving up smoking will improve a smoker’s overall health, speed up the healing process and help prevent disease could help build their motivation to quit. With an appropriately trained pharmacy team pharmacies can offer services such as carbon monoxide testing and one-on-one advice on an ongoing basis, all year round.

Pharmacies are ideally placed to advise people on how to stop smoking and to provide information on the supply of medication.

Many will also be able to provide treatment for smokers who want to stop. The contribution pharmacists can make to improving the health of the population has been widely recognised.

Pharmacists are in a pivotal position to help patients find the most effective methods to successfully quit smoking and choose from the many OTC smoking cessation products currently on the market.

OTC TREATMENTS Nicotine patches This treatment reduces or removes withdrawals associated with giving up smoking. Patches suit the moderately addicted smoker. They can be used for 16 hour or 24 hour periods. There is no difference in the effectiveness of 16 hour and 24 hour patches.

They work by giving a steady dose of nicotine into the blood through the skin. The 24 hour patch keeps the nicotine levels constant and is for people who smoke as soon as they wake up and people who smoke during the night.

Customers should be advised to put the patch on a different part of the body each day so it won’t irritate the skin. Some people may have high skin sensitivity or react badly to the adhesive or latex in the patches. If this happens, advise a switch to a different form of NRT. Nicotine gum Nicotine gum relieves withdrawal symptoms and gives ‘something to do with the mouth’ in place of smoking. This can help change a habit of smoking. The gum is available in various strengths depending on how the level of addiction to nicotine.

Nicotine inhaler The inhaler (sometimes called an inhalator) is made up of a mouth piece and cartridges which contain nicotine. When it’s inhaled, the nicotine and menthol vapour is sucked into the body. This is absorbed into the blood through the lining of the mouth and throat.

Nicotine lozenges

“Follow ‘The 5 Rs’:

The lozenge comes in various strengths depending on the level of addiction. Some people prefer the taste of lozenges over other oral forms of NRT. Lozenges may irritate the mouth and stomach and cause hiccups as the nicotine is swallowed.

• Relevance: patients should be encouraged to think about the reasons why quitting is important

DRUG INTERACTIONS

• Rewards: patients should be asked to identify any potential benefits they anticipate from cessation

Because tobacco smoke interacts with various pharmacologic agents through pharmacokinetic or pharmacodynamic mechanisms that may result in decreased therapeutic efficacy or, less commonly, increased toxicity, pharmacists are key in identifying possible drug interactions and contraindications associated with tobacco use.

Examples of drug interactions with tobacco smoke include hormonal contraceptives, betablockers, theophylline, and benzodiazepines.

ASSIST AND ADVISE Pharmacy staff are at the front line to encourage customers to take a look at the reasons why they smoke and consider giving up. Combining behavioural advice with pharmacotherapy for smokers who visit the pharmacy with an ailment or long standing condition could increase their chances of stopping.

There are a number of tips and techniques that can assist pharmacists in their quest to help smokers kick the habit.

Advise a quit date. Deciding upon a specific date allows for adequate preparation including coming to terms with it mentally, which can have a huge impact on the outcome.

W W H A M

• Risks: patients should be asked to identify the negative health consequences of smoking

• Roadblocks: help the patient identify barriers to quitting and assist in overcoming these. E.g. stressful periods, trigger factors such as always having one with a cup of tea, boredom, negative side effects of quitting • Repetition: repeat the message when possible Always acknowledge and congratulate a patient’s efforts, this can promote a positive mental attitude. Remind patients that slip-ups are normal and that they shouldn’t punish themselves. Promoting patients to take their cessation journey one day at a time, often allows for more reasonable goals.

In addition, for cravings, promoting “The 4 Ds” is a good way to overcome them: • Distract • Delay (until the urge passes- usually within 3-5 minutes) • Deep breathe (about 20 times) • Drink (patients find water extremely beneficial)

Who? Any adults who smoke.

What? N/A How long have they had the symptoms? The length of time they have smoked and the volume is essential to determining what NRT to recommend.

Action already taken? Sufferers may already be trying to cut down or stop smoking all together.

Medication: No more than 15 of the higher strength NRT lozenges should be used per day. Inhalators should be used in caution with patients with COPD or chronic throat disease.

th e

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David Keane 087 279 2860 087 647 0764 Fintan Byrne Eamonn Connolly 087 238 5648

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-3

©20

SPORTS INJURIES

SPORTS INJURIES Sport injuries can be acute or chronic. Acute sports injuries occur as a result of a sudden impact or awkward movement. Examples include a cut to the skin or a sprained ankle.

Chronic sports injuries develop over time, often due to continual use of the same joints or muscle groups.

Chronic sports injuries can occur due to bad technique or occasionally structural abnormalities, such as an inherited bone or muscle problem. These injuries should be further investigated by a medical professional to determine the cause and to prevent the injury getting worse.

INJURY TYPES Some of the most common sports injuries include: • Sprains.

• Strains.

• Cuts and bruises.

• Bone fractures and breaks.

• Tendonitis (inflammation of a tendon).

• Blisters.

• Head injuries.

Whilst the figures regarding sports injury presentation to A&E are of note, community pharmacies will collectively see many more minor sports injuries.

CAUSES AND PREVENTION Common risk factors for sports injury include inadequate warm up, fatigue, over intensive training, unsuitable equipment and a changed environment (e.g. very hot weather, poor lighting, or physical contact with another person or equipment).

Injury prevention can be achieved through dynamic stretching before activity.

A sprain or a twisted joint can happen in most limbs but most commonly in the ankle. One or more ligaments of the ankle experience excessive stress and become abnormally stretched when the foot is moved past its normal range of motion. The sudden excess stress puts a strain on the ligaments. Once the strain goes beyond the yield point, the ligament becomes damaged, or sprained.

Blood vessels leak fluid into the joint, starting from the site of the injury. Increased blood flow and inflammatory exudates including white blood cells, macrophages and leukocytes migrate to the area, causing both inflammation and swelling.

This results in pain, sensitivity and throbbing as the nerves are further sensitised. As further blood flow increases to the site, the area looks a lot redder, feels a lot warmer, becomes more sensitive and there is a decrease in mobility.

69

TREATMENT Use non-steroidal anti-inflammatory drugs (NSAIDs) to treat pain, reduce any localised heat, decrease swelling and improve mobility.

Oral pain relief normally starts soon after the first dose and the full analgesic effect occurs within a week.

Topical NSAIDs can be applied directly to the site of the injury. Topically applied NSAIDs penetrate the skin and result in therapeutically significant concentrations in underlying inflamed soft tissues, joints and synovial fluid, probably entering the synovial joint mainly via systemic circulation.

In tendinopathies (painful tendons), inflammation plays a lesser role and so NSAIDs have little influence on healing but they can help with short-term analgesia. If used in the first seven days in sprains, strains or ligament tears, NSAIDs can also be used to limit pain and swelling thus increasing the chances of the patient regaining function and returning to activity sooner.

Patients should be advised to take NSAIDs with food. Following that advice, short-term use of NSAIDs is safe but patients should be advised that long-term use increases the risks of systemic side effects (such as gastrointestinal and cardiovascular effects).

COMMONLY PRESENTED INJURIES Tennis elbow (epicondylitis) is a painful condition that affects the outside of the elbow. It is caused by strenuous overuse of the muscles and tendons of the forearm and around the elbow joint.

The symptoms of tennis elbow include: • tenderness around the elbow.

• pain when moving the elbow.

Tennis elbow is caused by repetitive movement of the muscles in the lower arm.

It can be treated with anti-inflammatory medication, an elbow splint to support the arm or a cortisone injection. Sufferers should be advised to avoid activities that cause pain and, in a sporting setting, obtain advice to correct faulty technique.

Tendonitis is a fairly common injury that can result from a strain or tear in a tendon.

Tendonitis can occur in the tendons around the shoulder, elbow, wrist, finger, thigh, knee or the back of the heel (Achilles tendonitis).

Symptoms of tendonitis include:

W W H A M

• swelling, redness and pain at the injured area, • restricted movement of the affected area, and sometimes • a change in appearance of the affected area, such as a lump or a visible change in position of a limb.

Blisters are a common minor injury caused by friction on soft skin. Endurance athletes, such as long-distance runners, sometimes develop blisters on their feet. Rowers are at risk of developing blisters on the palms of their hands.

Although painful, most blisters will heal on their own unless they become infected, but they can be easily prevented in the first place by covering tender spots with a frictionresistant dressing or plaster. If they do occur, then specialist blister plasters, which claim to aid rapid healing by absorbing the fluid, protecting skin from bacteria and helping relieve the pain of friction and pressure, can be used.

Remind customers who have diabetes to be particularly vigilant when checking for blisters, as their foot injuries take longer to heal due to poorer blood circulation.

Athlete’s foot (tinea pedis) is a fungal infection that usually begins between the toes.

Symptoms include itching or burning and flaking skin, particularly between the toes, although the whole foot can be affected.

The condition can be treated with products containing fungicidal or fungistatic ingredients.

Making sure the feet are completely dry after washing; regularly changing footwear and wearing cotton socks can help ensure feet are less fungus-friendly.

Who? Any adults taking part in variety of sports/exercise.

What are the symptoms? These could range from instant pain due to fall, cut or break, or gradual throbbing/ache from blisters, sprain or strain, swelling and redness at injury site.

How long have they had the symptoms? Depending on type of injury.

Action already taken? Sufferers may have already tried bandaging and/ or compress/changed footwear, tried blister plasters.

Medication: Topical NSAIDs to site of pain, anti-inflammatory medication, splints, friction-resistant plasters, fungicidal medications.

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Vitamin D

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SUPPLEMENTS FOR CHILDREN

71

SUPPLEMENTS FOR CHILDREN Growing children, especially those who don’t eat a varied diet, sometimes don’t get enough vitamins A and C. It can also be difficult to get enough vitamin D through food alone for them.

That is why it’s important pharmacy teams are knowledgeable and educated about vitamin supplements and what advice to give to parents.

VITAMIN A Vitamin A is important for babies and young children, and some may not be getting enough.

It strengthens their immune system, can help their vision in dim light, and keeps skin healthy.

Good sources of vitamin A include: • dairy products • fortified fat spreads • carrots, sweet potatoes, swede and mangoes • dark green vegetables, such as spinach, cabbage and broccoli Vitamin supplements containing vitamins A and C are recommended for babies and children aged 6 months to 5 years old, unless they’re getting more than 500ml (about a pint) of infant formula a day.

VITAMIN C Vitamin C is important for children’s general health and immune system. It can also help their body absorb iron.

Good sources of vitamin C include: • oranges • kiwi fruit • strawberries • broccoli • tomatoes • peppers Multivitamins are often sought by new parents to ensure that baby has all the nutrients they need for the best start, no matter if breast or bottle fed.

VITAMIN D The health promotion message really is hitting home with parents that this is an essential part of a new baby regimen.

Probiotics have surged in popularity in recent years and are often endorsed by pharmacist recommendations in cases of poor health or to support recovery after antibiotic therapy.

Calcium is the essential building block of bones and teeth. The more bone a child builds now, the more reserves they will have when bone loss begins in later years.

Foods That Have It: Dairy products, fortified foods, salmon, and dark green leafy vegetables such as kale.

Fibre isn’t a vitamin or mineral, but foods that are high in fibre also tend to be packed with many important nutrients, like vitamin E, vitamin C, calcium, magnesium, and potassium.

Even though most children who eat a healthy diet won’t need vitamins, specific circumstances may warrant supplementation.

Certain vitamin and mineral supplements may be necessary for kids who are at risk of deficiencies, such as those who: • follow a vegetarian or vegan diet • have a condition that affects the absorption of or increases the need for nutrients, such as coeliac disease, cancer, cystic fibrosis, or inflammatory bowel disease (IBD) • have had a surgery that impacts the intestines or stomach • are extremely picky eaters and struggle to eat a variety of foods With respect to healthy lifestyle advice, pharmacy colleagues who are parents can empathise that we’re all aware of the healthy eating advice that can be followed for children.

However, the worry that goes along with making sure they eat something, even if it’s not the “right” thing is very stark for any parent and so it is important to offer this advice in a non-judgemental way. This is where continued relationship building with patients that is the

cornerstone of pharmacy practice becomes invaluable. Knowing that you have advice to give and really understanding your customer so that you know when and how to deliver it is key on this topic.

It’s important to focus on the evidence base and align advice with national guidelines, so make sure you and your team are aware of them.

Checking with parents how they think things are going can help lead a conversation e.g.: “How do you think your little one is doing in getting their 5 a day? It can be really hard, can’t it?”

“With all the advice that is around, it can be hard to choose the right foods to give a balanced diet - will we check what is recommended for your child and look at some appropriate supplements?”

“If you’d like to check what’s considered a healthy and normal weight for the age of your little one, we can help you find out. We can even help take the measurements if you’d like.”

For specific scenarios like when vegetarian parents make a choice for their child to eat a vegetarian diet, the job of the pharmacy is to highlight potential deficiencies that may arise, but more importantly offer solutions to support parents. Signposting details for Nutritionists and Dieticians should be available to the team to refer for extra care if needed.

Pharmacy and pharmacists still remain one of the most accessible healthcare professionals and first ports of call for queries from patients regarding infant and toddler feeding or supplements. Having a reliable range to recommend from is invaluable to ensure that your advice is acted on and even inspires the next visit to the pharmacy for any other queries at each life stage of children.

TARGETED PAIN RELIEF

73

TARGETED PAIN RELIEF When patients experience muscle and joint pain, pharmacists can recommend topical analgesics (rubs, creams and sprays) to help provide relief for their symptoms. Helping customers choose the right topical analgesic for their individual needs is key if they are to gain optimum benefit.

Musculoskeletal pain is likely to affect a significant percentage of the population and encompasses a huge range of conditions.

Low back pain, for example, is acknowledged to be the leading cause of disability worldwide and osteoarthritis is purported to affect 60% of 60-year-olds.”

While musculoskeletal conditions and the pain, stiffness and immobility that go with them can compromise the lives of sufferers in many obvious physical ways, mental health and wellbeing is also affected.

Patients will often use OTC topical analgesics for the treatment and management of musculoskeletal injuries and disorders. These products may have local analgesic, anaesthetic, antipruritic, and/or counterirritant effects.

Topical analgesics for musculoskeletal pain can be used alone or in conjunction with oral analgesics when appropriate and warranted.

External analgesic products may contain one or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsicum, and trolamine salicylate.

ASSISTING SELECTION Patient confusion regarding the wide array of topical products and formats available can also hinder usage. Consumers want help and reassurance when it comes to self-treating.

They do not understand the difference between various types of topical – hot, cold and non-steroidal anti-inflammatory drugs – or how to use them. Following the introduction of the codeine regulations, pharmacists now encourage the use of acetaminophen as first in line choice of pain relief, followed by ibuprofen, before codeine-based analgesics.

In addition, patients must be made aware of how to use the medication properly and must be informed by pharmacists of the possible side effects that can occur when a product is used after the recommended period of three days.

Products may have local analgesic, anaesthetic, antipruritic, and/or counterirritant effects.

Topical pain killers, or analgesics, are sprayed on or rubbed into the skin over painful muscles or joints. Although all are designed to relieve pain, different products are made up different

ingredients. Counterirritants are approved for the topical treatment of minor aches and pains of muscles and joints.

They are often employed for the treatment of acute musculoskeletal injuries and as an adjunct therapy in the treatment of chronic musculoskeletal disorders.

Counterirritants differ from other external analgesics in that pain relief results more from nerve stimulation than depression.

Topical analgesics for musculoskeletal pain can be used alone or in conjunction with oral analgesics when appropriate and warranted.

External analgesic products may contain or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsicum, and trolamine salicylate.

Salicylates: These same ingredients that give aspirin its pain-relieving quality are found in some creams. When absorbed into the skin, they may help with pain, particularly in joints close to the skin, such as the fingers, knees, and elbows.

W W H A M

Capsaicin: The main ingredient of hot chilli peppers, capsaicin is also one of the most effective ingredients for topical pain relief. When first applied, capsaicin creams cause a warm tingling or burning sensation. This gets better over time. Users may need to apply these creams for a few days up to a couple of weeks before they will notice relief from pain.

Topical analgesic products are available in a variety of formulations, including gels, ointments, creams, lotions, and patches in single-entity or combination formulations.

Topical heat therapy patches are also available in various sizes for treating joint and muscle pain and provide eight to 12 hours of continual, portable heat therapy.

OTC topical analgesics are intended to be used for mild to-moderate pain for no longer than seven days. The factors that a pharmacist may consider when recommending a topical analgesic include dosage form, cost, ease of use of product, as well as the patient’s medical history, including possible allergies.

Who? Anyone suffering from pain, musculoskeletal problems or fever.

What are the symptoms? Dependent on the condition suffered.

How long has the patient had the symptoms? Dependent on the condition suffered.

Action already taken? Pain relief.

Medication? Apply topical products only to intact skin. Areas treated with counterirritants should not be covered with tight bandages or occlusive dressings. Patients on anticoagulation therapy should be advised not to use topical products that contain salicylates, because concomitant use has been associated with prolonged prothrombin time.

Cystitis?

Uva-ursi and Echinacea Cystitis oral drops is a traditional herbal medicinal product used to help relieve minor urinary complaints associated with cystitis in women such as:

•

Burning sensation when urinating

•

Frequent urination

Things to note • • • • •

Suitable for adult women 18+ Take 15 drops in a little water 2 – 5 times daily It is not recommended to take this product for more than 7 days Take product at first sign of symptoms Can often be recommended for those who cannot take conventional cystitis remedies that contain sodium citrate

5005

Available from: Wholefoods Wholesale Unit 3 Kylemore Ind Estate, Killeen Rd, Dublin 10.

T: 01 6262315 F: 01 6261233 W: www.wholefoods.ie A.Vogel Uva-ursi & Echinacea Cystitis oral drops Active ingredients: Each 15 drop dose contains: 357.5 mg of tincture from fresh Arctostaphylos uva-ursi (L.) Spreng, herba (Bearberry herb) and 120 mg of tincture from fresh Echinacea purpurea (L.) Moench, herba (Purple Coneflower herb). Indications: Traditional herbal medicinal product used to help relieve minor urinary complaints associated with cystitis in women, such as burning sensation during urination and/or frequent urination, exclusively based upon long-standing use. For women aged 18 and over only. Dosage and administration: For oral short-term use only. Take 15 drops in a little water 2-5 times daily. Do not take this product for more than 7 days. If symptoms persist, worsen or do not improve after 4 days, a qualified healthcare professional should be consulted. Contraindications: Hypersensitivity to the active substance(s), to plants of the Asteraceae (Compositae) family, to Bearberry or to any of the excipients. Echinacea extracts must not be used in cases of progressive systemic disorders, autoimmune diseases, immunodeficiencies, immunosuppression and diseases of the white blood cell system. Patients with current or previous kidney disorders or restricted fluid intake. Not to be used during pregnancy and lactation. Warnings and Precautions: Do not exceed stated dose. If symptoms such as fever, spasms, acute urinary retention, dysuria, urinary incontinence, or blood in urine occur, a healthcare professional should be consulted. There is a possible risk of anaphylactic reactions in atopic patients. Atopic patients should consult their doctor before using Echinacea. Not to be used in men. Uvae ursi folium may cause a greenish-brown colouration of the urine. Contains a small amount of alcohol (213mg per 15 drop dose). Interactions: Not to be used concomitantly with immunosuppressant medications. Should be avoided in patients taking medicines known to interact with alcohol.

Side effects: Gastrointestinal symptoms (e.g. nausea, vomiting and stomach ache have been reported). Hypersensitive reactions may occur. Echinacea can trigger allergic reactions in atopic patients. Association with autoimmune diseases has been reported. The alkylamides present can affect the buccal mucosa which may be experienced as tingling, irritation and numbness in the mouth. The frequency of adverse reactions is not known. Legal classification: P. Registration number: TR2309/021/001. Registration holder: A.Vogel Ireland Ltd, 48 Upper Drumcondra Road, Dublin 9, Ireland D09 F3C7. Date of preparation: November 2020.

URINARY TRACT INFECTIONS

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URINARY TRACT INFECTIONS Urinary tract infection (UTI) is the collective term used to describe infections involving any part of the urinary tract, which includes the kidneys, ureters, bladder and urethra.

Infections of the bladder (cystitis) and urethra (urethritis) are known as lower UTIs and infections of the kidneys (pyelonephritis) or ureters are classed as upper UTIs. Urinary tract infections (UTIs) are among the most common infections affecting adult women. One-half of all women will experience at least one UTI in their lifetime. Recurrence of UTIs is common, with a reported rate of 25% within 6 months of the first occurrence.

DIAGNOSIS The incidence of UTIs in adult males under age 50 years is low. Up to 40% of women develop a UTI at some point in their life, compared to 12% in men. In men, cystitis is often associated with infection and inflammation of the prostate gland (prostatitis).

Anatomically, the female urethra is shorter and located closer to the anus than in males, which makes it easier for bacteria to reach the female urethra and bladder.

Adult women are 30 times more likely than men to develop a UTI, with almost half of them experiencing at least one episode during their lifetime and one-in-three women experiencing their first episode by the age of 24 years. UTIs are most commonly seen in sexually-active young women.

Types of UTI UTIs can be classified as ‘uncomplicated’ (sometimes referred to as a ‘simple’ UTI) or ‘complicated.’ Uncomplicated infections present most frequently in women without any structural or functional abnormality of the urinary tract, any history of renal disease, or other comorbidity (e.g. immunocompromised patients or those with diabetes), which may contribute to more serious outcomes.

Complicated UTIs are associated with a condition or underlying disease that interferes with the patient’s immune mechanisms and increases the risk of acquiring infection.

Recurrent UTIs, defined as at least two UTIs in 6 months or three UTIs in 1 year, are a significant burden for the patient and result in high costs to the health system.

The most commonly prescribed regimens are trimethoprim-sulfamethoxazole (or trimethoprim alone), nitrofurantoin, cephalexin and the fluoroquinolones at a quarter of the usual daily dose for 6 months.

SYMPTOMS • Pain or a burning sensation when passing urine • Needing to urinate more often during the night • Urine that looks cloudy

• Needing to urinate more urgently than usual

Cranberry juice and capsules

• Blood in the urine

Drinking cranberry juice may help to prevent UTIs. For those with recurring UTIs, higher strength cranberry capsules are recommended.

Children with UTIs may also: • Have a high temperature • Appear generally unwell • Wet the bed or themselves • Be sick

TREATMENT Those suffering with UTIs can be advised to take paracetamol up to four times a day to help reduce pain and a temperature. Children can take liquid paracetamol. They should also be advised to rest and drink fluids so that they can pass urine more regularly during the day.

It may also help for sufferers to avoid sexual intercourse until symptoms have passed.

Uva-ursi supplements Uva ursi works to reduce bacteria in the urine because it has chemicals called glycosides.

In the body, glycosides are transformed into hydroquinone, which possesses antibacterial properties.

Uva ursi’s infection-fighting properties come from several of the plant’s natural chemicals, including arbutin and hydroquinone. It also has tannins, a property that enables uva ursi to have an astringent effect.

W W H A M

However, advise customers that they should not consume cranberry juice or cranberry capsules if they are taking warfarin.

Treat constipation promptly Constipation (where it is difficult to pass stools) can increase the chances of developing a UTI. Recommended treatments for constipation include: • increasing the amount of fibre in the diet (20g to 30g of fibre a day) • using a mild laxative on a short-term basis • drinking plenty of fluids

WHEN TO REFER • Someone who has symptoms of a UTI for the first time • A child has symptoms of a UTI • A man with symptoms of a UTI • Pregnant women with symptoms of a UTI • Symptoms of a UTI after surgery • Symptoms get worse or do not improve within 2 days

Who? Adults, mainly women.

What are the symptoms? Pain when urinating, urinating more frequently, high temperature, frequent urinating at night.

How long has the patient had the symptoms? Recurrent UTIs can be as frequent as 2 in six months.

Actions already taken? Cranberry juice and drinking water regularly may help. Avoiding constipation can be a deterrent.

Medication: Antibiotics.

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VAGINAL DRYNESS

77

VAGINAL DRYNESS Normally, the walls of the vagina stay lubricated with a thin layer of clear fluid. The hormone estrogen helps maintain that fluid and keeps the lining of your vagina healthy, thick, and elastic. A drop in estrogen levels reduces the amount of moisture available and can lead to vaginal dryness.

It is a common but treatable problem that many women experience at some point in their lives. It can be a problem at any age, but is a particular issue for women who are going through or have experienced the menopause.

Sufferers will often feel embarrassed about seeking help but can be advised that there are a number of treatments that can help.

CAUSES

TREATMENTS

Menopause - decreased levels of the hormone oestrogen during the menopause can cause persistent vaginal dryness (also known as vaginal atrophy or atrophic vaginitis).

Sufferers of vaginal dryness can be advised that it’s worth trying self-help options first. The most common treatment for vaginal dryness due to low estrogen levels is topical estrogen therapy. These replace some of the hormone the body is no longer making. That helps relieve vaginal symptoms, but it doesn’t put as much estrogen in the bloodstream as the hormone therapy in pills.

Breastfeeding/Childbirth - oestrogen levels can temporarily decrease after giving birth and make the vagina feel drier than usual.

Arousal - if a woman doesn’t feel aroused before having sex, her vagina may not produce natural lubricant and sex may be uncomfortable.

Contraception - the combined contraceptive pill and contraceptive injection can occasionally cause vaginal dryness, although this is uncommon.

Cancer Therapy - radiotherapy to the pelvic area, hormonal cancer treatments, and sometimes chemotherapy can cause vaginal dryness.

Vaginal dryness is also sometimes caused by an underlying condition such as diabetes or Sjögren’s syndrome, where the immune attacks the glands in the body that produce fluid.

SYMPTOMS Some women only have symptoms of vaginal dryness at certain times, such as during sex, while others have them all the time.Problems associated with having a dry vagina include:

Lubricants - liquids or gels that are applied to the vulva, vagina or the partner’s penis just before having sex to keep the vagina moist.

They offer immediate but short-term relief from vaginal dryness.Several different brands of lubricant are available to buy from pharmacies without a prescription.

Vaginal moisturisers - creams that are applied inside the vagina to keep it moist. They may be better than lubricants if the dryness isn’t just causing problems during sex, as they tend to have a longer-lasting effect. They usually need to be applied every few days.

Vaginal oestrogen - a GP may prescribe vaginal oestrogen if the dryness is caused by

W W

• vaginal irritation, discomfort, itchiness or a burning sensation • discomfort during sex • a reduced sex drive • difficulty getting aroused and reaching orgasm • the surface of the vagina looks pale and thin • narrowing or shortening of the vagina • needing to pass urine more often than usual • repeated urinary tract infections (UTIs)

H A M

the menopause. This works by increasing the level of oestrogen that declines during and after the menopause.

Vaginal oestrogen is available as pills that are placed in the vagina (pessaries), vaginal creams and vaginal rings. Oestrogen treatment can be more effective than lubricants and moisturisers for menopausal women, and it generally causes few side effects.

However, it can take a few weeks to start working, so the patient may want to use a lubricant or moisturiser as well to begin with.

Treatment usually needs to be continued indefinitely, as the dryness tends to return if treatment stops.

Hormone replacement therapy - HRT is a treatment that involves taking medication to replace the hormones that start to decline during the menopause.

It’s available on prescription from a GP either as tablets, a skin patch, an implant under the skin, or a gel that’s applied to the skin. HRT has a wider effect on the body than vaginal oestrogen, so may be best if the person has other menopause symptoms, such as hot flushes. However, it also has more side effects.

Who? All women, but more prevalent during the menopause.

What are the symptoms? Vaginal irritation, discomfort, itchiness or a burning sensation, discomfort during sex, a reduced sex drive, difficulty getting aroused and reaching orgasm, the surface of the vagina looks pale and thin, narrowing or shortening of the vagina, needing to pass urine more often than usual, repeated urinary tract infections (UTIs).

How long has the patient had the symptoms? Many women will delay seeking medical advise because they may be embarrassed about the symptoms.

Action already taken? A number of self-care treatments may already have been used by the sufferer.

Medication? Topical estrogen therapies replace some of the hormone the body is no longer making.

VITAMIN

2000IU

3

Contributes to: • maintenance of normal bones • normal function of the immune system • maintenance of normal muscle function MADE IN IRELAND Food supplements should not replace a varied, balanced diet and a healthy lifestyle.

Mylan Ireland, Newenham Court, Northern Cross, Malahide Road, Dublin 17, Ireland. www.mylan.ie Date of Preparation: April 2020 Code: COL-2020-0004

VITAMIN D

79

VITAMIN D Vitamin D is an essential micronutrient that is required for bone and musculoskeletal health and may have a role in the prevention of chronic conditions such as diabetes, cancer and cardiovascular disease.

Researchers are now discovering that vitamin D may also be important in helping to fight infection and in making sure that the muscles, heart, lungs and brain are healthy.

In Ireland and the UK, vitamin D synthesis from sunshine exposure is almost negligible from late September to March each year due to the decreased availability of UVB light.

However, even during the Irish summer it can be difficult to make vitamin D due to cloud cover and lack of sunshine.

SOURCES Sunlight On average, 10-15 minutes of sunshine exposure to exposed skin (before sunscreen protection is added) is sufficient to make adequate vitamin D for each day. Although older adults, those who cover up, wear SPF makeup/sunscreen or those who are obese typically synthesize less vitamin D from sun exposure.

Diet However, vitamin D can also be obtained from the diet though few foods are rich in this micronutrient. These include wild salmon, mackerel, UVB exposed mushrooms and fortified foods such as fortified dairy products and cereals.

However, Ireland only has liberal voluntary vitamin D food fortification with no formal policy meaning few foods contain adequate amounts of vitamin D. Supplements The Food Safety Authority and the Health Service Executive recommend that all babies 0 to 12 months should receive a vitamin D supplement. Products which contain other vitamins as well as vitamin D should not be used.

Most people should be able to get the vitamin D they need by eating a varied and balanced diet and by getting some sun.

Taking 25 micrograms (0.025mg) or less a day of vitamin D supplements is unlikely to cause any harm.

The Institute of Medicine in the United States suggests that the average person needs 10 µg of vitamin D each day. Some people will need as high as 15 to 20 µg of vitamin D. The relevant expert authorities in the UK and Nordic region recommend 10 µg of vitamin D each day. All of these recommended intakes have been established with a view to protecting the bone health of the population.

RESEARCH The ODIN project, which is being coordinated by Professors Kiely and Cashman

at the Cork Centre for Vitamin D and Nutrition Research is carrying out research studies to provide the scientific evidence on which to base recommended dietary intake for vitamin D for children, teenagers, pregnant women and dark-skinned ethic groups.

These subgroups are covered in the current recommendations but have been based on very limited experimental data up to now.

Sunlight is a major source of vitamin D; however, since Ireland is situated between latitude 51 and 55 ºN, negligible cutaneous synthesis of vitamin D occurs between October and March. In addition, cutaneous synthesis of vitamin D decreases with age.

The Food and Nutrition Board, Institute of Medicine (1997) suggests a daily vitamin D intake of 10µg for adults aged 51-70 years.

A recent Irish study found that 89% of

W W H A M

51-64 year olds do not achieve the 10µg/day recommendation, with mean daily intakes (MDI) of vitamin D from food sources being 4.01 µg in men and 3.39 µg in women (Hill et al., 2004). Results from other studies (Hill et al., 2002, 3003) observed low vitamin D status in 50-75 year old Irish women between late winter and early spring. These findings indicate that dietary intake of vitamin D is not sufficient in Ireland to reach recommendations for the elderly population and vitamin D supplementation should be promoted among this population group.

Nonetheless, in 2011, the FSAI proposed that all Irish citizens should be taking a daily vitamin D supplement as neither the dietary sources consumed or sun exposure obtained in summer is sufficient to maintain adequate vitamin D status throughout the winter months.

Who? Anyone should consider their Vitamin D intake, particularly in Winter.

What are the symptoms? Fatigue, bone pain, mood changes.

How long has the patient had the symptoms? Symptoms can persist over months until adequate vitamin levels are reached.

Action already taken? People may have taken steps to improve the balance of their diet.

Medication? Some supplements could prevent prescribed drugs from working as intended, or result in additional side effects. Always check the label.

December 2020 Week 1

28 Monday

29 Tuesday

30 Wednesday

December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

January 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

31 Thursday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

1 Friday

Dec 2020/ Jan 2021

2 Saturday

3 Sunday

January 2021 Week 2

4 Monday

5 Tuesday

6 Wednesday

December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

7 Thursday

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

8 Friday

January 2021

9 Saturday

10 Sunday

January 2021 Week 3

11 Monday

12 Tuesday

13 Wednesday

December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

14 Thursday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

15 Friday

January 2021

16 Saturday

17 Sunday

January 2021 Week 4

18 Monday

19 Tuesday

20 Wednesday

December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

21 Thursday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

22 Friday

January 2021

23 Saturday

24 Sunday

January 2021 Week 5

25 Monday

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27 Wednesday

December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

28 Thursday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

29 Friday

January 2021

30 Saturday

31 Sunday

February 2021 Week 6

1 Monday

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3 Wednesday

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

4 Thursday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

5 Friday

February 2021

6 Saturday

7 Sunday

February 2021 Week 7

8 Monday

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10 Wednesday

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

11 Thursday

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

12 Friday

February 2021

13 Saturday

14 Sunday

February 2021 Week 8

15 Monday

16 Tuesday

17 Wednesday

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

18 Thursday

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

19 Friday

February 2021

20 Saturday

21 Sunday

February 2021 Week 9

22 Monday

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24 Wednesday

January 2021 4 11 18 25 M 5 12 19 26 T 6 13 20 27 W 7 14 21 28 T F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

25 Thursday

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

26 Friday

February 2021

27 Saturday

28 Sunday

March 2021 Week 10

1 Monday

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February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

4 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

5 Friday

March 2021

6 Saturday

7 Sunday

March 2021 Week 11

8 Monday

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February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

11 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

12 Friday

March 2021

13 Saturday

14 Sunday

March 2021 Week 12

15 Monday

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February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

18 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

19 Friday

March 2021

20 Saturday

21 Sunday

March 2021 Week 13

22 Monday

23 Tuesday

24 Wednesday

February 2021 M 1 8 15 22 T 2 9 16 23 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

25 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

26 Friday

March 2021

27 Saturday

28 Sunday

March 2021 Week 14

29 Monday

30 Tuesday

31 Wednesday

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

1 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

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April 2021

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4 Sunday

April 2021 Week 15

5 Monday

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March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

8 Thursday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

9 Friday

April 2021

10 Saturday

11 Sunday

April 2021 Week 16

12 Monday

13 Tuesday

14 Wednesday

March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

15 Thursday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

16 Friday

April 2021

17 Saturday

18 Sunday

April 2021 Week 17

19 Monday

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March 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 31 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

22 Thursday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

23 Friday

April 2021

24 Saturday

25 Sunday

April 2021 Week 18

26 Monday

27 Tuesday

28 Wednesday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

29 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

30 Friday

April/ May 2021

1 Saturday

2 Sunday

May 2021 Week 19

3 Monday

4 Tuesday

5 Wednesday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

6 Thursday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

7 Friday

May 2021

8 Saturday

9 Sunday

May 2021 Week 20

10 Monday

11 Tuesday

12 Wednesday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

13 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

14 Friday

May 2021

15 Saturday

16 Sunday

May 2021 Week 21

17 Monday

18 Tuesday

19 Wednesday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

20 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

21 Friday

May 2021

22 Saturday

23 Sunday

May 2021 Week 22

24 Monday

25 Tuesday

26 Wednesday

April 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 S 4 11 18 25

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

27 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

28 Friday

May 2021

29 Saturday

30 Sunday

May/ June 2021 Week 23

31 Monday

1 Tuesday

2 Wednesday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

3 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

4 Friday

June 2021

5 Saturday

6 Sunday

June 2021 Week 24

7 Monday

8 Tuesday

9 Wednesday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

10 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

11 Friday

June 2021

12 Saturday

13 Sunday

June 2021 Week 25

14 Monday

15 Tuesday

16 Wednesday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

17 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

18 Friday

June 2021

19 Saturday

20 Sunday

June 2021 Week 26

21 Monday

22 Tuesday

23 Wednesday

May 2021 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

24 Thursday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

25 Friday

June 2021

26 Saturday

27 Sunday

June 2021 Week 27

28 Monday

29 Tuesday

30 Wednesday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

1 Thursday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 M 2 9 16 23 30 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

2 Friday

July 2021

3 Saturday

4 Sunday

July 2021 Week 28

5 Monday

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7 Wednesday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

8 Thursday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 M 2 9 16 23 30 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

9 Friday

July 2021

10 Saturday

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12 Monday

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14 Wednesday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

15 Thursday

August 2021 M 2 9 16 23 30 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

16 Friday

July 2021

17 Saturday

18 Sunday

July 2021 Week 30

19 Monday

20 Tuesday

21 Wednesday

June 2021 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

22 Thursday

August 2021 M 2 9 16 23 30 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

23 Friday

July 2021

24 Saturday

25 Sunday

July 2021 Week 31

26 Monday

27 Tuesday

28 Wednesday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 M 2 9 16 23 30 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

29 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

30 Friday

July/ August 2021

31 Saturday

1 Sunday

August 2021 Week 32

2 Monday

3 Tuesday

4 Wednesday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

5 Thursday

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

6 Friday

August 2021

7 Saturday

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August 2021 Week 33

9 Monday

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11 Wednesday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

12 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

13 Friday

August 2021

14 Saturday

15 Sunday

August 2021 Week 34

16 Monday

17 Tuesday

18 Wednesday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

19 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

20 Friday

August 2021

21 Saturday

22 Sunday

August 2021 Week 35

23 Monday

24 Tuesday

25 Wednesday

July 2021 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

26 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

27 Friday

August 2021

28 Saturday

29 Sunday

Aug/ September 2021 Week 36

30 Monday

31 Tuesday

1 Wednesday

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

2 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

3 Friday

September 2021

4 Saturday

5 Sunday

September 2021 Week 37

6 Monday

7 Tuesday

8 Wednesday

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

9 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

10 Friday

September 2021

11 Saturday

12 Sunday

September 2021 Week 38

13 Monday

14 Tuesday

15 Wednesday

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

16 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

17 Friday

September 2021

18 Saturday

19 Sunday

September 2021 Week 39

20 Monday

21 Tuesday

22 Wednesday

August 2021 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

23 Thursday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

24 Friday

September 2021

25 Saturday

26 Sunday

September 2021 Week 40

27 Monday

28 Tuesday

29 Wednesday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

30 Thursday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

1 Friday

Sept/ October 2021

2 Saturday

3 Sunday

October 2021 Week 41

4 Monday

5 Tuesday

6 Wednesday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

7 Thursday

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

8 Friday

October 2021

9 Saturday

10 Sunday

October 2021 Week 42

11 Monday

12 Tuesday

13 Wednesday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

14 Thursday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

15 Friday

October 2021

16 Saturday

17 Sunday

October 2021 Week 43

18 Monday

19 Tuesday

20 Wednesday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

21 Thursday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

22 Friday

October 2021

23 Saturday

24 Sunday

October 2021 Week 44

25 Monday

26 Tuesday

27 Wednesday

September 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 S 4 11 18 25 S 5 12 19 26

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

28 Thursday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

29 Friday

October 2021

30 Saturday

31 Sunday

November 2021 Week 45

1 Monday

2 Tuesday

3 Wednesday

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

4 Thursday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

5 Friday

November 2021

6 Saturday

7 Sunday

November 2021 Week 46

8 Monday

9 Tuesday

10 Wednesday

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

11 Thursday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

12 Friday

November 2021

13 Saturday

14 Sunday

November 2021 Week 47

15 Monday

16 Tuesday

17 Wednesday

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

18 Thursday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

19 Friday

November 2021

20 Saturday

21 Sunday

November 2021 Week 48

22 Monday

23 Tuesday

24 Wednesday

October 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

25 Thursday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

26 Friday

November 2021

27 Saturday

28 Sunday

Nov/ December 2021 Week 49

29 Monday

30 Tuesday

1 Wednesday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

2 Thursday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

January 2022 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

3 Friday

December 2021

4 Saturday

5 Sunday

December 2021 Week 50

6 Monday

7 Tuesday

8 Wednesday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

9 Thursday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

January 2022 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

10 Friday

December 2021

11 Saturday

12 Sunday

December 2021 Week 51

13 Monday

14 Tuesday

15 Wednesday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

16 Thursday

January 2022 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

17 Friday

December 2021

18 Saturday

19 Sunday

December 2021 Week 52

20 Monday

21 Tuesday

22 Wednesday

November 2021 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

23 Thursday

January 2022 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

24 Friday

December 2021

25 Saturday

26 Sunday

December 2021 Week 53

27 Monday

28 Tuesday

29 Wednesday

December 2021 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

January 2022 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

30 Thursday

February 2022 7 14 21 28 M T 1 8 15 22 W 2 9 16 23 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

31 Friday

Dec 2021/ Jan 2022

1 Saturday

2 Sunday

186

COMPANY LISTINGS

Sharon Cahill Key Account Manager sharoncahill@brandshapers.ie Mob: +353 87 405 5364

Ascension

Customer Service: customerservice@brandshapers.ie

100 Pall Mall, 1st Floor, St. James’s, London, SW1Y 5NQ, United Kingdom Type of company: Biopharma Website: www.flexiseq.ie Tel: 087-2953582 Customer Queries: enquiries@flexiseq.com Products: All FLEXISEQ® products contain Sequessome™ vesicles – tiny lipid spheres that pass through the skin when the gel is applied topically. FLEXISEQ® (OA) contains the maximum concentration of these vesicles. FLEXISEQ® Active contains a lower concentration of the vesicles, making it lighter and therefore suitable for the daily needs of joint pain and early stage arthritis sufferers, seeking a sustainable drug-free solution.

Local Contacts: Marketing Manager, Allie Forde Allie.forde@ascension.co.uk Tel: 087-2953582

Brandshapers Ballytramon Business Park, Ardcavan, Castlebridge, Co. Wexford Y35 Y19A

Calco Ireland Limited Unit 1-1d Cork Airport Industrial Est., Ballygarvan, Co. Cork. Ireland T12 A470 Type of company: Wholesale Distributors to Pharmacy Website: www.calcoireland.ie Tel: 353 21 4962511 Fax: 353 21 4962994 Help Line Number: 353 21 4962511 Order Line:1850 240 000 – Trade only Products: Demak’Up, White to Brown, Oh My Glam, Manicare, Dove, Sure, Lynx, Alberto, Imperial Leather, Brylcreem, Fish, Mitchum, Pears, Carmex, Radox, Impulse, V05, Badedas, Simple, St Ives, Toni&Guy, Tresemme, Vaseline, Jakemans, Lockets, Fishman Friends, Gillette, Wilkinson Sword, Braun, Colgate, Vicks, Listerine, Tepe, Water Wipes, Eylure, Elegant touch, Dimples, Jolen, Durex, Duracell, Sun Care Local Contacts: F. Callaghan, S. Callaghan

Type of company: Sales, Marketing, Wholesale and Distribution Website: www.brandshapers.ie Tel: (053) 917 9007 Fax: (053) 915 9494 Order Line: (053) 917 9007 Email: info@brandshapers.ie Brands: Blistex, Bulldog Skincare, Cognikids, Eco-Tools, Evolve, Human + Kind, Infacare, Isadora, iWhite, Just For Men, Kandoo, Kidsner, LifeLine Hangover Defence, Moxi Loves, Nailner, Nakd, Real Techniques, Remescar, Sculpted by Aimee, Seabond, Seven Seas, Sugar Coated, Trek, TOMY, Vagisil, VComb, Vosene, Wartie Contact: Clinton Arblaster Commercial Controller Clintonarblaster@brandshapers.ie Mob: +353 87 963 2955

Clonmel Healthcare Ltd Unit 20A, Second Floor, Beckett Way, Park West Business Park, Nangor Road, Dublin 12 Website: www.clonmelhealthcare.ie Tel: 353 1 620 4000 Help Line: 353 1 620 4000 Order Line: 1800 26 26 26 Services: Distributors of Medicines and OTC Products direct to Pharmacies, Hospitals and via Wholesalers Ethical: 4SURE Blood Glucose Monitoring; Amidex; Amitriptyline; Amlotan; Amoxicillin Clonmel,

Amlodipine/Valsartan; Amlodipine/ Valsartan/HCT; Anxicalm; Apo-Go; Aripiprazole; Aspirin; Atenomel; Atorvastatin Clonmel, Axid; Azacitidine; Azithromycin Clonmel; Binosto; Bisoprolol; Bortezomib; Calvepen; Candist; Candist Plus; Casomide; Caspofungin; Cimeldine; Cinacalet; Ciprotan; Clavamel; Clavamel Forte; Cleo Infusion Sets; Clonactil; Clonocid; Clopidogrel TAD; Cozatan; Cozatan Comp; Crystapen; Darunavir; Dasatinib; Denzapine; Donesyn; Doxatan; Doxatan XL; Duloxetine; Emtricitabine/ Tenofovir Disproxil; Distaclor; Distaclor LA; Distaclor LA Forte; Etalopro; Ezetimibe/Simvastatin; Flucloxacillin; Febuxostat; Folic Acid; Fungasil; Furosemide; Ibandronic Acid; Irbesartan Clonmel; Isomel SR; Itami; Keflex; Lercanidipine Clonmel; Letrozole; Levetiracetam Clonmel; Linezolide; Losamel; Maxilief; Melfen; Memantine; Memantine Drops; Minimed MIO Advance Infusion Set; Miramel; Montelair; Movymia; Mycophenolate mofetil Clonmel; Nebimel; Nepramel; Nizoral Shampoo; Nytamel; Olanzapine; Olanzapine ODT; Olmesartan/Amlodipine HCT; Olmesartan; Olmesartan HCT; Osteomel; Pantium; Paracetamol; Perdamel; Phenobarbital; Pipercin; Posaconazole; Pravamel; Prednisolone; Pregabalin; Profloxin; Prosentio; Prozamel; Ramitace; Rasagaline Clonmel; Rabeprazole; Rinozal; Risontel; Rosuvastatin; Serimel; Seropia, Seropia XR; Sildenafil Clonmel; Simtan; Solifenacin; Tamnic; Tamnexyl XL; Tadalafil; Telmisartan; Telmisartan HCT; Temozolomide; Tipuric; Toltertan SR; True Result Diabetes Monitor, True result Twist; Valtan; Valtan Comp; Venex XL; Xymel; Xymel SR; Xymel Comp; Zestan; Zomel; Zopitan.

OTC: Accurate; Acriflex; Anti-Hist Allergy; Caldease; Caldesene; Caldesene Adult; CaldeSpray; Caldesun; CaldeBaby Teething Gel; Cerumol; Cerumol Olive Oil; Clear Little Noses; Clear Kids Noses; Clonfolic; Desenex; Easofen for children strawberry oral suspension; Easofen; Easofen Max; Easolief DUO; Eye Drops from the makers of Anti-Hist Allergy; Eucryl; Eurax; Flexitol Heel Balm, Flexitol Moisturising Foot Cream, Flexitol Hand Balm; Galfer Caps, Galfer Syrup; Gloup Swallowing Gel; Hedrin Treat and Go, Hedrin Protect and Go Spray, Hedrin Dual Pack, Hedrin ONCE; Just a Drop; Maxilief, Nicochew 2mg Gum, Nicochew 4mg Gum; Nizoral Dandruff Shampoo; Nizoral Care Scalp Tonic; Oilatum; Paralief 500mg Tablets; Paralief

Effervescent Tablets; Paralief Extra; Paralief Hot Lemon Drink; Paralief Night; Paralief Sinus; Ridonex; Savlon; Tefin Suppositories; Tipol Suppositories; Viralief 2g cream; ViraSoothe Gel, ViraSoothe Spray.

Eurosales International Ltd Unit 3/4, Ballymount Business Park, Ballymount Drive, Ballymount Industrial Estate, Walkinstown, Dublin 12, D12 F884 Type of company: Beauty, Cosmetics & Healthcare Distributor Website Address: www.eurosalesinternational.ie Tel: 00 353 1 450 7771 Fax: 00 353 1 450 7795 Order Line: 00 353 405 0900 Products: 1000 Hour, 7th Heaven, Bathefex, Biovene, Broadway, Chase The Scent, Cuticura, Dentyl Active, e.l.f. Cosmetics, Egypt Wonder, HASK, Inecto, Kennedy & Co Grooming, KISS, Lip Smacker, Lusso Tan, Madison Makeup, MAM, NOTE Cosmetics, P20, Palmers, Perspirex, Q+A Skincare, Snuggle Soother, Soft & Gentle, Tangle Teezer, Touch of Silver, UltraDEX, Vintage Cosmetics, wet n wild, White Glo, Yes To Local Contacts: Sandra Cheung 01 405 0900 sandra@eurosalesinternational.ie Telesales: Ian Stacey 087 174 4568 ian@eurosalesinternational.ie Clare, Galway, Leitrim, Mayo, Offaly, Roscommon, Sligo, Westmeath Mark Keane 086 234 4408 mark. keane@eurosalesinternational.ie Cavan, North Dublin, West Dublin, Longford, Louth, Meath, Monaghan, Stephen O Neill 087 066 9823 stephenoneill@ eurosalesinternational.ie Carlow, Dublin City Centre, Kildare, Kilkenny, Laois, South Dublin, Wexford, Wicklow Suzanne Cooney 087 210 5126 suzanne@eurosalesinternational.ie Cork, Kerry, Limerick, Tipperary, Waterford Allyson White +44 074 07709109 Allyson@eurosalesinternational.ie Antrim, Armagh, Derry, Donegal, Down, Fermanagh, Tyrone

COMPANY LISTINGS

HRA Pharma UK & Ireland Ltd

KRKA Pharma Dublin, Ltd

Haines House, 21 John Street, Bloomsbury, London, WC1N 2BF, United Kingdom

Unit H, 1st Floor, Citywest Shopping Centre, Saggart, Co.Dublin

Type of company: Consumer Healthcare

Type of company: Pharmaceutical Supplier of Generic Ethical Medication

Website: www.hra-pharma.com www.ellaonepharmacist.ie

Website: www.krka.ie

MacuHealth Ltd Echo Unit 2, Cessna Avenue, Airport Business Park, Waterford X91 F857 Type of company: Eye Health Supplements Website: www.macuprime.ie

187

The Mentholatum Company Ltd 1 Redwood Avenue, Peel Park Campus, East Kilbride, G75 5PE Type of company: Pharmaceutical Manufacturer/ Supplier Website: www.mentholatum.co.uk

Tel: +353 51 271010

Tel: 01355 848484

Help Line Number: +353 51 271010

Order Line: Uniphar Customer Services

Tel: +44 (0)203 7501 720

Tel: 01 2399180

Help Line Number: 1800 812984

Help Line: 01 2399180

Order Line: Order MacuPrime through

Retail Pharmacy: +353 1-4687501

Order Line/Customer service: +353 1 463 2300

Order Line: 01 2399180

• Uniphar

Local Contacts: Keith Sheridan Sales & Marketing Manager 01 2939180

• United Drug

Products: Deep Heat Pain Relief Heat Patch, Deep Heat Pain Relief Heat Spray, Deep Heat Rub, Deep Heat Muscle Massage Roll-on Lotion, Deep Freeze Cold Patch, Deep Freeze Cold Gel, Deep Freeze Cold Spray, Deep Freeze Glide-on Gel

Customer service: cs.pemberton@united-drug.com Products: Emergency Contraception ellaOne – 30mg Film Coated Tablet. Ulipristal acetate; Footcare - Compeed Blister Plasters, Compeed Anti Blister Stick, Compeed Bunion Plasters, Compeed Callus Plasters, Compeed Corn Plasters; Lip Health – Compeed Cold Sore Patch Local Contacts: United Drug Consumer, Magna Drive, Magna Business Park, Citywest Road, Dublin 24, D24 XKE5, Ireland Any other info: https://udconsumer.com/

Johnson & Johnson (Ireland) Limited

customerservices@wmohealthcare.com Email: careline@macuhealtheurope.com

LifeScan Healthcare Ireland Limited Mespil Business Centre, Mespil House,Sussex Road, Dublin 4 D04 T4A6 Type of company: Medical devices, blood glucose meters, lancing devices, lancets

CEO: Frank O’Regan frank@macuhealtheurope.com For all orders: WMO Healthcare Ltd 01-01-4291200 Noel O’Loughlin 085-2837926 noel@wmoptical.com

Products: blood glucose meters, blood glucose testing strips, lancing devices, lancets, digital solution for patients with diabetes, patient mobile app, HCP web app.

Local Contacts:

Thomas McCrory 087 1386466 tmccror1@lifescan.com

Products: Nicorette®, Calpol®, Benylin®, Imodium®, Motilium®, Regaine®, Sudafed®, Sinutab®, Actifed®, Johnson’s®, Aveeno®, Neutrogena®, OGX®, Listerine®

Marketing Manager: Karen Fennell 087-7637489 karen@macuhealtheurope.com

customerservices@wmohealthcare.com

Type of company: Consumer Health

Help Line Number: 1800 22 00 44

Local Contacts:

Help Line Number: 1800 535 676

Regional Account Managers:

Tel: 01 466 5200

Products: MacuPrime 30 day, MacuPrime 90 day, MacuPrime PLUS 30 day

Website: www.myonetouch.ie

Airton Road, Tallaght, Dublin 24 D24 WR89

Website: www.jnj.com

• WMO Healthcare Ltd 01-4291200

Aoife Feeney 087 6919166 afeeney@lifescan.com Tadgh O´Riordan 087 2462963 toriord3@lifescan.com Maurice Doyle 087 7819881 mdoyle27@lifescan.com

Shane O’Loughlin 085-8069174 shane@wmoptical.com Any Other Info: Based in Waterford, MacuPrime is the most scientifically tested eye health food supplement on the market.

United Drug: T: +353 1 463 2300

Local contacts: Star OUTiCO part of the Uniphar Group Local Star OUTiCO Representatives: Colm Kelly, National Key Account Manager: 087 4623318 Ger Allen, Senior Retail Representative, South: 087 2958103 Toby Kavanagh, Senior Retail Representative, East: 087 9262991 Gary Lydon, Retail Representative, West: 085 8716855

W E A LT H M A N A G E M E N T

Moore Wealth Management

MacuPrime is supported by over 20 years of independent, published research and clinical trials at Waterford Institute of Technology and is recommended by Prof John Nolan, Director, Nutrition Research Centre Ireland.

Suites 3&4, Marine Point, Belview, Waterford

“We’ve tested the many supplements available on the market and the only one I would recommend is MacuPrime because it is pure, stable and effective. Put simply, we could not get the same results with any other supplement.

This formulation is unique because of its enhanced bioavailability and how it is prepared with all three carotenoids.”

Help Line: 051 -832 839

Prof John Nolan, Director Nutrition Research Centre Ireland

Type of company: Financial Advisers Website: www.mwm.ie Tel: 086-8603953 Products: Pensions, Investments, Life Cover, Serious Illness, Income Protection Any other info: As Certified Financial Planners™ and recommended providers of Financial Advice to IPU member you can have the confidence of knowing your financial advice is at the highest accredited standard worldwide.

188

COMPANY LISTINGS

Any other info: We offer in-depth training to staff on benefits of supplements.

Mylan IRE Healthcare Limited

Samples for some products available on request from your Territory Account Manager.

Free marketing materials and support available on request.

Website: www.mylan.ie Tel: +353 1 8711600 Help Line Number: +353 1 8771 1069 Any other info: For details visit https://www.mylan. ie/en-ie/products

The Nature’s Bounty Co. Aldbury, Tring, HP23 5PT, United Kingdom Type of company: Food Supplements Website: www.solgar.co.uk www.naturesbounty.co.uk Tel: +44 (0) 1442 890 355 Help Line: +44 (0) 1442 890 355 Order Line: +44 (0) 1442 821 419

Website: www.novalabs.co.uk Tel: +44 (0) 116 223 0100 Help Line: (Customer Care Pharmacist) freephone number 0800 975 4840

Newenham Court, Northern Cross, Malahide Road, Dublin 17, Ireland.

Type of company: Pharmaceuticals - Biosimilars, generics, brand products and OTC medicines

any pharmaceutical dosage form, including non-sterile cytotoxic formulations. Our highly skilled team of formulation pharmacists continue to develop and produce new formulations, with >10,000 available.

Minami Mianmi, Nestlé Ireland,3030 Lake Drive, Citywest Business Campus, Dublin 24.

Type of company: Nutrition Website: www.minamihealth.co.uk Tel: 00800 6378 5385 Help Line: 00800 6378 5385 Products: MorEPA Platinum Elite + 1000IU Vitamin D, MorEPA Original, MorDHA Prenatal, PluShinz0-3, VeganDHA, MorEPA Move, MorEPA Cholesterol, MorDHA KIDS 3+, MorEPA KIDS 6+, MorEPA Mind, CBD + OMEGA-3, DHA+EPA Liquid Kids + Vitamin D

Order Line: freephone number 0800 975 4840 Email: sales@novalabs.co.uk Products: We have over 10,000 formulations available which include: Solutions; Suspensions; Creams; Ointments; Lotions; Capsules; Sachets; Suppositories; Enemas; Ear Drops; Nasal Drops; Cytotoxic Products; Pre-Filled Syringes; Mini Bags; Injectables Local Contact: Karen Cole, Group Sales & Marketing Manager Specials: 07944 450987 Dr Mike Edge - Head of Non-Sterile Manufacturing Tel: +44 (0) 116 223 0100

Local Contacts: Jason McGarry +353852374764 Any other info: At Minami, we create omega-3 products tailored to different lifestyles and life stages.

Our unique, advanced production process ensures our products are highly concentrated and highly sustainable, for a purity you can feel and trust.

Nutricia Ireland Block 1 Deansgrange Business Park, Deansgrange, Co. Dublin Type of company: Specialised Nutrition Website: www.nutricia.ie

Products: Vitamins, Minerals, Specialist Food Supplements

Tel: (01) 289 0283

Local Contacts:

Order Line: 1800 923 404

Regional Key Account Manager Sara Gibson Mobile: +35386 0406686 Email: sgibson@nbty.com

Any other info: Full product range - www.nutricia.ie 1800 923 404

John Kennedy Territory Account Manager (South Ireland) +353 86 7778771 Email: jkennedy@nbty.com Lorna Kerr Territory Account Manager (Dublin & Northern Ireland) +353 86 0422500 Email: lkerr@nbty.com Mary Goode Territory Account Manager +353 86 777 8770 Email: mgoode@nbty.com Bethan Carr Category and Product Training Manager Email: bcarr@nbty.com

Help Line: 1800 923 404

Nova Laboratories Ltd. Martin House, Gloucester Crescent, Wigston, Leicester LE18 4YL

Products for professional evaluation and supporting literature available by calling the freephone.

Help Line Number: Freephone 1800 286552 Order Line: Freephone 1800 286552 Local Contacts: Tena + 3,000 Lines Freephone 1800 286552 Any Other Info: Group Training Available

Pharmed Ltd. Unit 3 Clonmore Business Park, Mullingar, Co. Westmeath Type of company: Distribution Company Website: www.pharmed.ie Tel: +353 44 939 6188 Fax: +353 44 939 0140 Help Line: +353 44 939 6188 Order Line: +353 44 939 6188 Products: Cys-Control, Earol, Epitact, Footner, Gallinee, GoBrush, Kidsclin Craddle Cap, Macu-Save, Mancave, Medtronic, Mepore, Microlife, Migrastick, MyPro Kolicare, MyPro Diacare, Nasopure, Neostrata, Oralmedic, ORS Hydration Salts, PawPaw, Peppermint Grove, Pernaton, Phyto Soya, Poxclin Chicken Pox, Poxclin Shingles, PPE, Synbio, The Sun Mousse, Ultrapure Laboratories, Wartie Cool Local Contacts: Andrea Murphy: 087 228 8359 Elaine Kelly-Dunne: 086 130 1374 Office No: 0449334606 Moya McCarthy: 086 411 4597 Ursula Brooks: 086 023 5901 Sarah Cribbon: 086 130 1835 Ali O’Brien: 086 410 7128

Type of company: Full Line Specials Manufacturer Nova Laboratories Limited was established in 1994 and has since gained a global reputation for manufacturing complex and innovative experimental medicines and delivery devices, for a wide range of pharmaceutical and biotechnology companies. Nova is a UK leading independent supplier of both ‘Specials’ and clinical trial medicines to healthcare professionals. Our state-of-the-art facilities allow us to provide virtually

Parle & Hickey Ltd Pinewood Beechwood Close, Boghall Road, Healthcare Bray, Co Wicklow Type Of Company: Distributor Website: www.parleandhickey.com Tel: Freephone 1800 286552 Fax: 01 2865533

Unit 1, M50 Business Park, Ballymount, Dublin 12, Ireland Type of company: Accounts, Manufacturing and Marketing: Ballymacarbry, Clonmel, Co Tipperary, Ireland Tel: 00353 1 456 9123 (Dublin)

COMPANY LISTINGS

00353 52 61 86000 (Ballymacarbry) Fax: 00353 1 456 9125 (Dublin) 00353 52 61 36311 (Ballymacarbry) Email: customerservicem50@pinewood.ie Website: www.pinewood.ie Pharmaceutical Manufacturer and Distributor of Ethical and OTC Products Products: Ethical: Amlodipine, Amoxicillin, Aripiprazole, Atorvastatin, Calcium Acetate, Cetirizine, Chlorpromazine, Clarithromycin, Clopidogrel, CoDanthramer, Donepezil, Duloxetine, Doxycycline, DutasterideTamsulosin, Erythromycin, Esomeprazole, Febuxostat, Flucloxacillin, Kopen, Lansoprazole, Losartan, Memantine, Metformin, Minocycline, Omeprazole, Ondansedron, Pantoprazole, Pravastatin, Pregabalin, Risedronate, Rosuvastatin, Zopiclone.

OTC Confined: Acidex, Aqueous cream, Cetirizine, Codeine, Dispensing bottles, Glycerine Honey & Lemon, Hydrocortosine Cream, Ibuprofen Suspension, Laxose, Micolette, Paracetamol Suspension, Paracetamol Caplets, Pholcodine, Surgical Spirits, Viscolex.

Distribution: Direct to Pharmacies, Hospital Pharmacies and via Wholesalers Management: Mr Ajay Sahni:Managing Director Mr Jeffrey Walsh 087 669 4043 Head of Sales (Retail Division) Mr Jurgen Wegner 087 741 1411 Head of Secondary Care Mr Peadar Flynn: 087 259 4129 Pharmacy Business Manager Pharmacy Sales Representatives: Mr Pat Ahern 087 131 6663 - South Mr David Brannigan - East Mr Ciaran Clarke 087 770 0086 Dublin / North East Ms Aoife McDonnell 087 624 0817 - Dublin / East Mr Tom O’ Brien 087 255 9950 - South Hospital Representative Ms Katie Tobin 087 991 4404

Help Line: Healthcare 01 6305429 Consumer: (Household) 01 667318 Order Line: 01 4689200 Products: Bonjela, Dettol, Disprin, Durex, E45, Full Marks, Fybogel, Gaviscon, KY, Lemsip, Nurofen, Optrex, Scholl, Senokot Strepsils, Veet Local Contacts: Ciarán Woods, Senior National Account Manager Pharmacy

Solvotrin Therapeutics Hoffmann Park, Little Island, Cork, Co. Cork Tel: +353 (021) 4510220 Fax: +353 (021) 4510229 Email: info@solvotrin.com Products: Active Iron, Active Iron & B Complex Plus for Women and for Men, Active Iron Pregnancy, Active Iron Pregnancy Plus, Active Folic and Active Immune

Unit 7, Riverwalk, Citywest Business Campus, Dublin 24 Type of company: Consumer Health Website: www.rb.com Tel: 01 4689200 Fax: 01 4689299

Commercial Division: Teva’s commercial activities span the sales and support services for Teva’s large portfolio of medicines, both generics and branded innovative medicines, along with over-the-counter consumer health products.

We supply medicines to treat a wide range of diseases and conditions – from multiple sclerosis, asthma, cancer and Chronic Obstructive Pulmonary Disease, to pain relief, cholesterol reducers and antibiotics. Dosage forms include extended and immediate release tablets and capsules, injectables, creams, ointments, solutions, suspensions and inhalers.

Whether they’re used in hospitals or by GPs, nurses, or independent pharmacists, our medicines are supported by comprehensive advice and information from our Medical teams.

In additional to the field-based sales teams covering both primary and secondary care in Ireland;

West: Garrett Dolan Garrett.Dolan@theapamex.com Any other info: TheaPamex is the Irish subsidiary of Laboratoires Théa, Europe’s leading, pioneering and innovative Eye Health group founded in 1994 by Henri Chibret.

The Chibret family has been dedicated to Ophthalmology for more than 150 years.

Théa was the pioneer and remains the world leader in preservativefree eye care products. Thanks to Théa, ophthalmology has entered into the preservative-free era, allowing patients to benefit from a whole range of eye care treatments which respect their visual potential.

TheaPamex was introduced in 2018 in Ireland and within only a year managed to earn the trust of Ophthalmologists, Pharmacists and consumers all around the country and become their #1 choice for Eye Care. Our strength lies within our people: a team of dedicated, highly motivated and driven professionals ready to satisfy with the most efficient and effective way the increasing needs and wants of our Customers and Consumers for Eye Health.

Teva’s commercial teams and support functions are based in Swords, near Dublin.

United Drug

Teva Pharmaceuticals

United Drug, Magna Drive, Magna Business Park, Citywest Road, Dublin 24, D24 XKE5

Digital Office Centre Swords, Suite 101 – 103, Balheary Demense, Balheary Road, Swords, Co. Dublin, K67E5AO

TheaPamex

Type of company: Global pharmaceutical company

14 Moneen Business Park, Castlebar, Co. Mayo, Ireland

Website: www.Teva.ie

Type of company: Privately held

Email: Reception.UDW@united-drug.com Consumer Email: Consumer@united-drug.com Distribution Email: Distribution@united-drug.com

Website: www.theapharma.ie

Wholesale Email: Wholesale@united-drug.com

Tel: +353 94 925 0290

Type of company: Pharmaceutical distribution of products & services Website: www.united-drug.com

Clodagh Kevans, Director Specialty Medicines Ireland

Products: Thealoz Duo, Thealoz Duo gel, Hyabak, Blephaclean, Blephagel, Blephasol, Blephasol Duo, Blephademodex, Blephasteam, Otrivine, Nutrof Total, Azyter, Monopost, Timofluid, Azyter, Dexafree, Fydrane, Fixapost, Zoftacot

Any other info: We offer high quality generic, specialty and OTC medicines to patients across a wide range of therapeutic areas.

Local Contacts: East-North: Orla Smith Orla.SMITH@theapamex.com

Tel: 00353 1 9127700 Help Line: 1800201700 Products: Bisodol, Buplex, Cetriz, Cymex, Exorex, Infacol, Sudocrem, Orovite Local Contacts: Paul Neill, Director Generic Products Ireland

RB Ireland

Teva employs around 800 people in Ireland and has three sites in the Republic of Ireland and one site in Northern Ireland.

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And, we are continually expanding our range of products and services to better meet the needs of Irish patients and healthcare professionals.

East-South: Anne Austin Anne.AUSTIN@theapamex.com South: Andy Moloney Andy.MOLONEY@theapamex.com

Tel: +353 1 463 2300 Fax: +353 1 463 2333 United Drug Wholesale (Ballina) Crossmolina Road, Ballina, Mayo, F26 W6R6, Ireland.

Tel: +353 096 72555 Fax: +353 096 72400 United Drug Wholesale (Limerick) Johnsgate House, Old Clare Street, Limerick, V94 E3F1, Ireland.

Tel: +353 061 315411 Fax: +353 061 315012

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COMPANY LISTINGS

Valeo Healthcare

educational booklets available for customers. Nutritional Information Database covering: supplements, nutritional concerns, herbal remedies, drug-nutrient interactions, provides literature searches for a wide variety of nutritional topics. Media plans, POS and information available on request.

Website: www.valeohealthcare.ie

Nua Fertility: A natural fertility supplement with a gut health focus.

Biokult: Probiotic dietary supplements

Nutri Nua: A fully vegan range of nutritional supplements, exclusive to pharmacies

Biomedical: Cardio-K, Cardio-P, and Cardio-T. Bio-Strath: Herbal Tonic Celtic Wind: CBD Oil Eskimo Oil: Brainsharp Omega, Eskimo Kids and Eskimo Omega 3.

Merrywell Industrial Estate, Ballymount, Dublin 12, Ireland.

Type of company: Distributors of Vitamins, Minerals and Herbal Supplements, Aromatherapy Oils, Skincare, First Aid and Dietary Foods.

Bioglan: OAD Super Fish Oil, Red Krill, Stat-Guard, Glucosamine SR1500mg, Promensil.

Herbal Teas: Pukka, Tea Pigs, Heath & Heather and Yogi.

Wholefoods Wholesale

Higher Nature: The Saltpipe, Balance for Nerves, Red Sterol, Kids Range, Teens range, Full Vitamin range.

Unit 3 Kylemore Ind Estate, Killeen Road, Dublin 10

Hubner: Gastrointestinal Gel, Iron Vital Tonic, Silicea Caps – For Hair, Skin & Nails, Silicea Cold Sore Lip Gel and Silicea Beauty Gel.

Products: Extensive range of VMS, Herbal Products, Skincare, Medical Devices and Medicated Confectionary, including:

Tel: 01 626 2315 Fax: 01 626 1233

Jason: Personal and body care range.

Email: info@wholefoods.ie Website: www.wholefoods.ie

Vitabiotics (Pregnacare, WellBio, Wellwoman, Wellman, WellKid, Perfectil); Vit D3 (BabyVitD3 & Adult D3); Aqua Biome (High DPA fish oils for the microbiome); Enzymedica (Digestive Enzymes); Ortis (Fruit & Fibre Cubes); FSC (Waterfall); Kelkin (Vitamins, Aromatherapy Oils and Skincare); Fisherman’s Friend; Biofreeze; Dextro; Kobayashi Healthcare (Cura Heat, Kool N Soothe & Hot Hands); Hawkins & Brimble (Mens Skincare & Grooming Range); Attitude (Natural Skincare for all the family); Halter (Swiss Sugar Free Sweets); Passion For Life Healthcare (Actifresh, Audiclean & Snoreeze range); Vamousse (Head Lice Range) & First Aid supplies.

Types of Business: Agents and distributors of Herbal Remedies, Nutritional Supplements, Homeopathic Remedies, Flower Essences, Natural and Organic Bodycare, Manuka Honey, Sports Nutrition, Natural Hair colouring, Aromatherapy Oils, Gluten free and Dietary foods.

Jan De Vries Essences: Night, Craving, Concentration, Emergency, Relaxation, Confidence, Mood.

Tel: +353 (0) 1 405 1500 Help Line: +353 (0)1 403 1499 Order Line: +353 (0)1 403 1499

Local Contacts: Account Managers - David Keane: Customer Business Manager Stephen Moloney: Business Development Manager Maurice Horgan: Field Sales Manager Sales Representatives: Fintan Byrne, Munster +353 (0) 87 647 0764 Julie Webster, Midlands, Leinster +353 (0) 87 647 0765 Eamon Connolly, West, North West +353 (0) 87 238 5648 Product Training Advisor: Lucia Wright +353 (0) 86 162 4186 Any other info: Distribution: Direct to Pharmacies and via wholesale companies.

Special Services: Comprehensive range of literature (posters, window kits, samples) provided to health professionals and

Ethical: A.Vogel Herbal: Gingko Biloba, Hypericum Complex, Hypericum Perforatum, Serotone, St John’s Wort OTC Confined: A.Vogel Herbal: Prostasan, Uva-Ursi and Echinacea Non-OTC Confined: A.Vogel Herbal Tinctures: Echinacea for the family, Atrosan, Atrogel, Milk Thistle tincture and tablets, Passiflora, Dormeasan, Ivy Thyme, Venaforce, Sinuforce, Eye Drops, Bronchosan, Digestisan and Menoforce as well as a full range of other herbal remedies.

A.Vogel Veterinary: Jan De Vries Animal Essences – Animal Separation, Animal Emergency, Animal Highly Strung Essence, Animal Over-Dominant, Animal Timid. Amina Strath – Feed supplement (combination of yeast & herbs).

Avalon: Organic skin and body care. Shampoos, conditioner, moisturiser, shower gels.

Active Edge: Cherry Juice

Kinvara: Hyaluronic Youth Boost, Active Rosehip Day Cream, 24Hr Rosehip Face Serum, Omega Rich Hand & Nail Cream, Elemental Exfoliating Powder, Eye Wow! Eye Serum.

Life Boost: Children’s Honey & Lemon Syrup.

Lifestyle Products: Ecover, Lilly’s, The Saltpipe and Natracare (personal hygiene).

LithoLexal® Marine Plant ExtractBone Health, Joint Health, Bone Care MAG365: Powder based range of magnesium supplements.

MorEpa: Omega 3 supplement range Mother and Babycare: Earth Friendly Baby, Natural Babycare Nappies, Wipes and Bodycare.

Natural and Organic Bodycare: Jason, Avalon, Faith in Nature, Natura Siberica.

Naturtint Hair Colours: Permanent, Reflex (Semi Permanent).

Natura Siberica: Hair and body care range.

Nelsons Homeopathic Remedies: Nelsons Teetha Granules and Gel, Nelsons Arnicare, Nelsons Clikpak, topical and formulated remedies.

Bach Original Flower Remedies

Nourkrin Hair Supplements: Nourkrin Maintain, Nourkrin Man, Nourkrin Woman, Nourkrin Post Pregnancy, Nourkrin Active, Nourkrin Radiance, Scalp Lotion, Nourkrin Shampoo & Conditioner

Better You: Transdermal magnesium and oral vitamin sprays

Nourella: Active skin support supplement, Active skin rejuvenation cream.

Aromatherapy Oils: Atlantic Aromatics, Absolute Aromas, Ord River Tea Tree, Puressential.

Optibac Probiotics: A natural range of probiotic supplements suitable for the whole family.

Optima: Aloe Vera Gel, Gentle Action Colon Cleanse, Aloe Dent Toothpastes and Mouthwash, Joint Complex, Aloe Pura Juices, Allergenics Skincare, Lecithin, Optima Lifestyle Vitamins, Australian Tea Tree, Montmorency Cherry Juice, Cranberry Concentrate Juice.

Parasol: Suncare range.

Pernaton Green Lipped Mussel Extract: Pernaton Gel, Pernaton Relaxing Bath Therapy, Pernaton Capsules.

Pharma Nord: Scientifically founded food supplements and herbal remedies.

My Fertility Box: Pre-conception supplement Probiotic: Optibac.

Phizz: Rehydration + Vitamins and Minerals.

Quest Vitamins: A-Z range of vitamins, supplements and probiotics.

Rescue Remedy: Rescue Remedy, Rescue Night, Rescue Plus.

Salus Haus: Herbal tonics Sambucol Black Elderberry Extract: Sambucol Original, Sambucol Kids, Sambucol Effervescent.

Sea-Band, Hay-Band: Sea-Band Child, Sea-Band Adult, Sea-Band Mama.

Silicolgel: Oral gel containing colloidal silicic acid for the treatment of gastrointestinal disorders and IBS. Spatone Iron Supplement: Spatone Original and Spatone Vit C. Sports Nutrition: Optimum Nutrition, Maximuscle, Plantforce.

Teetha: Teething granules and gel.

Zerochol: Zerochol plant sterol supplement.

Zincuflex: Curcumin and Ginger food supplement.

Distribution: Direct to Pharmacies and via wholesalers (specific lines).

Number of Sales Force: 8 Territory: Ireland – For details of your local representative please contact the Wholefoods office on 01 6262315.

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NOTES

BUILDING GREAT HEALTHCARE BRANDS

MAH: McNeil Healthcare (Ireland) Ltd. & Johnson & Johnson (Ireland) Ltd. Airton Road, Tallaght, Dublin 24, Ireland.

Products not subject to medical prescription. Full prescribing information available from Johnson & Johnson (Ireland) Ltd. Airton Road, Tallaght, Dublin 24, Ireland.

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