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May 2018 Volume 10  Issue 5


In this issue: AWARDS: The Irish Pharmacy Awards 2018 – the finalists in full and details of the event. Page 58

NEWS: Calls to protect pharmacies from crime. Page 5

NEWS: Epipen shortage reaches Ireland. Page 14

FOCUS ON: Biosimilars and their use in Ireland. Page 11

CPD: COPD – analysis and treatment. Page 47

EVENT: The United Drug Pharmacy Show. Page 53


FOR SEVERE CHRONIC PAIN PALEXIA® SR Tablets are indicated for the management of severe chronic pain in adults, which can be adequately managed only with opioid analgesics1

PALEXIA SR® Prolonged Release Tablets Prescribing Information Refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 mg (white), 100 mg (pale yellow), 150 mg (pale pink), 200 mg (pale orange) and 250 mg (brownish red) prolonged-release tablets contain 50 mg, 100 mg, 150 mg, 200 mg and 250 mg of tapentadol (as hydrochloride) respectively. Indication: Palexia SR is indicated for the management of severe chronic pain in adults, which can be adequately managed only with opioid analgesics. Dosage and method of administration: Individualise according to severity of pain, the previous treatment experience and the ability to monitor the patient. Swallowed whole with sufficient liquid, not divided or chewed, with or without food. The tablet shell may not be completely digested and eliminated / seen in the patient’s stool which has no clinical significance as the active substance will have already been absorbed. Initial dose 50 mg twice a day. Switching from other opioids may require higher initial doses. Titrate in increments of 50 mg twice a day every 3 days for adequate pain control. Total daily doses greater than 500 mg not recommended. Discontinuation of treatment: Taper dose gradually to prevent withdrawal symptoms. Renal/hepatic impairment: Not recommended in patients with severe cases. Caution and dose adjustments with moderate hepatic impairment. Elderly: May need dose adjustments. Children below 18 years: Not recommended. Contraindications: Hypersensitivity to ingredients, suspected or having paralytic ileus, acute intoxication with alcohol, hypnotics, centrally acting analgesics or psychotropics. Not for use when mu-opioid receptor agonists are contraindicated (e.g. significant respiratory depression, acute or severe bronchial asthma or hypercapnia). Special warnings and precautions: Abuse and addiction potential of Palexia should be considered where there is increased risk of misuse, abuse, addiction or diversion. All patients should be carefully monitored for signs of abuse and addiction. At high doses or in mu-opioid receptor agonist sensitive patients, dose-related respiratory depression may occur. Caution and monitoring required with impaired respiratory function. Should not use in patients susceptible to intracranial effects of carbon dioxide retention (e.g. increased intracranial pressure, impaired consciousness or coma). Use with caution with head injury, brain tumors, moderate hepatic impairment, biliary tract disease including acute pancreatitis. Not recommended if history of or at risk of seizures or with severe renal or hepatic impairment. Care should be taken when combining with mixed mu-opioid agonists/antagonists (e.g. pentazocine, nalbuphine) or partial mu-opioid agonists (e.g. buprenorphine). Should not use with hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption. Interactions: Use with benzodiazepines, barbiturates and opioid analgesics, antitussive drugs and substitutive treatments may enhance the risk of respiratory depression. Central nervous system (CNS) depressants (e.g. benzodiazepines, antipsychotics, H1antihistamines, opioids, alcohol) can enhance the sedative effect and impair vigilance. Consider dose reduction with respiratory or CNS depressant agents. In isolated cases, there have been reports of serotonin syndrome in a temporal connection with the therapeutic use of tapentadol in combination with serotoninergic medicinal products (e.g. serotonin re-uptake inhibitors). Use with strong inhibitors of uridine diphosphate transferase isoenzymes (involved in glucuronidation) may increase systemic exposure of Palexia SR. Caution if concomitant administration of strong enzyme inducing drugs (e.g. rifampicin, phenobarbital, St John’s Wort) starts or stops as this may lead to decreased efficacy or risk for adverse events, respectively. Avoid use in patients who have taken monoamine oxidase inhibitors (MAOIs) within the last 14 days, due to cardiovascular events. Pregnancy and lactation: Use in pregnancy only if the potential benefit justifies the potential risk to the foetus. Not recommended during and immediately before labour and delivery. Do not use during breast feeding. Driving and using machines: May have major effect on ability to drive and use machines, especially at the beginning or change in dosage, in connection with alcohol or tranquilisers. Undesirable effects: Very common (≥1/10): dizziness, somnolence, headache, nausea, constipation. Common (≥1/100, <1/10): decreased appetite, anxiety, depressed mood, sleep disorder, nervousness, restlessness, disturbance in attention, tremor, involuntary muscle contractions, flushing, dyspnoea, vomiting, diarrhoea, dyspepsia, pruritus, hyperhidrosis, rash, asthenia, fatigue, feeling of body temperature change, mucosal dryness, oedema. Other important undesirable effects observed in clinical trials and/or postmarketing: drug hypersensitivity, depressed level of consciousness, mental impairment (uncommon ≥1/1000, <1/100), impaired gastric emptying, respiratory depression, convulsion, angioedema, anaphylaxis and anaphylactic shock (rare ≥1/10,000, <1/1000). No evidence of increased risk of suicidal ideation or suicide with Palexia SR. Additional information is available on request. Overdose: Seek specialist treatment (see SmPC). Legal classification: POM, CD (Schedule II). Marketing Authorisation numbers and pack sizes: 50 mg: PA 1189/7/4, 28 and 56 packs; 100 mg: PA 1189/7/5, 56 pack; 150 mg: PA 1189/7/6, 56 pack; 200 mg: PA 1189/7/7, 56 pack and 250 mg: PA 1189/7/8, 56 pack. Marketing Authorisation Holder: Grünenthal Ltd, Regus Lakeside House, 1 Furzeground Way, Stockley Park East, Uxbridge, Middlesex, UB11 1BD, UK. IRE/P18 0001. Date of Preparation: January 2018. Reference: 1. Palexia SR Summary of Product Characteristics. Date of Preparation: January 2018. IRE/P18 0005

Contents Page 5: May Measurement Months – hypertension awareness Page 8: Quick thinking pharmacist saves a life


Page 18: Pharmacy confidential Page 27: Diabetes from risk to treatment


Page 57: Landmark study on COPD

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com


COMMERCIAL MANAGER – SPECIAL PROJECTS Natalie Millar natalie.millar@ipnirishpharmacynews.ie

PHOTOGRAPHY Aidan Oliver CONTRIBUTORS Andrew Jennings, Deborah Lynch, Clair Naughton, Robert McOwan, Sarah Keogh, Keith Hourihane COMMERCIAL MANAGERS Natalie Millar and Nichola McGarvey






This month’s edition focuses mainly on the finalists for the awards and this year we have been almost overwhelmed at the calibre of entries. Ireland’s community pharmacists and their teams have shown us how they continuously go above and beyond for their patients and the wider community. All of our finalists are listed from page 58.

It’s also been a month of events recently with the annual PMI Business Day taking a focus on both biosimilars and the upcoming GDPR, our report is on page 22. You can read our full coverage of the United Drug Pharmacy Show starting on page 53. United Drug this year formally introduced their partnership with global giant McKesson and introduced pharmacists to the pharmacy of the future. The show was the best yet and featured the technology of the future that is clearly going to make a difference to the community pharmacist.

PUBLISHER IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

SENIOR JOURNALIST Kerry McKittrick editorial@ipnirishpharmacynews.ie

It’s been a busy month at IPN headquarters as we prepare for the Irish Pharmacy Awards 2018, taking place at the Clayton Hotel, Burlington on May 12th. This will be a major networking event for the pharmacy industry with more than 650 industry experts in attendance. This is one of the most exciting events in the community pharmacy calendar with the chance to network and celebrate those who are making a real difference in community pharmacy. This edition also introduces Raphael – our awards statue and one with great symbolism for the community pharmacist.

It’s also been a controversial month for community pharmacy, with the IPU’s proposal that pharmacists should be able to issue oral contraception without a doctor’s prescription. This has been a dividing issue among medical professionals – find out more on page 4.

Page 44: Headaches and migraines

ADVERTISING MANAGER Nicola McGarvey nicola@ipnirishpharmacynews.ie


Irish Pharmacy IRISH News is circulated PHARMACY to all independent, NEWS multiple and hospital pharmacist, government officials and departments, pharmacy managers, manufactures and wholesalers. Buyers of pharmacy groups and healthcare outlets. Circulation is free to all pharmacists subscription rate for Irish Pharmacy News ¤60 plus vat per year. All rights reserved by Irish Pharmacy News. All material published in Irish Pharmacy News is copyright and no part of this magazine may be reproduced, stored in a retrieval system of transmitted in any form without written permission. IPN Communications Ltd. have taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

Also coming up in May will be the announcement of the shortlist for the Pharmaton People’s Pharmacist of the Year Award on social media. This award is decided by public vote so now is your chance to give the four shortlisted community pharmacists your support. Voting continues until May 11th. This is a great opportunity to show your appreciation for pharmacists who really are the heart of the local community This month the spotlight is on conditions such as dysphagia, diabetes and COPD. We examine headaches and migraines on page 44 – how are they caused and what’s the difference between the two. We also shine a light on Coeliac Disease and what it means for the community pharmacist. On page 36 we have an investigation into rheumatoid arthritis and how it is linked to a high-risk genetic background. Next month we will have the full report from the Irish Pharmacy Awards including all of the winners and the special moment when the public vote reveals the Pharmaton People’s Pharmacist of the Year Award.



Feature: 36

Clinical profile:


Feature: Diabetes


CPD: 47

Product news:


Help prevent Diabetes. Identify patients at risk.

Email us pharmacy@realworldanalytics.com Call us 01 693 1433 Visit us realworldanalytics.com

Ignite Potential.

News news brief BREAKTHROUGH MIGRAINE TREATMENT ON THE HORIZON Hope is on the horizon for migraine sufferers with a new drug showing promising trial results. Erenumab is a self-injected smart drug that appears to cut episode migraine attacks in half.

A controversial proposal by the Irish Pharmacy Union is causing shockwaves across the healthcare sector.

The scheme proposes that the contraceptive pill be issued by pharmacists who had undergone extra training.

At the Charite-University Medicine Berlin patients included in the study had previously been shown to be resistant to between two and four other kinds of treatment for migraines.

The move comes after Health Minister Simon Harris’ announcement to the Dáil in March, during which he proposed the introduction of a free contraceptive service. The Minister said he would: “seek approval for a series of measures to further support women and improve access to counselling, contraception and perinatal care”.

"Our study found that erenumab reduced the average number of monthly migraine headaches by more than 50% for nearly a third of study participants. "That reduction in migraine headache frequency can greatly improve a person's quality of life." The drug targets and blocks calcitonin gene-related peptide (CGRP), a pain-signalling molecule in the brain. Migraines are sudden, painful attacks, the symptoms of which include sharp, painful headaches, nausea and light sensitivity among other things. Attacks vary in severity and can last up to three days. They can be enormously debilitating and can prevent sufferers from going about their daily lives. In Ireland it’s thought that around 15% of the population suffer from them. For the Phase III Liberty trial, 246 migraine sufferers were given injections of erenumab or a dummy placebo drug once a month for three months. Erenumab, marketed by the global drug company Novartis under the brand name Aimovig, is not yet licensed for use in the UK or Ireland. The recent findings were presented at the American Academy of Neurology’s annual meeting in April.

"As well as being the most effective form of contraception to prevent unintended pregnancy, LARCs are also more costeffective in the long-term than other methods." said Dr Henchion.

Last month the IPU submitted proposals to the Department of Health and Health Service Executive that would make the contraceptive pill free and available without prescription to women in Ireland.

The drug, injected in the same way as some medication for diabetics, has shown positive results in tests.

Trial leader Dr Uwe Reuter, said: "The people we included in our study were considered more difficult to treat, meaning that up to four other preventative treatments hadn't worked for them.


IPU propose prescription-free pill

Community pharmacies in Ireland often have extended opening hours and, unlike a visit to the GP, no appointment is necessary for a consultation. Pharmacists say the plan would dramatically increase access to safe and convenient contraception and could help reduce crisis pregnancies. IPU President Daragh Connolly said: “access to birth control is a major public health issue because of the risk of unwanted pregnancies. By making birth control easier and more convenient to obtain, more women will use it, which should result in reduced rates of unintended pregnancy. There are no clinical reasons why oral contraceptives should still require a prescription. The oral contraceptive is one of the safest and most well studied medicines available.” He continued by stressing: “this is not an attempt at excluding patients from seeing their GP or taking fees from GPs.” Dr Maitiu O’Tuathail, President of the National Association of General Practitioners said: “The provision of contraceptive services encompasses far more than just prescribing the pill. The patient’s sexual health, sexually transmitted infections, education, and the patient’s own physical and mental health are addressed”. As the patient’s primary care provider General Practitioners

Understandably the new policy would have advantages for both patients and pharmacists. A statement from the IPU said:

IPU President, Daragh Connolly are best placed to provide this service, both now and into the future. Continuity of care remains of paramount importance to us as GPs.” The GP committee of the Irish Medical Organisation have also condemned the move. Dr Padraig McGarry said that such a proposal would undermine efforts to provide women with a comprehensive sexual health programme. Dr McGarry said that a move like this was part of a trend of trying to disengage patients from regular contact with their GPs when such contact was vital to ensure that there was a well-established link between GPs and patient and a rounded knowledge of a patient's circumstances and health record. Also, the Irish Family Planning Association have expressed doubts about the scheme, saying that it could side-line more effective contraceptive methods and limit women’s choices over their options. Dr Caitriona Henchion, Medical Director of the IFPA, said: "The Government’s priority must be improving access to the most effective methods of contraception: long-acting reversible contraceptives (LARCs).” These include the injection, which lasts up to three months; the implant, which lasts up to three years; and hormonal and nonhormonal intra-uterine devices (coils), which last up to ten years.

“In light of the extent of their professional obligations, pharmacists would require remuneration over and above a standard dispensing fee for providing the service. It is the IPU’s view that, given the professional input and the time involved in providing the service, consultation fees in line with those already paid for the EHC consultation to GMS patients (currently ¤11.50 plus ingredient cost and standard dispensing fee) would be appropriate.” This isn’t the first time prescription-free contraception has caused controversy in Ireland. In a move unpopular with GPs at the time, the morning after pill became available for purchase from pharmacies in 2011. Now most women obtain emergency contraception from their pharmacist instead of their GP. A 2010 study on contraception by the HSE stated that convenience and accessibility were important for contraception supply. Nearly half the women questioned in the survey said they would prefer to get their contraception from a pharmacist instead of a GP. Across the globe the oral contraceptive pill is considered one of the safest and beststudied medicines on the market. According to the Oral Contraceptive OTC Working Group, at least 35 countries including New Zealand, Greece, India, China, and Egypt all formally issue the contraceptive pill without prescription, and it is available in many others on an informal basis. In the US a number of states have proposed legislation to do the same. Both the American College of Obstetricians and Gynaecologists and the American Association of Family Physicians back the move.

News The IPU calls for new measures to protect pharmacies from crime

news brief

The President of the Irish Pharmacy Union has warned that more needs to be done to protect pharmacy staff against violent crime.


Speaking to members at the Joint Oireachtas Committee on Business, Enterprise and Innovation, Daragh Connolly said: “Pharmacies throughout the country have been subjected to criminal activity on an ongoing basis and the problem continues to get worse”. The IPU revealed that four out of five pharmacies in Ireland were victims of crime in 2017. More than 80% were victims of two or more incidents and twice the number of pharmacies experienced some kind of raid last year than in 2016. A third of robberies were conducted with some kind of weapon. Mr Connolly explained: “The most violent type of crimes committed against pharmacies involve gangs who come in with a syringe, knife, gun or hatchet demanding prescription drugs . . . they are more likely to come into a pharmacy when it is open because they would not be able to access the drugs or cash themselves in an out-of-hours raid.”

Pharmacies now face additional costs to secure and insure their staff and premises. These can include the price of CCTV installation, tagging systems and the engagement of security guards. However, as Mr Connolly explained to the Committee, the most significant costs are hidden. “Crime has a negative impact on staff morale with the psychological aftermath and traumatic effects of these crimes – particularly violent crimes – leading to increased levels of absenteeism. Crime also damages businesses, threatens jobs and negatively impacts on staff morale. These hidden costs can have a far bigger impact on the pharmacy business than the direct costs of damage and loss.” Community pharmacists have expressed frustration with Garda response times, lack of follow-up on crimes that are reported and the leniency of sentences being handed down. The IPU has called for a number

of measures to be introduced, including: • More visible policing with an increase in Garda patrols; • Fast Garda response to reports of crime, the need for a targeted Garda operation to tackle crime against pharmacies; • Increased public CCTV, particularly in town centres; • A reassessment of sentences handed down for business crime to ensure they are adequate in terms of punishment and deterrent; • An increase in the development and implementation of business watch initiatives. Mr Connolly concluded his presentation to the Committee by warning that unless action is urgently taken “this sinister and frightening pattern of crime on pharmacies will continue, to the detriment of our members’ pharmacies and staff, and the local communities we serve.”

May Measurement Month Launched This month sees a global campaign to increase awareness of the risk surrounding high blood pressure, including World Hypertension Awareness Day on May 17. More than 10 million lives across the world are lost every year due to raised blood pressure. Blood pressure is universally regarded as a gauge of heart health and hypertension can be a warning sign of heart issues. In Ireland, one in four people have hypertension. For the population aged 50 or over, the statistics go up to more than half. It’s estimated that a third of people with the condition are undiagnosed and a third of those who have been diagnosed with high blood pressure aren’t able to adequately control it. Hypertension can put strain on the heart over time, causing stroke, heart attack or kidney damage. The condition can be controlled by medication as long as it is prescribed by a GP and a review carried out every six months. Most pharmacies stock blood pressure monitors and studies have shown that patients monitoring their condition have been able to lower their blood pressure by 10%. A 10% reduction

in high blood pressure can reduce the risk of stroke by half. Recent studies have shown that 24-hour blood pressure monitoring is thought to be considerably more effective in diagnosing hypertension than a one off clinic check. A new study assessed 63,000 patients who had their blood pressure monitored both in-clinic and over a 24-hour period wearing an ambulatory blood pressure monitoring device (ABPM). The findings showed that the ABPM was significantly more accurate in measuring blood

pressure – up to 50% - and therefore improved predictions of the risk of cardiovascular death. With a one off blood pressure check it has been possible to miss or mask hypertension. There is also the possibility of so-called white coat syndrome – when blood pressures spikes when being taken by a healthcare professional. However the study at the Institute of Cardiovascular Sciences at University College, London has stressed that in-clinic blood pressure measurements still remain useful, particularly when backed up with a 24-hour measurement.

After weeks of speculation and negotiation Takeda Pharmaceutical has reached an initial agreement to buy Irish pharmacy manufacturer Shire Several proposals were made by the Japanese firm before the Shire board accepted the fifth bid of around ¤49 billion, made up of cash and stock, giving the company a value of around ¤56 a share. This move could culminate an aggressive search by Takeda for overseas assets. Shire was targeted due to its cancer, stomach and brain portfolios. “The board has indicated to Takeda that it would be willing to recommend the revised proposal to Shire shareholders subject to satisfactory resolution of the other terms of the possible offer. “Accordingly, the Board will engage in discussions with Takeda in relation to these terms,” Shire said. This takeover would complete Takeda’s attempted to become a global pharma company, able to compete with rivals such as AbbVie and Pfizer. This is the largest foreign acquisition there has ever been by a Japanese company and if the deal is completed then it will be one of the largest ever pharmaceutical acquisitions. Botox maker Allergan also confirmed it would not make a bid for Shire, just a day after saying it was weighing up an offer. Although Takeda shares inititally dropped when the announcement made, business insiders have speculated that this could push other pharma giants, such as Pfizer, into a similar move. Shire has extended the negotiation deadline to allow Takeda to firm up their offer.


News Uniphar acquires SISK healthcare distribution Uniphar Group plc has announced the acquisition from SISK Group of its healthcare distribution business, SISK Healthcare for €100 million, subject to the approval of the Competition and Consumer Protection Commission. The healthcare group employs 220 and members of the Sisk family stand to receive €65 million over the course of two years along with equity stakes in Uniphar. The Independent newspaper has reported that a spokesman for Sisk Healthcare said that this was an important deal: “This represents an important step in the ongoing growth of Sisk Healthcare.” It would, he said: “see the continuity of involvement of the Sisk Family, who will become shareholders in Uniphar plc, and the senior management and wider team in Sisk Healthcare, who have successfully grown the business to date.” This is the largest proposed acquisition to date for Uniphar,

since the purchase of Cahill May Roberts in 2013. It falls in line with the company’s ambitious growth and development strategy, which aims to see it becoming sectoral leader in the provision of outsourced and specialist services to manufacturers in the pharmaceutical and medical sectors on a pan-European basis. Uniphar is already a leading provider of outsourced services to the pharmaco-medical sector in Ireland and the UK, with a diverse customer base and an annual turnover of around €1.3 billion. Today’s announcement represents the fourth acquisition by Uniphar over the last 12 months. In April 2017 it acquired the multichannel account management provider OUTiCO Limited; followed by a healthcare insights specialist Clinical Cube Limited in August

2017. Earlier this year, it acquired specialist medical devices distributor Macromed Limited. Commenting on the sale, Ger Rabbette, CEO, Uniphar Group plc said: “We see the acquisition of Sisk Healthcare, along with our other recent transactions, as creating a strong platform for growth in the provision of outsourced and specialist services to pharmaco-medical manufacturers and being key to the development of a successful pan-European business. Our current acquisition strategy seeks businesses with strong management teams and good potential for growth which Uniphar can help to accelerate and realise. SISK Healthcare has a talented, knowledgeable team and brings a new area of related expertise into our business. It’s an excellent

Ger Rabbette fit for Uniphar and will work well within our expanding portfolio of stand-alone companies, all of whom collaborate to deliver integrated outsourced solutions in the healthcare sector in Ireland, the UK and the Benelux.”

HPRA concern over illegal medicines It has been revealed that almost one million units of illegal medicines were detained in 2017. The 948,915 dosage units of tablets, capsules and vials represent a 40% rise in the number of illegal prescription medicines seized and detailed by the Health Products Regulatory Authority’s enforcement section last year. In 2016 the figure was just 673,906 and in 2015 it was just 38,049 Of the products seized almost half were anabolic steroids (47%), nearly a quarter were sedatives (23%) and erectile dysfunction products made up 13% of the haul. The products were confiscated through ongoing surveillance and targeted intelligence. The HPRA reported grave concerns about the sale, supply and import of such products into Ireland. Drugs like these are completely unregulated and therefore can pose serious health risk to consumers. There are also no guarantees to the quality of such drugs issued outside a prescription setting and without the advice of a qualified pharmacist.


Most worrying is the sharp rise in the illegal medicine market in Ireland. “It is extremely concerning to see this year on year increase in detentions which indicates that people are continuing to put their health in the hands of individuals who operate unauthorised supply routes,” commented HPRA Director of Compliance John Lynch. “We know from our investigations and prosecutions that those who seek to profit from illegal medicines have little regard for the health of the end users of the medicines they are supplying. It is of continuing concern that members of the public would use potent prescription medicines without medical supervision. “We also know that there is absolutely no guarantee that these products contain the type or quantity of active ingredient that’s stated on the label. In some cases, they can contain different substances altogether which can have serious consequences for the

health of those who use them.” The supply of illegal or counterfeit medicines is a cause for concern in both Ireland and beyond. Recently, the reclassification of Viagra as an over-the-counter medication came as a measure to prevent online and unsafe sales of the drug. In Ireland the morning-after pill became available from pharmacies for the same reason in 2011. But the HPRA has expressed most concern over the significant rise of anabolic steroids that were seized in 2017. John Lynch said: “The abuse and misuse of anabolic steroids can have serious consequences for the long-term health of the individuals who take them. They have been linked to a range of significant side-effects including liver damage, blood clots, heart attacks and strokes. For men, the risks also include reduced sperm count and infertility. We would urge anyone using illegally sourced anabolic steroids to stop doing so and to seek advice from their healthcare professional if they have

John Lynch any concerns about their health.” The HPRA is Ireland’s regulatory body for both human and animal medicines, medical devices and other medical products. The body works closely with Revenue Customs, An Garda Siochana, the Department of Agriculture, Food and the Marine and the Pharmaceutical Society of Ireland among others.


Quick-thinking pharmacist urges caution for allergy sufferers An Irish pharmacist has saved the life of a teenage boy in Dublin. Pharmacist, Diana Truta was working in Hickeys Pharmacy in O’Connell street when an American tourist rushed in with her son who was struggling to breathe and whose neck was visibly swelling. "He went into the back and they administered oxygen for a few minutes and he left a little bit shaken up but fine. "I would just like to thank Olga, the front of shop manager and the other staff present at the time. They were a huge help in managing this terrible situation." Diana is originally from Romania but moved to Ireland and registered with the PSI last year. She said “There's a major difference between what happens here and in Romania. I think the pharmacist in Ireland has much more responsibility and is much more involved in ensuring the wellbeing of their patients, offering a large variety of services. I had to learn about all these and I really valued every experience along the way. “But, it's something different to be put into action, to face the pressure of having someone dying in front of your eyes. “It was definitely a challenging situation, when I had to put into practice everything I learned. I tried to stay calm, to think clearly and to keep the patient as calm as I could, as he was so panicked and anxious. I had to constantly assure him that he will be fine. He was holding my hands and thanking me many times.”

Pharmacist Diana Truta

The pharmacy team quickly cleared and closed the shop while Diana injected the young man with epinephrine. She consulted with paramedics over the phone before administering a second dose seven minutes later and closely monitored her patient. When paramedics arrived, they treated the boy with oxygen and he was released without a trip to hospital. Speaking with Dublin Live, Diana said: "He had obvious signs of anaphylaxis like a swollen neck, he was struggling to breathe, had itchiness all over & anxiety. An asthma attack or a panic attack can produce similar symptoms but once you see swelling along with the other symptoms mentioned you can tell it's anaphylaxis. "My next thought was to organise the staff. The front of shop


manager began to dial 999 and I asked the staff to try and clear the pharmacy. Thankfully the store had an emergency pack in place complete with adrenaline and instructions for assessing patients and for administration. In a stressful situation being able to put my hands on this information so easily was a great help. "After getting his consent, I injected the epinephrine into his outer thigh and noted the time. I spoke to the paramedics on the phone and then I went back and sat with him while the medication took effect & tried to comfort him. "I wasn't happy with his progress so administered a second dose seven minutes later. A couple of minutes after that his symptoms abated and the ambulance arrived.

Tom Concannon, Superintendent Pharmacist at Hickey’s Pharmacy Group said that this is the eighth time a Hickey’s pharmacist has administered adrenaline to someone suffering from anaphylaxis in the last 18 months. “Pharmacists have been able to administer adrenaline in emergency situations since 2015, along with glucagon, salbutamol and naloxone. It means those suffering from anaphylaxis can get much more immediate help while waiting for an ambulance.” He continued: “The unfortunate reality is that many patients with known allergies are not carrying adrenaline and some are taking chances with their food choices because they haven’t had an episode in a long time. It’s important that the message

getting to patients is to carry adrenaline and to heed allergen advice on foods. I would hate to think patients are more likely not to renew their adrenaline prescription or to take a chance with food if there is a pharmacy close by. “This one worked out – thankfully they all have for us so far, but someday someone will die and that’s the sad reality of it. In this case the young man had a known peanut allergy and yet decided to try a brownie that contained peanuts. This was on the basis that the brand of peanut butter he eats doesn’t affect him. “Another potentially dangerous phenomenon we’ve come across is patients, carers or restaurant owners running around trying to find a pharmacy to administer adrenaline without having first contacted the emergency services. Anaphylaxis is a serious reaction and always needs to be treated as soon as possible. In one instance it took the ambulance 45 minutes to arrive and despite administering adrenaline the patient remained in a critical condition. All healthcare professionals need to be reinforcing these key messages with patients at every opportunity” Diana concluded with the following advice, “My advice for people who are aware of their allergies would be to be responsible and carry adrenaline pens with them at all times as they don't know when they might need them. Nowadays you can encounter traces of allergy triggers in all sort of products and just avoiding particular foods is not sufficient. An adrenaline pen can save your life. “For those who aren't aware of their allergies, be cautious when trying a new food and listen to your pharmacist's advice when it comes to medicines. At the first symptoms of an allergy (difficulty breathing, itching, swelling of eyes/ lips/ throat, rash, dizziness, anxiety, nausea), stop taking the medication or eating that food and call the emergency services on 999. If there is a pharmacy close by try to get there.”

N E iff & W er en t! D

Added Extra Added Confidence Adex Gel


Adex Gel offers a new, simple and different approach to the treatment and management of mild to moderate eczema. Adex Gel emollient can help reduce inflammation and redness because Adex Gel provides Added Extra anti-inflammatory action.

Recommend Adex Gel and see the results occur with emollients when applied to damaged skin. Such symptoms usually subside after a few days of treatment, however, if they are troublesome or persist, stop using and seek medical advice. Rarely skin irritation (mild rashes) or allergic skin reactions can occur on extremely sensitive skin, these tend to occur during or soon after the first few uses and if this occurs stop treatment. As safety trials have not been conducted during pregnancy and breast-feeding, seek medical advice before using this product. Care should be taken as emollients which soak into clothing, pyjamas, bedlinen etc. can increase the flammability of these items. Patients should avoid these materials coming into contact with naked flames or lit cigarettes etc. As a precaution, dressings and clothing, etc., should be changed frequently and laundered thoroughly. Ingredients: Carbomer, glycerol, isopropyl myristate, liquid paraffin, nicotinamide, phenoxyethanol, sorbitan laurate, trolamine, purified water.

Pack sizes: 100g tube and 500g pump pack. Legal category: Class III medical device with an ancillary medicinal substance. Further information is available from the manufacturer: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: August 2017. ‘Adex’ is a trademark. Adverse events should be reported to Dermal. ADX PR009/I/DEC16

Adex™ Gel Presentation: White opaque gel. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and/or inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Directions: Adults, the elderly and children from 1 year of age. For generalised all-over application to the skin. Apply three times daily or as often as needed. Adex Gel can be used for as long as necessary either occasionally, such as during flares, or continuously if the added anti-inflammatory action is beneficial. Seek medical advice if there is no improvement within 2-4 weeks. Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. Keep away from the eyes, inside the nostrils and mouth. Temporary tingling, itching or stinging may


Biosimilars could lower Ireland’s "unsustainable" drugs bill, study suggests 50 Report

An increase in the use of biosimilar medicines has the capacity to lower Ireland’s unsustainable drugs bill, new research has suggested.

Biosimilars could lower Ireland’s ‘unsustainable’ drugs bill, study suggests

Ireland has An had an “exceptionally increase in the use of low” uptakebiosimilar of biosimilar medicines has the capacity to settings lower Ireland’s medicines in clinical unsustainable drugs bill, new compared to other countries research has suggested. because prescribing is not Irelandthe hasnewly had an mandated here, “exceptionally low” uptake published review has stated, of biosimilar medicines in clinical settings compared

The paper ‘Biosimilar to other countries because infliximab introduction the prescribing is into not mandated here, the newly publishedin a gastroenterology care pathway has stated,hospital: large acute review Irish teaching a story behind evidence’ The the paper ‘Biosimilar describes how a hospital in Ireland infliximab introduction into the care pathway introduced gastroenterology biosimilar infliximab in a large Irish teaching for the treatment ofacute inflammatory hospital: a story behind the bowel disease (IBD). evidence’ describes how a hospital in Ireland introduced

The authorsbiosimilar note: “In the for the infliximab of inflammatory absence of treatment a national Irish bowel disease (IBD). biosimilar medicines policy and with perceived uncertainty The authors note: “In the of a national Irish surroundingabsence biosimilar medicines, biosimilar medicines policy this descriptive review adds to and with perceived uncertainty the literature by illustrating the surrounding biosimilar independent systematic evidence medicines, this descriptive base behindreview the decision-making adds to the literature by illustrating the independent process to introduce biosimilar systematic evidence base infliximab CT-P13 into secondary behind the decision-making care treatment of IBD.” process to introduce biosimilar infliximab CT-P13 into

A biosimilarsecondary is a biologic medicine care treatment of IBD.” that is approved based on showing that it is highly A biosimilar is asimilar biologicto an existing medicine approved innovative that is approved based on showing that it is biological product highly similar to an existing approved innovative biological product

In June 2013 infliximab was licensed by the European Medicines Agency (EMA). The agency’s Committee for Medicinal Products for Human Use (CHMP) recommended the granting of marketing authorizations for the first two monoclonal antibody biosimilars, Remsima® and Inflectra®, both of which contain the same known active substance infliximab CT-P13. May 2018 • HPN

In June 2013 infliximab was A large acute hospital licensed by Irish theteaching European introduced the biosimilar infliximab Medicines Agency (EMA). The agency’s Committee for Medicinal Products for Human Use (CHMP) recommended the granting of marketing authorizations for the first two monoclonal antibody biosimilars, Remsima® and Inflectra®, both of which contain the same known active substance infliximab CT-P13.

A large acute Irish teaching hospital introduced the biosimilar infliximab

But the European Crohn’s and Colitis Organisation (ECCO) recommended that most biosimilars in patients with IBD should require testing in the particular patient population with comparison to the appropriate innovator product (Remicade®) before But theapproval. European Crohn’s and In 2015, the National Institute

given that EMA had already licensed the biosimilar

Colitis Organisation (ECCO)

for Health and Care Excellence

added that ‘hospital budget coordinators were pleased given that the biosimilar product was cheaper than the originator brand’. The authors say that, as patients were given reassurance on the safety and efficacy of the biosimilar, physicians did not face resistance to the prescribed agent.

“Work which aims to enhance switch all patients who were Inoriginator 2016, NICE and the theunderstanding British of stable on the The authors state: “In fact, Ireland biosimilar medicines infliximab toSociety the biosimilar. of Gastroenterology (BSG) amongst has the second lowest record of stakeholders and to encourage updated their guidance to indicate However, despite the fact biosimilar use due to Irish HCPs best practice of biosimilar use that clinicians that this hospital moved morein consultation is currently being conducted being slow to accept biosimilars. quickly thanwith any other in patients should the bybe a collaborative organisation This is possibly owing to a lack Ireland, the decision to switch of various interested parties. final authority on switching, and of confidence, unwillingness or patients “could have been should not automatically “However, it could be argued regarded asproducts over cautious, knowledge to prescribe biosimilars substituted at the thatpharmacy Ireland has exceptionally delayed andbe conservative which is also seen in other

recommended thatchief most pharmacist Despite this the (NICE) voiced support for medicine [3] years earlier,” the However, despite the fact that this and added that state. “hospital biosimilars in patients with IBD prescribing decision” the biosimilar, authors and consultant gastroenterologist require testing in the and Ireland’s Health Products hospital moved more quickly than budget coordinators were pleased ofshould a large acute Irish teaching They continue: “One wonders particular patient population Regulatory given Authority released any other in Ireland, the decision to that the biosimilar product hospital decided why prescribers had not with comparison to to theintroducea guide to biosimilars for switch was cheaper than the originator switched patients sooner,” and patients “could have been biosimilar CT-P13 for appropriateinfliximab innovator product healthcare providers as over cautious, delayed add that “a [3]as year timeregarded lag for before approval. (Remicade brand”. The authors say that, and patients. use in new®) patients in September next biosimilar medicine, and conservative given that EMA patients were giventhe reassurance 2014. Despite this the chief In 2016, NICE and the British from market authorisation to already licensed the biosimilar had on the safety and efficacy ofswitching the pharmacist and consultant Society of Gastroenterology the patient process, medicine [3] years earlier,” the The report authors gastroenterologist of asaid that the biosimilar, physicians didnot notoccur.” face (BSG) updated their guidance should large acute Irish authors state. to indicate that cliniciansto in the prescribed agent. pharmacist andteaching gastroenterologist resistance The authors state: “In fact, hospital decided to introduce consultation with patients “believed there was enough Ireland has the second lowest biosimilar infliximab CT-P13 should be the final authority continue: “One wonders accumulated evidence In and 2015, the National Institute for use They record of biosimilar due for use in new patients in from on switching, products various sources to Irish HCPs being slowwhy to prescribers had not switched September 2014. to support their Health and Care Excellence (NICE) should not automatically sooner,” and add that biosimilars. is be substituted at thesupport for accept voiced prescribing the This patients The report authors said possibly owing to a lack“a of [3] year time lag for the next pharmacy level. biosimilar, and Ireland’s Health that the pharmacist and confidence, unwillingness biosimilar medicine, from market gastroenterologist “believed Products Regulatory Authority to prescribe Following these changes, or knowledge authorisation to the patient there was enough accumulated the chief pharmacist and biosimilars which is also seen released a guide to biosimilars for switching process, should not evidence from various sources consultant gastroenterologist in other European countries. healthcare providers and patients. to support their decision” and of the hospital elected to occur.”


European countries.

Following these changes, the chief pharmacist and consultant gastroenterologist of the hospital elected to switch all patients who were stable on the originator infliximab to the biosimilar.

“Work which aims to enhance the understanding of biosimilar medicines amongst stakeholders and to encourage best practice of biosimilar use is currently being conducted by a collaborative


Profile Undisputedly, this review demonstrates that increased biosimilar medicine usage is of benefit to all stakeholders organisation of various interested parties. “However, it could be argued that Ireland has exceptionally low biosimilar uptake because biosimilar prescribing is not mandated unlike in other countries. “In addition, the Irish biosimilar market does not appear very appealing to pharmaceutical companies. Despite the potentially huge cost savings to be made from switching, only 54 packets of the biosimilar product Benepali® were sold since its introduction to Ireland in August 2016 compared to almost 46,856 of the established originator brand Enbrel® (as of May 2017). “Furthermore, various funding systems of different countries can too have an impact where, for example, in the UK, a major motivation for switching was reinvestment of some of the cost savings in improvements to patients’ care.” They continue: “With regard to the current biosimilar medicine landscape, it is possible that prescribers may feel more comfortable issuing biosimilars if national authorities would actively enforce and implement individual EMA biosimilar related decisions as they are published. “EMA has the best knowledge of biosimilars amongst regulators but cannot influence interchangeability that is within the mandate of individual national regulatory agencies.” “With continually emerging positive evidence, it is clear that a three year time lag for the next biosimilar medicine, from market authorisation to the patient switching process, should not occur.” The authors state that progress is being made towards a national policy on the use of biosimilars.


“Following on from information released by the medicine management programme (MMP) on biosimilars in the Irish healthcare setting in 2016, and guidance issued by the national cancer control programme (NCCP) on the use of biosimilar medicines in oncology in August 2017, the Department of Health (DoH) disseminated a consultation paper in mid August 2017. “This paper indicates that the DoH is developing a national biosimilar medicines policy which aims to increase biosimilar use in Ireland by creating a robust framework where biologicals and biosimilars can be safely, cost-effectively and confidently used in the health service.” They add: “One of the consultation paper’s recurring themes is that there is too much money being spent on originator biologicals when there are cheaper, equally effective alternatives available. “It highlights that only 11 biosimilars are currently reimbursable by the Irish healthcare system, while over Euros 200 million is spent each year on biological drugs that already have approved biosimilars or that will have available biosimilars throughout 2018. “It is clear that the potential cost savings to be accrued from switching to biosimilars can increase patient access to other new medicinal products.” The authors state: “The Irish Pharmaceutical Healthcare Association (IPHA) framework agreement plans to save money on biological medicines where most of these medicines are reimbursed on Ireland’s high-tech medicine scheme. “This scheme has seen an increase in expenditure from Euros 177.49 million in 2005 to Euros 562.29 million in 2015.

“This prodigious level of pharmaceutical expenditure cannot be maintained. Research from the Irish National Centre for Pharmacoeconomics (NCPE) has shown that when pharmaceutical companies submit budget impact analyses (BIAs) for new high-cost medicines such as biologicals, the majority of these high-cost medicines have a greater cost burden on the budget than what is forecasted in their BIAs. “This results in taxpayers spending more than anticipated. Thus, an increase in the uptake of biosimilar medicines would be a more sustainable approach to lower the Irish drug bill.” One way forward could be the establishment of gainsharing agreements at hospital level, the authors have suggested. “One approach the DoH could take would be to establish gainsharing agreements at hospital level. Hospitals could be financially awarded for using biosimilars or fiscally penalised for lack of utilisation. “Gainsharing agreements have already proven to be a powerful incentive in increasing biosimilar use at EU level. With respect to the Danish biosimilar landscape, their initial passive approach to switching actually led to an administrative order. “Thus, another approach the DoH could adopt would be to introduce reference pricing of biological products which would accelerate the path to increased biosimilar usage. Reference pricing of SMCE medicines has already resulted in savings of millions of euro in the Irish primary care setting.” The authors conclude that the Irish hospital safely and effectively introduced biosimilar infliximab CT-P13 into the gastroenterology care pathway.

They say: “There was a significant time lag between regulatory approval and clinical acceptance notwithstanding that EMA had granted market authorisation for biosimilar infliximab CT-P13 three years prior to the initiation of this hospital’s switching process. “However, the conservative approach to biosimilar infliximab implementation discussed in the review is justified given the conflicting and changing evidence disseminated from various sources over this three year period. “Alternative approaches that could be used to increase biosimilar medicine adoption into healthcare environments have been suggested. “Undisputedly, this review demonstrates that increased biosimilar medicine usage is of benefit to all stakeholders: increased access for patients, more treatment options for prescribers, sustainable healthcare budgets for payers and more business opportunities for manufacturers.” Reference O’Brien, GL, Carrol D, Mulcahy M, Walshe V, Courtney G, Byrne S. Biosimilar infliximab introduction into the gastroenterology care pathway in a large acute Irish teaching hospital: a story behind the evidence [published online February 27, 2018]. GaBI J. gabi journal.net/ biosimilarinfliximab- introductionintothe- gastroenterologycarepathway-in-a-large-acuteirishteaching-hospital-a-storybehindthe-evidence.html.

News EpiPen shortage comes to Ireland The Irish Pharmacy Union has confirmed that the global Epipen auto-injector shortage has now reached this country. Although there had been warnings of a global shortage of EpiPens, the auto-injector has only recently been added to the list of known shortages. This lack of supplies is expected to continue into early May. Shortages of the EpiPen 0.3mg (senior) auto-injector have been reported in the UK since the beginning of April, with pharmacies restricting their supplies to two per person on a prescriptiononly basis. Supplies EpiPen for children, with a 0.15mg dose of adrenaline, do not appear to have been affected. The UK Epipen website says: “there are intermittent supply constraints on EpiPen®0.3mg Adrenaline Auto-Injector in the UK.” It continues: “Mylan is working closely with Pfizer to manage supply carefully to avoid longterm supply shortages. Pfizer anticipates that production rates will increase over the coming months; however, at this time, cannot commit to a specific time for when the supply constraint will be fully resolved. Mylan is working closely with Pfizer to manage supply carefully to avoid long-term supply shortages. Pfizer anticipates that production rates will increase over the coming months; however, at this time, cannot commit to a specific time

for when the supply constraint will be fully resolved. Similar shortages have been reported in Australia and Canada, with rumours that shortages in the US are imminent. EpiPen is manufactured by Meridian Medical Technologies, a Pfizer company. A spokesperson for the organisation in Ireland said: “We understand how important this potentially life-saving product is to patients and are working tirelessly to increase production and expedite shipments for the global market from a manufacturing facility in the United States”.

It was also reported that Pfizer said it was: "Working tirelessly to increase production and expedite shipments as rapidly as possible". Darragh O'Loughlin, of the Irish Pharmacy Union, said as the device becomes scarce, there are alternatives available in Ireland, including the Jext and Emerade adrenaline auto-injectors. EpiPens work by reversing the life-threatening symptoms of severe anaphylaxis, which include a drop in blood pressure and constricted airways.

progress rapidly and be fatal if a person's heart or breathing stops. People with potentially serious allergies are often prescribed adrenaline auto-injectors to carry at all times. They should be used as soon as a serious reaction is suspected, either by the person experiencing anaphylaxis or someone helping them. In Ireland, Epipens and other autoinjectors are usually prescribed by doctors, but since 2015 the law changed allowing pharmacists to administer adrenaline in emergency situations.

Anaphylaxis left untreated can

New research aims to target treatment resistant epilepsy in children Developing new treatments for childhood epilepsies and neuro-developmental diseases is the aim of a new partnership between RCSI (FutureNeuro, the SFI Research Centre for chronic and rare neurological diseases based at the Royal College of Surgeons in Ireland) and F. Hoffmann-La Roche Ltd. announced recently. The three-year partnership aims to guide scientists to new gene targets to control some of the devastating childhood epilepsies that do not respond to existing therapies. The research will be conducted from Professor David Henshall’s lab in FutureNeuro, the SFI Research Centre for Chronic and Rare Neurological diseases based at RCSI. An estimated 2,000 children in Ireland are resistant to current treatment methods for epilepsy, which is one of the most common neurological conditions. This means that many children with epilepsy are having numerous, uncontrolled seizures every day. Over a prolonged period, this can have a devastating effect on their cognitive abilities. “We are excited by the potential of this collaboration to advance our treatment options for children with


currently un-treatable epilepsy,” said Professor David Henshall, academic supervisor of the research project and FutureNeuro Centre Director. “Our research aims to identify new biological targets that modify brain excitability and understand how these may be altered in children with difficult-to-control seizures. By joining up we can design and test new experimental therapies targeting these molecules” added Professor Henshall.”

The partnership will build on recent breakthroughs in understanding how gene activity is controlled in the brain. This ultimately determines how signals are sent and received by neurons – the excitable cells in the brain - and explains why some areas of the brain suddenly fire all together causing a seizure. The team will look for unusual gene expression patterns in brain tissue and cell models of childhood epilepsies, focusing

on the genome’s so-called ‘dark matter’ - stretches of DNA which do not code for proteins but work as molecular switches to activate or inhibit protein production. The research partnership will be led by a dedicated team of neuroscientists and bioinformaticians at the FutureNeuro Research Centre in RCSI who will work together on the project over the next three years.


Abbreviated Prescribing Information. Please consult the summary of product characteristics for full prescribing information. Nicorette Quickmist 1mg/spray, oromucosal spray, solution. Composition: One spray delivers 1 mg nicotine in 0.07 ml solution. 1 ml solution contains 13.6 mg nicotine. Pharmaceutical Form: Oromucosal spray, solution. Indications: Nicorette QuickMist is to be used for the treatment of tobacco dependence in adults by relief of nicotine withdrawal symptoms, including cravings, during a quit attempt. 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. Paediatric population: Do not administer Nicorette QuickMist to persons under 18 years of age. There is no experience of treating adolescents under the age of 18 with Nicorette QuickMist. 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: Nicorette QuickMist 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 spray. 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. Nicorette QuickMist may cause adverse reactions similar to those associated with nicotine given by other means and these are mainly dosedependent. 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, 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 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. MA Holder: McNeil Healthcare (Ireland) Limited, Airton Road, Tallaght, Dublin 24 Ireland. MA Number: PA 823/49/29. Revision of text: January 2016. Legal Category: Not subject to medical prescription.If you require full prescribing information or wish to report an adverse event please contact Johnson & Johnson (Ireland) Ltd., Airton Road, Tallaght, Dublin 24, Ireland. Telephone: 1800 22 00 44 Date of Preparation: August 2017


News A number of drugs are being withheld from Irish patients, largely on cost grounds The drugs – nine in total – are mostly cancer therapies and are widely available to patients in Europe, however in Ireland they are awaiting approval from the HSE and, on average, have been waiting for around two years. Two of the medicines are for cardiovascular disease, one for musculoskeletal treatment and six are cancer drugs. The drugs have undergone the Health Technology Assessment. This determines their costeffectiveness, safety, clinical effectiveness and budget impact. In contrast, seven new IPHA drugs have been approved for reimbursement since the start of the year. Reflecting on these facts, IPHA Chief Executive OIiver O’Connor said: “It is not good enough that patients in Ireland should be among the last in western Europe to have access to these new medicines. “In some cases, these medicines are available in other EU Members States beyond the EU-14. This is according to the Irish Pharmaceutical Healthcare Association’s new Medicine Availability Bulletin.

The new bulletin will now regularly monitor and report on the availability in the EU of drugs that have not yet been approved in Ireland. It was reported in 2017 Ireland ranks 18th of 26 European countries for the availability or reimbursement of new medicines first authorised by the European Medicines Agency in the years 2014 – 2016. IPHA is the representative organisation of the research based pharmaceutical industry in Ireland. It represents 47 international companies who discover and develop new medicines which can treat or cure many medical conditions and so improve both the quality of life and the life expectancy of patients.

IPHA Chief Executive OIiver O’Connor

The industry has had pricing and supply agreements with the State for almost 40 years, with the most recent version in place from August 2016 to July 2020. Estimated savings of ¤785m that IPHA members will deliver

in that period should provide headroom for the HSE to fund new medicines, assisting, but not removing, the need for increased Exchequer funding. While part of the Agreement covers the pricing

of medicines (including annual downwards price realignments, price reductions on off-patent products and cash rebates), it also provides a pathway for the reimbursement of new medicines.

New solution for allergy sufferers A new device could give chemical-free relief for hay fever sufferers. The Nasal Medical Allergy Filter is an allergy prevention solution without tablets or sprays. The filter prevents allergens and polluted air from entering the nasal system, allowing sufferers to enjoy the outdoors without debilitating symptoms during peak hay fever season. The filter was developed by Kerry farmer Martin O’Connell, who was inspired to create the device by his livestock. After the herd of cows on Martin’s family farm wiped out by tuberculosis, Martin was keen to prevent such a thing from happening again and came up with the idea of a filter to block bacteria reaching cows’ lungs. In 2014 Martin founded Nasal Medical along with mechanical engineer Keith Yeager and now the


company develops nasal devices to assist better breathing for hay fever, also known as allergic rhinitis. As well as hay fever, the company produces aids to help with breathing during travel, sport and a snoring aid. There is no cure for hay fever and sufferers usually resort to antihistamine tablets and sprays to combat the symptoms. The recently launched Allergy Nasal Filter offers a drug-free solution for preventing allergies, blocking allergens such as pollen, dust, pet dander and mould from entering the nose. With studies both ongoing and completed in key universities and hospitals, science backing, innovation, customer-focused approach and clinical testing is at the forefront of Nasal Medical’s core values.

Dr Paul Carson, a well-known allergy doctor and founder of Allergy Ireland in the Slievemore Clinic Dublin has conducted clinical trials of the allergy filter. “We have found that the Nasal Medical Allergy Filter is a simple but effective way of preventing allergens entering the nasal system, therefore reducing the symptoms associated with hay fever.” Director and co-founder of the company Martin O’Connell, Nasal Medical Ltd continued: “Being a drug free solution, our filter is especially of interest to those who can't take medication for their allergies, such as pregnant women,” Nasal Medical Allergy Filter is available in pharmacies nationwide or through the www.nasalmedical.com.

The Hay Fever Relief App developed by Dr Carson is another valuable tool in helping sufferers to combat hay fever, especially when used in conjunction with Nasal Medical Allergy Filter. This App provides live pollen updates both in Ireland and in the UK, sending push notifications when the pollen count is high in the users’ area, therefore alerting people to know exactly when to use their Nasal Allergy Filter.

A GREAT SELLING PRODUCT, right under your nose A popular, trusted brand, offering around the clock relief from hayfever and other allergy symptoms Max strength treatment Zirtek D includes an active decongestant to help to clear blocked noses Available in extra value packs of 30 Awareness and sales driven by high-profile marketing activity, including online advertising and social media Point-of-sale material available for your use

Contact your regional representative today to order Zirtek, your point-of-sale support, or to discuss your requirements. www.zirtek.ie


Zirtek IE

Please consult the Summary of Product Characteristics before prescribing, information about this product can be found at www.medicines.ie Further information is available on request from UCB Pharma Ireland Ltd, United Drug House, Magna Drive, Citywest Road, Dublin 24 MA Numbers:

Zirtek 1 mg/ml oral solution: PA 891/8/3, Zirtek Plus Decongestant 5/120mg Prolonged Release Tablets PA 891/8/1, Zirtek Tablets PA0891/008/005

Product licence holder:

UCB Pharma Limited Legal Category: OTC


Zirtek tablets & oral solution: Cetirizine dihydrochloride Zirtek Plus Decongestant prolonged release tablets: Cetirizine dihydrochloride, Pseudoephedrine hydrochloride

Adverse events should be reported to the Health Products Authority at www.hpra.ie or via email to medsafety@hpre.ie Adverse events should also be reported to UCB Pharma Ireland Ltd via email UCBCares.IE@ucb.com

February 2017 UK/16ZI0052

Judging by the sheer number and nature of AGM motions at the IPU Conference, pharmacists have never been so vexed, dissatisfied and agitated. The 1996 Contract was ground breaking, far sighted, innovative and professionally respectful to all parties, especially the patient who was at its centre. However, over the last 10 years or more the State has systematically picked apart the many pieces it now doesn't like, and it only observes in the breach. Any relationship is a settlement between parties, but when one side holds all the power and purse strings things tend to become abusive. The Joint Consultative Group has now collapsed, there is no dialogue when it’s all diktats from one dominant side. The atmosphere has soured utterly and become quite toxic. The PCRS is rightfully focused on paying on proper claims but their software seems systematically constructed to under pay or "ghost " claims. A full Comptroller and Auditor General insight would be enlightening. Responsibility is not one-sided but must cut both ways. This is not good for the profession, tax payers and least

Jailed pharmacist has registration cancelled A pharmacist convicted of theft and fraud has had her registration cancelled by order of the Hight Court. Teresa Crowley (73), was jailed for six months last year having been found guilty of defrauding the HSE of ¤70,000 when she pleaded to 21 sample counts of theft and fraud. In total 170 charges were brought against Ms Crowley which took place over a number of years. The fraud involved an elaborate scheme of falsifying drug payment scheme claims. Ms Crowley was handed down a two-and-a-half-year sentence which was suspended bar six months. The Pharmaceutical Society of Ireland had sought the cancellation after a meeting of its Professional Conduct


of all patients. We all deserve much better. Fiscal probity is of course important, but pharmacists and their 10,000 staff are major tax payers too. A new vision is overdue to break this impasse and deliver a 21st century solution for all. The PSI 2020 vision statement is a good starting place and the IPU is primed and ready to engage meaningfully, but where lies the PCRS and Hawkins House? There is a paucity of new ideas and thinking in the civil service and at its heart is the lack of a dynamic, properly funded Chief Pharmacist who can articulate the fact that Ireland is over 20 years behind the pace of best international pharmacy practice, and hence patient care. An example of this narrow, derelict thinking is that in the planned new and long overdue National Paediatric Hospital, they seemingly forgot to put a large pharmacy department at its centre. This only came to light when BDP architects, who built the world leading Alder Hey Committee in December 2017. The inquiry was prompted after a complaint by the society’s registrar following Ms Crowley’s conviction. Ms Crowley previously owned two pharmacies in Dunmanway, Cork.

Orphan drugs availability differs between European countries There are differences in the availability of orphan medicines between different European countries, a new study from the University of Eastern Finland shows. Orphan medicines are pharmaceutical products developed specifically for the treatment, prevention or diagnostics of rare diseases. Rare diseases are lifethreatening or permanently

facility in Liverpool, pointed out the glaring omission. This was after many millions had already been spent on preplanning. We as patient-facing pharmacists have unique insights as to where funds are squandered, but we must be engaged in a genuine, openended discussion. It’s not about winners and losers but about harnessing knowledge into patient care and better outcomes for all. There is growing evidence from behaviour and attitude that the pharmacy profession is apathetic and demotivated by crippling state bureaucracy. Young, able graduates are leaving pharmacy, voting with their feet, some even to become the overpaid management consultants mentioned in the paediatric hospital debacle above. The same sad story is disabling medical conditions, and they affect some 30 million people in Europe and more than 300,000 people in Finland alone. People suffering from a rare disease do not always have access to the medicines they need. Factors limiting the availability of orphan medicines include them not entering the markets or their financial burden on the patient or society being too high. The study focused on the availability and distribution channels of 10 orphan medicines used in outpatient care in 24 European countries. On average, five of the 10 medicines were available on the markets, but there was variation between the countries. All ten medicines were available only in three countries: the Netherlands, Malta and Poland. Five to nine medicines were available in ten countries: Austria, Finland, Germany, Iceland, Italy, Norway, Slovakia, Spain, Sweden and the United Kingdom. Four countries,

repeated for young graduates in teaching, nursing and medicine as they take education gained at home only to work abroad. They find themselves valued below the entitled civil servants. Proper career structures aren't planned for only glib short termism. What is lacking is the political vision and will to engage. We have two pharmacist TDs in the Dail, Kate O'Connell and John Brassil, who both fully understand the issues from a number of sides. Whatever way the numbers fall in the next election, having their input as a minister could be transformational for societal gain. The ball is firmly in the State court, perhaps pharmacy services should become an election issue.

namely Latvia, Lithuania, Turkey and Belarus, did not have any of the medicines studied available. The study also explored whether the European countries studied had implemented policies to regulate decisions relating to the pricing and reimbursement of rare medicines specifically. Typically, no policies applicable to rare medicines alone were in place; instead, decisions on rare medicines were made on the same grounds as decisions on other medicines. However, 13 countries reported some type of a special arrangement. In Latvia and Russia, for example, rare medicines come under a separate budget, and countries such as Spain, Lithuania and Hungary have set special conditions on the reimbursability of rare medicines. The study was funded by the Social Insurance Institution of Finland, Kela, and the University of Eastern Finland.













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Dysphagia a growing problem among healthcare professionals Dysphagia is a difficulty or inability to swallow either food or liquid. There are two kinds; oropharyngeal dysphagia affects the throat while oesophageal dysphagia affects the oesophagus. Those suffering from this condition may cough or choke when trying to eat or drink, they might experience a persistent feeling of food stuck in the chest or throat and they may drool persistently. Other symptoms include drooling or croaky or wet sounds when speaking. Swallowing There are four stages of swallowing: • Food is broken down by chewing and movement around the mouth. • The tongue moves food to the back of the throat • Broken down food then moves to the back of the throat towards the oesophagus, as it does, the epiglottis should close, protecting the airway and preventing food from entering the lungs. • Peristalsis contracts the muscles in the oesophagus, passing food down into the stomach. The effects Patients may find that when they try to swallow, the epiglottis doesn’t close over the trachea and food or drink may pass into the lungs. Therefore, those with dysphagia are often at great risk from choking, aspiration and as a result repeated chest infections and pneumonia. Sufferers are likely to suffer from, dehydration and weight loss. Malnutrition is one of the most severe affects of dysphagia. Associated illnesses Dysphagia is often a symptom of some other underlying conditions such as: • Parkinson’s disease

least 8% of adults with learning difficulties suffer from dysphagia. Diagnosis As with many symptoms, a patient experiencing dysphagia should immediately be referred to their GP who may refer them for further tests with a speech and language therapist, neurologist, or gastroenterologist. Tests will establish if the patient suffers from oropharyngeal or oesophageal dysphagia. A dietician may also carry out a nutritional assessment to establish if the patient is malnourished. Once a diagnosis has been established, the proper treatment can be given. Treatment Treatment of dysphagia varies between oropharyngeal and oesophageal conditions. In some cases, treatment of the underlying condition such as mouth or throat cancer, can lessen swallowing difficulties. The treatment of oropharyngeal dysphagia is usually through diet, swallowing therapy through a speech and language therapist or through a feeding tube. Over the counter pharmacy products are now available on the market for both softening food and thickening liquids thus making them easier to swallow, but there may be certain foods that sounds be avoided altogether by patients of dysphagia.


Anne Marie Bennett, Senior Dietitian at St Mary’s Hospital in Dublin said:

• Stroke

“A person with a diagnosis

• Oesophageal cancer

• Brain tumour • Multiple sclerosis • Dementia • Motor neurone disease • The elderly Estimates vary greatly but recent studies also show that at


of dysphagia may be recommended a modified consistency diet, e.g. soft, minced, moist or smooth pureed, by a speech and language therapist. When the diet becomes modified it can often become nutrient dilute and less appetising or less visually pleasing, this can sometimes lead the person to become






undernourished or lose weight, this can have detrimental health consequences especially for the frail elderly person. It may become necessary to fortify the diet with extra calories and protein in this instance. Factsheets on how to do this can be obtained on www.hse. ie/nutrition-supports/public. If there is any concern relating to weight loss or poor oral intake, then please request a referral to a community dietitian from the GP.” Early assessment of any nutritional risk to the patient is vital and can prevent secondary complications that could lead to a long-term disability. Oesophageal dysphagia can be treated with medication. Drugs used to treat digestive problems such as proton pump inhibitors can improve damage to the oesophagus, making swallowing easier. Botox is another remedy used – it can relax the tightened muscles of the oesophagus. However, the effects of Botox only last around six months. In extreme cases, surgery can be used to eliminate obstructions in the oesophagus or to widen it in cases of scarring.

Oesophageal cancer patients often have a stent placed in their oesophagus instead of endoscopic dilation due to the risk of perforation. The stent is placed using x-ray and will slowly expand to allow food to pass down. Advice for patients • Take care of the mouth. An inability to swallow can lead to a build up to of bacteria which can lead to mouth sores. • Those suffering from dysphagia should not use straws. • Pay attention to the teeth. Use a toothpaste with fluoride on a dry toothbrush and don’t rinse the mouth after brushing – keeping fluoride in the month can help prevent tooth decay. • Aim to keep the mouth moist – special sprays or gels are available for this.Lip balm can also prevent dry, chapped lips. • Medications come in other forms than syrups and pills. Consultation with a pharmacist could reveal another delivery system for a prescribed medication. Always check with a pharmacist before crushing a pill or mixing it with water.





PMI Conference PMI celebrate the 29th annual business day The Pharmaceutical Managers’ Institute celebrated their 29th annual Business Day at Carlton House, Co. Kildare recently. Executive Director – Global Regulatory Policy, MSD both speaking on the subject. Dr Adams revealed that the HSE must save ¤346 million. She made the point that four of the main hospitals in Ireland have now switched to biosimilars and are making cost savings. Generics are up to 80% cheaper and yet they are not being used in Ireland. The overwhelming message on the day was that biosimilar drugs could save the Irish health service hundreds of thousands of Euro a year. However, the point was made that innovative medication will always be expensive as development and clinical trials are expensive. But, biosimilars drive down prices – in London 5,000 more patients were treated in two years using biosimilars. Biosimilirs alleviate cost pressure on the patient, but we need to be aware of.

Host Matt Cooper


The event was again hosted by journalist, author and broadcaster Matt Cooper. It was opened by PMI president Eoin McAtamney who welcomed attendees, exhibitors and sponsors.

The theme for this year’s business day was Partners in Progress with experts speaking on and leading discussions about innovations in the pharmaceutical industry.

As this was the 29th year of the Business Day, Mr McAtamney looked to the future in his speech.

There was a focus on biosimilars with Dr Roisin Adams, Chief Pharmacist, Health Service Executive and Dr Virginia Acha,

Eoin McAtamney, President, PMI

Dr Roisin Adams, Chief Pharmacist, HSE

Dr Acha further explored the topic by reviewing the key factors that have led to success in developing biosimilars in Europe. A sustainable future, she said, is not automatic and putting strategies in place for today is important for tomorrow. Professor Trevor Duffy, Consultant Rheumatologist at Connolly Hospital examined biosimilars from a clinical perspective.

Professor Trevor Duffy, Consultant Rheumatologist, Connolly Hospital


Attendees were able to take away a greater sense of the emerging trends of the pharmaceutical industry – one that is as ever expanding rapidly. Other highlights of the day included economist Dr Stephen Weir’s lecture on the future of the Irish healthcare system and a snapshot of primary care in the future by Barry O’Brien. Tricia Higgins and Maria Murphy who paid special attention to the current hot topic of GDPR. These new regulations coming into force at the end of the month are not something that the pharmacy industry can afford to ignore. Now is the time to ask if our businesses are compliant.

A little light relief was provided by Niamh Sherwin Barry, co-founder of the Irish Fairy Door Company. She gave a talk on the power of storytelling and how it can strengthen your brand. The PMI is a professional membership organisation dedicated to the continuous

learning, development and support of those working in management within the pharmaceutical industry. The institute has a diverse membership and focuses on four different event series each year – pharma managers, pharma leaders, women in leadership and masterclasses.



Diabetes from risk to treatment By Clair Naughton, Diabetes Nurse and Regional Development Officer with Diabetes Ireland In 2006 the United Nations Generally Assembly passed a resolution recognising diabetes as a chronic debilitating and costly disease associated with major complications. November 14th was designated an official United Nations Day marking World Diabetes.1 The International Diabetes Federation (IDF) estimate that globally there are 425 million adults with diabetes, with one in two remaining undiagnosed. In Ireland the prevalence is approximately 225,840 people living with the condition.2 The increasing incidence of diabetes has and will have significant economic consequences. It is estimated that in excess of 10% of healthcare spending in Ireland is diabetes related and these costs will increase by up to 25% by the year 2040.3 The most common forms of Diabetes can be classified into the general categories of Type 1 diabetes, Type 2 diabetes, Pre-diabetes and Gestational Diabetes. There are other forms of diabetes such as monogenic diabetes, diabetes caused by diseases of the exocrine pancreas (cystic fibrosis related diabetes or pancreatitis) or drug induced diabetes (with glucocorticoid use) and also rarer forms of diabetes that will not be discussed in this article. Traditionally it was thought that Type 2 diabetes occurred in adults and Type 1 in children, but this paradigm is no longer accurate as both diseases can occur at any age.4 Type 1 diabetes is caused by an auto-immune destruction of the insulin producing -cells in the pancreas resulting in absolute insulin deficiency. Those with a genetic predisposition to develop Type 1 diabetes interact with an environmental agent(s) causing the autoimmune pancreatic -cell destruction. It is one of the most common endocrine diseases in children with on average 23 children under the age of 15 being diagnosed per month in Ireland. Risk factors for Type 1 diabetes include having another autoimmune condition or a close relative with Type 1 diabetes.6 Type 1 Diabetes, a diagnosis not to be missed The classic presenting symptoms of Type 1 diabetes are polyuria, polydipsia, lethargy and weight loss.5 However, the signs of Type 1 Diabetes can be subtle at times, making an early diagnosis challenging. Other symptoms that warrant further investigation are enuresis in the previously toilet trained child, constipation particularly

in younger children who cannot articulate their thirst or access extra fluids; increased hunger and persisting weight loss despite increased food intake and mood-swings/irritability. At times the symptoms of Type 1 diabetes can be thought to be due to more common conditions, polyuria due to a urinary infection, abdominal pain due to an acute abdomen, secondary enuresis due to an upset in the childâ&#x20AC;&#x2122;s life etc.6, 5 In children under two years of age fatigue and weight loss are frequently reported as presenting symptoms.5 Adolescents can also be a challenging age group to diagnose due to their increased independence and privacy particularly in relation to toileting. In cases where the symptoms are subtle and harder to recognise increased vigilance is needed as children with a delayed diagnosis of Type 1 diabetes can deteriorate rapidly into Diabetes Ketoacidosis (DKA) an acute life-threatening complication of Type 1 Diabetes6. DKA remains the leading cause of morbidity, mortality and hospitalisation in children and adolescents with Type 1 diabetes. Children and young people with suspected Type 1 diabetes should be referred on the same day to a Multi-Disciplinary Paediatric Diabetes Team to provide a diagnosis and immediate care.6 A multidisciplinary approach should be used to provide optimal care for all individuals with Type 1 Diabetes to cover areas such as ongoing education, nutrition, therapeutics, identification and management of complications of diabetes, footcare, counselling and psychological care.7 Type 2 Diabetes occurs due

By Clair Naughton, Diabetes Nurse and Regional Development Officer with Diabetes Ireland

to a progressive loss of beta cell insulin secretion on a background of insulin resistance. The insulin deficiency is not sufficient to compensate for the insulin resistance and hyperglycaemia develops. Type 2 Diabetes can often go undiagnosed for many years, because, hyperglycaemia develops gradually and is often not severe enough for the individual to experience the classic symptoms of diabetes.4

Without a diabetes register in Ireland it is difficult to be entirely sure of the prevalence of the condition, but it thought that 205,000 people have the condition with Type 2 diabetes accounting for 85%-90% of people with Diabetes.8 The risk for developing Type 2 diabetes increases with age, obesity, lack of physical activity, having a family history


Feature and Pregnancy

of Type 2 diabetes in a first degree relative, hypertension and hyperlipidaemia. It occurs more frequently in women with prior gestational diabetes and in certain racial/ethnic subgroups such as African and Asian groups.4 There is overwhelming evidence that demonstrates the potential to prevent Type 2 Diabetes with intensive lifestyle intervention. The Diabetes Prevention Programme (DPP) demonstrated that intensive lifestyle intervention, healthy eating, regular physical activity, and weight management could reduce the incidence of Type 2 diabetes by 58% over three years.13 An online risk assessment tool for Diabetes is available at www.diabetes.ie. It involves a quick questionnaire to determine a person’s personal risk for developing diabetes and advice on how to reduce further risk of developing Type 2 diabetes. Pre-Diabetes refers to blood glucose levels that do not meet the criteria to diagnose Type 2 diabetes but are two high to be considered normal. Pre-diabetes is a risk factor for Type 2 diabetes and cardiovascular disease. The treatment for Pre-diabetes is adopting a healthy balanced diet, taking regular physical activity and weight management, particularly reducing abdominal or visceral fat. An individual with pre-diabetes should be screened yearly to ensure they haven’t progressed to Type 2 Diabetes. Diabetes can be diagnosed by taking a venous plasma glucose level, a 75gm oral glucose tolerance test (OGTT) or by a HbA1c blood test. World Health Organisations methods and


criteria for diagnosing Diabetes are as follows:

The management of Type 2 Diabetes focuses on diabetes self-management education, dietary advice, managing blood glucose levels, managing cardiovascular risk and identifying and managing long term complications of diabetes such as eye disease, foot disease and renal disease.12

any form of diabetes or glucose intolerance with its first onset during pregnancy. At a booking antenatal visit all pregnant women should be screened for risk factors for gestational diabetes. Some but not all of the risk factors include; having a family history of diabetes in a first degree relative, having a BMI ≥ 30kg/m2, maternal age > 40 years, being from a high risk ethnic group, having glycosuria, having a history of polycystic ovary disease, having previously delivered a baby weighing ≥ 4.5kgs. For at risk women screening for GDM should be carried out at 24-28 weeks gestation using a 75gm OGTT. Diagnosis of GDM is made when one or more of the following values are met or exceeded. A fasting venous plasma glucose level of >5.1mmol/L or using a 75gm OGTT, a one-hour value of 10mmol/l and a two-hour value of 8.5mmols. Having a pregnancy complicated with GDM is considered high risk, therefore antenatal care should be delivered by a combined diabetes/obstetric multidisciplinary team in the hospital setting.11 At the six-week postnatal check-up, the mother should have a repeat 75gm OGTT using diagnostic criteria for the non-pregnant population to detect if Pre-diabetes or Type 2 diabetes is present. Having a history of GDM is a risk factor for the development of Type 2 diabetes. Mothers should be advised to have annual screening for Type 2 diabetes for life and aim to lead a healthy lifestyle i.e. healthy eating, regular physical activity and have a weight that is appropriate for their height in order to prevent or delay the onset of Type 2 diabetes.

Gestational Diabetes (GDM) is

Pre-gestational Diabetes

1. Symptoms of diabetes plus a random venous plasma glucose concentration of ≥ 11.1mmol/l. 2. In an asymptomatic individual, two fasting venous plasma glucose concentrations of >7mmols/l on two separate occasions are needed to diagnose diabetes. A fasting glucose of between 6.1-6.9mmols/l is Impaired Fasting Glycaemia(IFG) or Pre-diabetes. 3. HbA1c blood test can be used to determine a diagnosis of diabetes, HbA1c <42mmol/ mol is normal, HbA1c 4347mmol/mol is Pre-diabetes and a HbA1c >48mmol/mol is Diabetes. 4. A 75gm oral glucose tolerance test can also be used to determine a diagnosis. A venous plasma glucose concentration, two hours post a glucose load of 11.1mmols is diagnostic of Diabetes. A plasma glucose value two hours post glucose load of between 7.8mmol-11.1mmols is Impaired Glucose Tolerance(IGT) or Pre-Diabetes.9

It is essential that all women of childbearing age with Diabetes are informed of the importance of pregnancy planning to ensure optimal blood glucose control at conception and throughout the pregnancy. This is essential to avoid major maternal and fetal complications. If a woman with pre-existing Diabetes is considering pregnancy she should speak to her diabetes team about being referred for pre-pregnancy care in order to get her pregnancy off to a healthy start11. Who should be tested for Type 2 Diabetes and how often? For all adults screening for Type 2 diabetes should begin at age 45. If tests are normal and there is no evidence of Diabetes or Pre-Diabetes repeat testing should be carried out every three years. If a person is at risk of developing Type 2 diabetes, testing can begin at any age i.e. if a patient is overweight or obese and has one or more additional risk factors such as a family history of diabetes, is from a high risk ethnic group, has hyperlipidaemia or hypertension.4 A VHI Healthcare Screening study for Diabetes and Pre-diabetes tested 30,000 people between 2009 and 2013. Their findings demonstrated that 1.8% had undiagnosed Type 2 diabetes and 10% had confirmed Pre-diabetes. Abnormal blood sugar levels, Pre-diabetes and Diabetes were found to be more common in men than in women with men twice as likely to have abnormal blood glucose levels and undiagnosed Diabetes. The study also found that the risk of having undiagnosed diabetes increased by 89% for every 5kg/m2 increase in body mass index which demonstrates the importance of modifiable lifestyle factors in preventing diabetes.10 Recent Research In December 2017 Diabetes UK published the results of the first year of the DiRECT study (Diabetes Remission Clinical Trial). The trial looked at the possibility of putting Type 2

Feature diabetes into remission using a low-calorie, diet-based weight management programme. After one year, 45.6% of individuals who took part in the trial had put their Type 2 diabetes into remission. There was a close link between weight-loss and the potential for diabetes remission. Results indicated that remission of Type 2 diabetes was associated with sustained weight loss, with 10-15kg weightloss showing higher levels of achievement. Remission was defined as HBA1C <48mmol/mol after at least two months off all antidiabetic medications, from baseline to month 12.14 These findings are hugely encouraging, and further results from this study are eagerly awaited. Diabetes Ireland is the national charity dedicated to helping people with diabetes and has been serving the diabetes community since 1967. They provide support, education and motivation to people affected by diabetes; individuals, their families and carers. Diabetes Ireland also raises public awareness of diabetes and its symptoms and funds research into finding a cure for diabetes. Living with diabetes is not easy. However, with the right help, advice and support, there is no reason why Irish people with diabetes cannot live life to the full. Diabetes Ireland provides patient education, information, and support to thousands of Irish people with diabetes and their families when needed most.

Diabetes Ireland can support your patients by: Patient support is available through our helpline Monday-Friday 9am-5pm, telephone 1850 909 909 or email info@diabetes.ie Online education Diabetes Smart is a 55-minute online module on the Diabetes Ireland website. It has five sections; What is Diabetes? Healthy Eating, Physical Activity, Medications, and Complications. It is suitable for anyone with Type 2 Diabetes or Pre-diabetes with basic IT skills Diabetes Ireland Care Centres are in Santry in Dublin and Cork city. They are purpose built and the team has expertise in the needs of people with diabetes. The following services are available, Podiatry, Orthotics, Footcare Services, Dietetic consultations, and a counselling service. Call Dublin 01-842 8118 and Cork 021-427 4229. Structured education for patients with Type 2 Diabetes is available through the community education programmes called CODE (Community Orientated Diabetes Education). Access to a wide range of diabetes information both online and via booklets. Support groups, children and adolescent activities, family weekends and more.

See www.diabetes.ie for more details or telephone 01-842 8118. References 1. International Diabetes Federation. United Nations Resolution 61/225. World Diabetes day 2. International Diabetes Federation Atlas 8th edition 2017 3. HSE Diabetes Expert Advisory Group. First report April 2008. 4. Classification and Diagnosis of Diabetes: Standards of medical care in Diabetes 2018. Diabetes Care 2018;41 (Suppl.1):S13-S27 5. Lokulo-Sodipe K, Moon RJ, Edge JA, Davies JH. Identifying targets to reduce the incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in the UK. Arch Dis Child. 2014 May;99(5):438-42. 6. Roche Edna. Vague symptoms? Think childhood diabetes. Diabetes and Cardiology review Vol 3 Issue 1 Spring 2016: 12-13. 7. National Institute of Clinical Excellence 2015. Guidelines for the management of Type 1 Diabetes. 8. Diabetes Ireland: Prevalence of Diabetes in Ireland www. diabetes.ie 9. Definition and Diagnosis of Diabetes Mellitus and intermediate hyperglycaemia. Report of a World Health Organisation and International

Diabetes Federation consultation 2006. 10. VHI Healthcare Screening Project 2013 Sinnott et al Fasting Plasma Glucose as Initial Screening for Diabetes and Prediabetes in Irish Adults: The Diabetes Mellitus and Vascular Health Initiative (DMVhi). PLOS ONE Journal, published: April 15, 2015 11. Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Postnatal period. HSE 2010. 12. Type 2 diabetes in adults: guidelines for management. National Institute of Clinical Excellence (NICE) 2015. 13. Knowler et al Diabetes Prevention Programme Research Group. Reduction in the Incidence of Type 2 Diabetes with lifestyle intervention or Metformin. New England Journal of Medicine 2002. 14. Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, Peters C, Zhyzhneuskaya S, Al-Mrabeh AA, Hollingsworth KG, Rodrigues AM, Rehackova L, Adamson A, Sniehotta FF, Mathers JC, Ross HM, McIlvenna Y, Stefanetti R, Trenell M, Welsh P, Kean S, Ford I, McConnachie A, Sattar N and Taylor R. Primary careled weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018; 391 (10120), 541-551. Published online 5.12.2017. Available from https://doi.org/10.1016/


A new study has discovered a link between a vitamin D deficiency and an increased risk of diabetes for the obese. Obesity and low levels of vitamin D are both known risk factors for diabetes by themselves. However, scientist in the US have revealed that if both are present there can be a significant increase in the likelihood of insulin resistance, a classic precursor to diabetes. The study involved more than 6,000 people and revealed that obese patients with normal vitamin D levels were 20 times more likely to experience insulin resistance compared to patients who weren’t obese. However, obese patients with low vitamin D levels were found to be 32 times more at risk. Speaking to the journal Diabetes Care, scientists from Drexel University in Pennsylvania said: "Vitamin D insufficiency and obesity are individual risk factors for insulin resistance and diabetes. “Our results suggest that the combination of these two factors increases the odds of insulin resistance to an even greater degree than would have been expected based on their individual contributions.” The scientists have admitted more research is needed to ascertain whether taking supplements could reduce the risk of developing insulin resistance and diabetes in people who are obese. Vitamin D is essential for healthy bones. It is made in the body when ultraviolet rays from the sun hit the skin and is not present in many foods. Because of this, populations of northern countries which lack sunlight in the winter months such as Ireland can lack the vitamin. Many choose to take supplements to make up for this deficiency.


Get your “Sunshine vitamin” (even in Ireland!)


Did you know that: • Sunlight is our primary source of vitamin D and its very difficult to get an adequate amount from our food alone. • We fail to get sufficient vitamin D because the sun is too weak seven months a year. • An SPF 8 or higher blocks the production of vitamin D. • Vitamin D is important for healthy skin, bones and teeth. • Vitamin D supports the immune system. • Vitamin D helps maintain muscle function. D-Pearls: • Are dissolved in cold-pressed olive oil for optimal absorption. • Come in small, easy-to-swallow “pearls” which are also chewable. • Available in 38ug(1520iu) and 75ug(3000iu). • Made from lanolin – the best organic vitamin D source. Please contact us if you would like more information on D-Pearls Pharma Nord®

+ Available in pharmacies and health food stores!

Tel: 01 899 1650 • Fax: 01 885 3893 Email: ireland@pharmanord.com Web: www.pharmanord.ie

News Risk factor between antiepileptics and dementia uncovered by study

news brief

A new study has revealed an increased risk for dementia and Alzheimer’s disease to patients using antiepileptic drugs in the long term.


The study, undertaken by the University of Eastern Finland and the German Centre for Degenerative Diseases (DZNE), has revealed that the continuous use of antiepileptic drugs for a period of more than one year can lead to increased risk of either neurological condition. In the Finnish dataset there was a 15% rise in Alzheimer’s risk and the German dataset was found a 30% rise of dementia. Certain antiepileptics are already known to impair cognitive function and researchers have found that the risk of Alzheimer’s and dementia was significantly increased when using these drugs – a 20% increased risk of Alzheimer’s and a 60% rise in the risk of dementia. It was found that those antiepileptic drugs that do not impair cogitative function are

not accompanied by this increased risk. Research also discovered that the higher the dose of drug that impairs cognitive function, the higher the risk of dementia. As well as epilepsy, some antiepileptic drugs can be used to treat disorders such as neuropathic pain, bipolar disorder, migraines and anxiety. Some antiepileptic drugs also carry increased risks of birth defects or developmental issues if used by pregnant women. This study was the largest so far and the first to investigate the risk in accordance with frequency of use, dose and comparing drugs both with and without cognitive-impairing effects. Senior Reasearcher, Heidi Taipale, of the University of Eastern

Finland said: “More research should be conducted into the longterm cognitive effects of these drugs, especially among older people.” The report was published in the Journal of the American Geriatrics Society. This study is part of the nationwide register-based MEDALZ study, which includes all 70,718 persons diagnosed with Alzheimer's disease in Finland during 20052011 and their 282,862 controls. The association of antiepileptic drug use with dementia was investigated in a sample from a large German statutory health insurance provider, Allgemeine Ortskrankenkasse (AOK). The dataset includes 20,325 persons diagnosed with dementia in 20042011, and their 81,300 controls.

The Irish pharmacy sector has once again lead the way in online sales according to Retail Excellence The Retail Excellence/StudioForty9 eCommerce Dashboard Report is a monthly publication measuring the impact of retail sales online. The report calculates key metrics and is an invaluable tool for retail businesses to evaluate their impact with online sales. The highest desktop conversion rate of any sector was that of pharmacy, which showed a desktop conversion rate of over 3% and a rate of almost 2% on mobile devices. This continues the strong growth in online sales that the pharmacy sector has been demonstrating for the last 12 months. The February report showed a 34% year-on-year increase in mobile browsing across all of retail compared to the same period in 2017. eCommerce Manager at Retail Excellence David Campbell said:e “The data produced by our Dashboard Report gives an excellent insight into the current state of play within the Irish online marketplace and in particular, consumer shopping behaviour. It is an invaluable support we offer Irish retailers trading online where

they can determine their digital strategies based on these trends”. He continued: “With unemployment levels reducing and increased engagement on mobile devices by commuters going to and from work it is crucial for discerning retailers to developing digital marketing strategies to take advantage of these trends so they can reach consumers browsing on the Dart, bus or Luas en route home after a day’s work”. “Retail is becoming increasingly boundaryless and we need to embrace omnichannel opportunities in order to reach out to consumers both within Ireland and further afield. With over e600 billion expected to be spent by European consumers online in 2018 it is clear that retail is now a huge global opportunity for retail entrepreneurs”.

Pharmacists in Ireland should brace themselves for an upsurge in hay fever and asthma symptoms this month thanks to the weather. The inclement weather experienced in Ireland in the first quarter of the year, coupled with the sunshine and higher temperatures that arrived in April are expected to result in a so-called pollen bomb. Thanks to the Beast from the East and Storm Emma, several species of tree and grass were prevented from blooming in early March as was their norm due to the cold snap. Now that temperatures have finally started to rise, and the sun has come out, several species of trees, grasses and plants will be releasing their pollen at the same time. The Met Office has predicted that pollen levels will be extremely high this month as a result. Experts have warned pharmacists of the need to stock up on antihistamines and allergy prevention. Asthma sufferers who experience hay fever symptoms are expected to find conditions especially challenging. As well as itchy eyes and nose they could run the risk of a potentially lifethreatening asthma attack. Health experts have recommended regular use of antihistamines and nasal sprays and that asthmatics should keep reliever inhalers with them at all times.

David Campbell, Retail Excellence eCommerce Manager Director of StudioForty9 Gerard Keohane commenting on the latest publication “We are delighted to partner with Retail Excellence to produce the eCommerce Dashboard which is a critical resource for benchmarking Irish Retail eCommerce KPIs and sales statistics”.

In Ireland one in five people reportedly suffer from hay fever, this equates to around one million people in the country. A third of sufferers have said their allergies can give them problems sleeping, one fifth said hay fever can prevent them from eating out and socialising and one in 10 people. There is a significant link between hay fever and asthma and many asthmatics will suffer from hay fever symptoms. It’s thought up to 90% of sufferers experience an allergic reaction to grass pollen, but a significant number of people suffer from both a grass and tree pollen allergy.



Coeliac Disease and the Irish Pharmacist By dietitian Sarah Keogh with input from Keith Hourihane, Superintendent Pharmacist, Pharmacy First Plus Coeliac disease affects one in 100 people in Ireland, although some can wait up to 10 years to be diagnosed and some might never be given a diagnosis. Because of this, coeliac disease is sometimes known as the silent disease. Pharmacists are ideally placed to advise and assist patients with coeliac disease and to prompt them to see their GP for an earlier diagnosis. diagnosed between the ages of 40 and 60. HOW CAN THE COMMUNITY PHARMACIST HELP? Spotting undiagnosed coeliac patients Although it is estimated that 47,500 people in Ireland have coeliac disease the actual numbers diagnosed are much lower. It is estimated that for every person diagnosed as coeliac in Ireland, there could be as many as 10 people with the disease remaining undiagnosed. Community pharmacists are ideally placed to improve rates of diagnosis as they are a first portof-call for many people looking for help with the symptoms. Pharmacists are also familiar faces within the community who already have a relationship with many customers. People may feel more comfortable talking to their pharmacist about their symptoms. In Ireland, testing is now routinely offered to those with autoimmune thyroid disease, dermatitis herpitformis, IBS, type one diabetes and those with a parent, sibling or child with the disease.

Sarah Keogh, Dietician What is coeliac disease? People with coeliac disease have an abnormal reaction to gluten, a protein found in wheat, rye, barley and some other grains. This abnormal reaction leads to inflammation and damage of the gut wall. This in turn leads to a reduction in the ability of the gut to absorb nutrients from food. People with undiagnosed coeliac disease can suffer from digestive symptoms, including diarrhoea, constipation and bloating. They are also more likely to suffer from conditions such as anaemia, osteoporosis, weight loss, recurring mouth ulcers, alopecia,


depression, ataxia and skin rashes.

Who might need a coeliac test?

Why can coeliac disease be missed?

Those who might need a coeliac test are like to be suffering from the following:

Coeliac disease can look like several other diseases. Many people with coeliac disease have been told that they have irritable bowel syndrome – or have selfdiagnosed IBS. Many people with coeliac disease are also temporarily lactose intolerant. Avoiding milk usually improves digestive symptoms but doesn’t eliminate coeliac disease. Coeliac disease can be develop at any age but most people are

• Ongoing gastrointestinal pain • Gastro symptoms following consumption of glutencontaining foods such as pasta, bread or cereals. • Lethargy and fatigue • Unexplained weight loss – failure to thrive is a common symptom in children with coeliac disease.

• Recurring mouth ulcers • Skin rashes – dermatitis herpetiformis, an intensely itchy rash, is most closely linked with coeliac disease • One in 10 people who have a first degree relative with coeliac disease are also coeliac. • Unexplained infertility and recurrent miscarriage – both partners may need to be tested. Patients who have selfdiagnosed with irritable bowel syndrome should also be encouraged to see their GP for a coeliac test. An opportunity to engage Any time a patient presents in a community pharmacy it is an opportunity for pharmacists and OTC staff to have a meaningful engagement. In the case of undiagnosed coeliac disease, the mere suggestion by the pharmacist that a patient’s symptoms may be eliminated without medication by following a strict gluten free diet can be enormously important to a patient. A patient will never forget the pharmacist that suggested further investigation if it leads to a dramatic change in their quality of life. Diagnosing coeliac disease The first step is a blood test by the patient’s GP. It is essential that patients are eating foods containing gluten for six weeks before having coeliac tests. The blood test is for antibodies to gluten: Immunoglobulin A (IgA); anti-tissue transglutaminase antibodies (IgA tTGA) and antiendomysial antibodies (IgA EMA). If results show raised tTG or positive EMA, the patient should be referred to a consultant gastroenterologist for a biopsy of the gut. The biopsy

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Feature coeliac disease were able to access some gluten-free foods on prescription schemes e.g. GMS (medical card), which was discontinued in 2012. Now that most patients no longer receive their bread or flour from their pharmacy, they may never discuss their coeliac disease diagnosis with their pharmacist. However, it is important for patients to inform their pharmacists of a coeliac disease diagnosis. This could be essential when considering symptoms or issues patients may have related to any OTC query or suggestions that patients cannot tolerate prescription medication due to gastro-intestinal adverse effects. There are also several medications that contain gluten e.g. Lioresal (Baclofen). Some OTC products state they are gluten free e.g. Easofen for Children. Other OTC products may contain very low levels of gluten and therefore comply with requirements for glutenfree product claims for food in accordance with Codex Standard 118-1981 (amended 1983) with a provisional gluten level of 20mg/ kg (20ppm). Pharmacist Keith O'Hourihane

is an important step and is needed to confirm the diagnosis. Patients must continue to eat gluten between having a positive blood test and having a biopsy. A negative blood test does not always mean the patient does not have coeliac disease. Patients who continue to have symptoms, even with a negative blood test may still need to be referred for a biopsy. The blood test is also unreliable if patients have IgA deficiency and in children under the age of three. Advising Coeliac Patients After diagnosis, coeliac patients will require long-term, substantial advice and support. The only treatment to alleviate the symptoms is a strict gluten-free diet for life. Patients need to be seen by a CORU Registered Dietitian with experience in coeliac disease. It is important that patients have accurate, detailed advice on managing a gluten-free diet as well as managing the related nutritional deficiencies common in this patient group. Patients can be referred to HSE hospital or community dietitians or can


access a CORU registered dietitian privately at www.sedi.ie. Patients with undiagnosed coeliac disease are unable to absorb important vitamins and minerals such as calcium, which can particularly affect those people experiencing symptoms during their childhood and early teens. As this can affect bone mass density, patients with coeliac disease are at significantly higher risk of osteoporosis. As some patients with coeliac disease are also temporarily lactose intolerant, they need advice on how to reduce lactose without compromising the intake of key nutrients such as calcium and vitamin D. Community Pharmacists are ideally placed to advise patients on how to access essential dietetic services for their patients and some aspects of managing their diet. They are also essential in advising patients on the possible presence of gluten in their medicines. Talking to Coeliac Patients In the past, patients with

Apart from advising patients on suitable medicine, it may also be useful for pharmacists to familiarize themselves with supermarkets in their locality that offer a variety of gluten-free foods. Patients who are newly diagnosed with coeliac disease tend to focus on what they can’t eat rather than what they can eat. Being able to assist them in this transition is very much appreciated and further builds relationships between patient and pharmacist. Patients also welcome being advised that they are entitled to submit claims to Revenue for relief on gluten-free foods purchased, along with medical expenses by visiting their account at www.Revenue. ie, and using the Review Your Tax option in PAYE Services for the year the expenses were incurred. Problems after Diagnosis Pharmacists are often the first health professionals to pick up on problems that coeliac patients experience: What to look out for: • Patients who have stopped following the gluten-free diet once they start to feel better. You can advise patients that their gut is still being

damaged by gluten even if they feel better and that they need to follow the gluten-free diet for life. • Patients who are following the diet but have started having problems such as bloating, diarrhoea, fatigue or anaemia again may need to go back to their dietitian to see if they are inadvertently consuming gluten or to go to their GP to see if there is another issue. • Anaemia that continues after diagnosis or recurs – this can indicate that the patient is not following the diet correctly or they may be consuming insufficient iron and/or B vitamins. Supplements and/or referral back to their dietitian may be required. Associated Conditions Patients with coeliac disease are more likely to develop osteoporosis, diabetes, anaemia and hypothyroid disease. These will require medications and supplements and the community pharmacist is ideally placed to advise and support. Supplements for Coeliac Patients Coeliac patients typically require a vitamin D supplement and may also need calcium and B vitamin supplements. Working Together The Coeliac Society of Ireland is the national charity supporting people diagnosed as coeliac. We are keen to build stronger relationships with pharmacists as we believe Irish pharmacists are in a unique position to raise awareness and diagnosis of coeliac disease among their patients. Professional membership to the Society is available to all pharmacists, priced at ¤40 a year. As part of membership you will receive the Food List, a comprehensive listing of gluten free products available in Ireland, including OTC medications and supplements; a monthly e-zine with news from the Society and a quarterly magazine. You will also have access to our phone support team. The Society is here to help you help your patients. If you have any questions, please give us as a call on 01 872 1471 or visit www.coeliac.ie for information.


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Rheumatoid arthritis influenced by a high-risk genetic background By Dr. Maria Benito

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease influenced by a high-risk genetic background, in combination with epigenetic marks and environmental factors that lead to the induction of synovitis and subsequent destructive arthritis. Clinically, RA is the result of chronic inflammation of the synovium, characterized by interactions of resident fibroblast-like synoviocytes (FLS) cells with cells of the innate (macrophages, dendritic cells, mast cells and natural killer (NK) cells, neutrophils) and adaptive immune system (B and T lymphocytes) that take place within the joint. RA patients can be divided into two groups according to the presence or absence of antibodies to citrullinated protein antigens (ACPAs) and rheumatoid factor (RF); seropositive RA patients –approximately two-thirds– display a more severe disease course. ACPAs and RF are often present in the blood long before any signs of joint inflammation,


which suggests that the triggering of autoimmunity may occur not at the joints but at other sites. Clinical studies and genetic evidence point to an immunemediated etiology associated with stromal tissue dysregulation that develop in chronic inflammation and articular destruction. The initial phase –before the clinical onset of RA encompassing synovitis and systemic comorbidities affecting the vasculature, metabolism, and bone appear– is generally characterized by the presence of circulating auto-antibodies and increasing concentration of inflammatory cytokines and chemokines. Chemokines promote leukocyte infiltration and activation, angiogenesis, osteoclast differentiation, synoviocyte proliferation and activation, and –through the release of neurotransmitters– regulate the equilibrium between damage/ repair and relief/pain. Genetic factors –together with gene sequences and epigenetic

marks– play a role in RA risk, severity and progression. The class II major histocompatibility (MHC) locus is the most important genetic risk allele for RA, accounting for about 40% of the genetic influence, with MHC class II HLA-DR4 present in 70% of patients that develop RA. Data support the notion that HLADR risk for RA is based on the increased efficiency of antigen presentation for altered peptides rather than native proteins. Lungs, the oral mucosa and the gastrointestinal tract are three frontiers between external influences and the immune system involved in RA. In individuals with risk HLA alleles, peptides could be presented and ACPAs or innate B cells could initiate responses to modified self-peptides, and present peptide to T cells that would react to auto-antibodies. In addition to the HLA, over 100 single nucleotide polymorphisms (SNPs) and genes associated with ACPA+ RA have been identified using meta-genomic analyses, with different characteristics from ACPA-RA

patients, supporting the notion that seronegative RA should be considered a distinct clinical pathology. Several epigenetic mechanisms, including histone modification –through methylation, acetylation and citrullination–, DNA methylation, and microRNA (mir) expression have been implicated in RA. DNA methylation that alters particularly synovial fibroblastlike synoviocytes (FLS) function in the synovial inflammatory environment –involving genes and pathways related to cell adhesion, matrix regulation, immune function, and cytokine signaling– can evolve over time and patterns can fluctuate between joints, with signaling pathways like interleukin-6 (IL-6)Janus tyrosine Kinase (JAK)Signal Transducer and Activator of Transcription (STAT) involved. RA FLS express histone deacetylases (HDACs) that can regulate their function –proinflammatory cytokines can increase HDAC1 expression in FLS; HDAC1 or 2 deficiency

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Feature increases p53 tumor suppressor gene and matrix metalloproteinase 1 (MMP1) expression in synovial cells. mir124a –which suppresses cell cycle and chemokine gene expression and monocyte chemoattractant protein-1 (MCP1) production– is dysregulated in RA; as it is mir203 that increases MMPs and IL-6 expression; mir155 is implicated in monocyte activation and cytokine production via TLR signaling. The immunologic response involves a rise in chemokines and cytokines causing an ongoing systemic inflammatory pathology. In established disease, ACPAs –together with RFs– are present in 80% to 90% of RA patients and are independently associated with greater disease activity, extra-articular manifestations and joint damage. However, a combination of vascular, neuro-regulatory, microtrauma, or infections merged with RFs and ACPAs is required for the evolution of synovitis. Once established the disease in the joint, auto-antibodies may bind antigens, activating resident cells, recruiting new immune cells and promoting stromal cell activation, which can produce additional cytokines and chemokines to self-perpetuate the process. Other hypotheses for the development of RA suggest that stromal cells play a critical role. FLS are permanently altered in and could initiate or exacerbate disease through mechanisms of abnormal DNA methylation, somatic mutations in various genes, defective expression of tumour supressors, with a therapeutic opportunity in the role of mesenchymal cells in disease initiation and progression. Synovial membrane is relatively acellular consisting generally of 2-3 lines of FLS and stromal tissue with scattered macrophages and sparse blood vessels, with the primary function of lubricating and nourishing the articular surface. In pre-RA phase, the thickness synovial lining layer expands up to 10-12 cells depth, including macrophages and FLS, although there is neither obvious leukocyte infiltrates, nor transcriptional changes. However with the onset of RA and the articular swelling, there is a dense


interstitial cellular infiltrate containing macrophages, dendritic cells, mast cells, NK cells, innate lymphoid cells, and of adaptive responses –B and T lymphocytes, and plasma cells– associated with significant neovascularization.

FLS direct damages cartilage via MMP1 and MMP3 by promoting chondrocyte activation and tissue catabolism through cytokine release –IL-1, TNF and IL-17– in conjunction with macrophages, which result in bone damage.

are independent predictors of remission, no previous administration of non-steroidal anti-inflammatory drugs or methotrexate alter the response to etanercept, while smoking influences the respond to infliximab.

M1 phenotype macrophages, expressing RF and ACPA, cytokines –tumour necrosis factor (TNF), IL-1, IL-6, chemokines, MMPs, vasoactive peptides, oxygen and nitrogen intermediates–, compromising several activation pathways.

Monitoring biomarkers are useful to detect patients at risk for RA; the earliest RA can be detected, the earliest the treatment can start to prevent its development and further damage. Thus, biomarkers such as RFs and ACPAs can be used to identify subjects before the onset of RA symptoms, and can predict bone erosions and severe disease progression; the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels offer information about disease activity.

Future Biomarkers

Different lymphocyte subpopulations including regulatory T cells (Tregs), T helper 17 (Th17) cells and regulatory B cells (Bregs) play crucial roles in maintaining self-tolerance and preventing autoimmunity disorder, and could regulate antibody production, therefore playing a main role in the physiopathology of RA. The interaction with T cells acting through IL-15, IL-7 and IL-6 can further activate the pathway, with Th1 and Th17 T cells detected in established disease. The role of Th17 –a CD4+ T-lymphocytes subpopulation that produces the pro-inflammatory cytokine IL-17– appears to be significant during the onset of RA and influenced by treatments later. B lymphocytes and humoral immunity also play a key role in RA, with ACPA and RF production. Breg –subpopulation of B cells– have immuneregulating properties and play a part in peripheral tolerance, mainly via secretion of IL10. B cell lineages, including mature plasma cells at each stage of development, are detected in synovium. Studies in experimental mouse models have showed that regulatory B cells that produce IL-10 are critical in preventing and curing autoimmune diseases. FLS –primary source of IL-6 in the RA synovium– contribute to the matrix deposition and tissue remodeling that characterizes RA, with migratory activity, local proliferation and release high levels of MMP and TIMPs (tissue inhibitors of metalloproteinases), cytokines and chemokines, and together with collagens and other extracellular matrix components, seem to be particularly dependent upon cadherin 11 for their effector function. All of them are considered critical component of the RA inflammatory response.

Between 30-40% of RA patients treated with biological agents that target inflammatory mediators do not respond to the prescribed agent. TNF-α inhibitors (TNFIs: etenercep, infliximan), IL-1 receptor antagonist (anakinra), IL-6 receptor antagonist (tocilizumab), T-cell co-stimulation binding CD80/CD86 (abatacept), or B-lymphocyte antigen (antiCD20 B cells: rituximab) are some of the biologic agents used to treat RA. Predictive biomarkers allow matching patients most likely to respond to new therapies helping in decision making, while pharmacodynamic biomarkers can be used to monitor the response. Several studies suggest that a poor response to anti-TNF drugs is associated with a high level of baseline disability. Thus, RF negativity and male gender

miR146a –which suppresses apoptosis and IL-2 production– is expressed by activated T cells in the synovial tissue and is associated with increased RA disease. miR155 expression – which induces the development of Th1 and Th17 cells– is increased in mononuclear blood cells of RA patients. Memory CD24hiCD27+ B cells and Th17 cells may offer predictive value as biomarkers of therapeutic response under biologic drugs and may be able to guide in the choice of a tailored treatment. And targeting specific chemokine/chemokine receptor interactions can be a promising tool for therapeutic intervention. The early establishment of treatment is one of the best predictive factors for response to therapy and to delay further damage in the joints. Currently, novel biologics approaches are being investigated and in stage of development. The hope for RA future treatments is to identify specific phenotypes of the disease using the advances in the fields of proteomics, genomics, and metabolomics, in order to develop therapies focused on specific patients and particular phases of the disease. • References available on request

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indicated in pregnancy or lactation. Interactions and Adverse Effects: None stated. Overdose: In the event of significant overdose, serum electrolytes should be evaluated as soon as possible, correct any abnormalities and monitor levels until return to normal, especially in the very young and in cases of severe hepatic or renal failure. Precautions for Storage: Do not store above 25°C. The reconstituted solution should be used immediately but may be stored for up to 24 hours in a refrigerator at 2-8°C. Marketing Authorisation Holder: Sanofi Ireland Ltd., Citywest Business Campus, Dublin 24. Marketing Authorisation No. PA 540/98/1 (Blackcurrant), PA 540/98/2 (Citrus), PA 540/99/1 (Natural) Legal Category: P Further information: Available from Sanofi Ireland Ltd., Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi. com. Please refer to Summary of Product Characteristics which can be found on IPHA at http://www.medicines.ie/ before prescribing. Date of Preparation: January 2016 Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Suspected adverse events can also be reported to Sanofi Ireland Ltd. directly by emailing IEPharmacovigilance@Sanofi.com or calling 01 403 5600. Date of Preparation: March 2017 SAIE.DIO.17.01.0010b

News Retail Excellence Retail Retreat promises to be the best yet Retailers to learn from world-class speakers at the Retail Excellence Retail Retreat 2018 in May as industry leaders will share their experience, vision and trends at the two-day conference in Citywest Hotel. Retail Excellence, Ireland’s largest retail industry representative body, is delighted to launch their 7th Annual Retail Retreat & Expo which will be held in Citywest Hotel and Convention Centre on Tuesday and Wednesday the 15th and 16th of May and promises to be a retail spectacular unmatched in previous years. The event will feature 70 worldclass and inspirational speakers such as CEOs and business leaders past and present. From Victoria's Secret, Applegreen, Leon restaurants, John Lewis, Dreams, Woodies, Harvey Norman, The Retail Doctor, Paul O'Connell, Brian Cody, David McWilliams and an advisor to former British Prime Minister John Major. Speakers will address delegates covering a diverse range of retail aspects including how to re-retail, the 10 pillars of retailing excellently, selling online to China, the opportunities Brexit will present, customer service, retail crime, the food revolution, GDPR, how to deliver an experiential shopping environment and the future of retail. CEO-designate of Retail Excellence Lorraine Higgins said: “With the number of delegates already registered and confirmed it is clear that the Retail Excellence Retreat and Expo has become a priority event in the calendar of retailers. Given the strength and depth in this year’s lineup undoubtedly this year will be an experience like no other.

CEO, David Fitzsimons and Deputy CEO Lorraine Higgins launching the Retail Retreat and Expo “Along with 70 world-class speakers we will also have 150 cutting edge expo partners focused on meeting retailers needs from payments and technology, ecommerce, innovation, legal, accountancy, education, retail finance, financial planning, security, cash in transit and many more supplier solutions”. Lorraine Higgins concluded: “The significance of retail to the Irish economy cannot be understated with 282,000 workers employed

in the industry. This is why the development of top class retail standards and skills, and the promotion of vibrancy and competitiveness are essential for a secure future. Consequently, the Retail Retreat is simply unmissable for all discerning retailers who want to engage their customers, increase sales and loyalty while asserting their position in the marketplace”.

owned by its members and is the largest retail industry body in Ireland. The group invests in innovative and exciting learning, market intelligence, human resources services, government representation and member networking initiatives. Retail Excellence has almost 2000 leading retail companies which are among the most progressive and innovative retailers in Ireland.

Established in 1995, Retail Excellence is an organization

New look for Medicines.ie The second most-viewed health website in Ireland has undergone a revamp. Medicines.ie is the most comprehensive source of information on medicinal products available in Ireland with accurate, up-to-date, regulatory approved information. The new design sees the website equipped with several new features designed to enhance the user experience. This site is now also mobile optimised, ensuring that health professionals on the go, such as paramedics or health care visitors, can ensure they have access to the most up-todate information on all drugs and medicines. The new design has also been optimised for speed. Other key features of the site now include access to education material for those requiring additional information on


how to administer a medicine correctly. Users will now see the medicine’s name linked directly to the SmPC (Summary of Product Characteristics), the PIL (Patient Information Leaflet) and where necessary, regulatory approved educational material. Pharmaceutical companies can now manually create XPILs, which are PILs in Extensible Mark-up Language (XML) format, with the purpose of aiding screen readers.

Affairs Manager at IPHA said: “Our data shows that medicines.ie is Ireland’s most popular source of accurate and reliable medicines information. At IPHA we believe that our new look website will cement this status even further, giving healthcare professionals and patients a greater range of essential medicines information quickly and easily.

This site is managed by The Irish Pharmaceutical Healthcare Association (IPHA), which represents 47 research based pharmaceutical companies in Ireland.

“Healthcare professionals need comprehensive, regulatoryapproved information about medicines that is always to hand. By optimising the site for mobile and tablet use we believe medicines.ie will meet their information needs even better.

Commenting on the new site going live, Dr Rebecca Cramp, the Scientific and Regulatory

“With so much commentary on health online, it is vital also that patients and media have

an absolutely reliable source of accurate, regulatory approved information on medicines. The patient information and educational materials available for medicines online should provide greater assurance and assistance. “The launch of the new look medicines.ie is the beginning of an exciting period of redevelopment for the website. Over the coming months we look forward to introducing more new features which will further boost the benefits of using this free website”. The new look website went live in April and remains free of charge to users. The site is not solely for the use of IPHA users but remains open to all pharmaceutical companies to put their medicines’ information on the site.

Pharmacy Sponsorship Focus Careplus Pharmacy Continues Sponsorship of Carer of the Year Awards The dedication, commitment and kindness of family carers around Ireland must be celebrated. There are people in towns and cities all around the country who give their time each and every week caring for those they love. The work carers do is so important and makes a truly significant difference is the lives of so many. This work is vital to ensuring those who need care, receive it. Ireland’s carers make remarkable sacrifices on a daily basis and this must be celebrated and recognised. It is for these reasons that CarePlus Pharmacy is sponsoring the Carer of the Year Awards for the second year running this year. In addition, CarePlus Pharmacy is also proud to sponsor the Young Carer Awards for the first time. CarePlus pharmacies around Ireland help to provide a vital link between carers and their communities. CarePlus pharmacists are always on hand to offer advice to those caring for a loved one and help with anything that might be worrying them. This is why the sponsorship of the Carer of the Year Awards is so important to CarePlus Pharmacy. Providing care for somebody can have both financial and health impacts for those providing the care. A recent European Quality of Life Survey found that 16% of full-time carers rated their health as ‘bad’ or ‘very bad”. It is so important that carers are looked after and CarePlus Pharmacy want to make sure the carers are cared for. Pharmacists can provide help and information with medicine management to mental health and wellbeing advice. Niamh Lynch, Commercial Director of CarePlus Pharmacy said “CarePlus Pharmacy is honoured

to sponsor the Family Carer of the Year awards, which recognises the tireless efforts of thousands of people across the country. Carers are the heart of every community and meet our pharmacy owners and staff every day. We look forward to working closely with Family Carers Ireland and supporting the awards throughout our fifty community pharmacies nationwide”. Family carers provide on average 38.7 unpaid hours of care per week, which is the equivalent of a fulltime job. One in twenty people in Ireland is a family carer, which means a saving to the Government of ¤10 billion in unpaid care each year. By 2030, demographic changes predict that one in five people will take on a caring role. Catherine Cox, Head of Communications and Carer Engagement with Family Carers Ireland said: “Family Carers Ireland are thrilled to enter our second year partnering with CarePlus Pharmacies on our flagship event CarePlus Carer of the Year Awards. The local pharmacy is one of the first and key points of contact for our family carers with health professionals and the relationship that develops is crucial in supporting family carers to care safely and with confidence in their homes.”

Carer of the Year hosts Marty Whelan and Mary Kennedy with Young Carer Jack Cooney (11) from Tipperary

This year CarePlus Pharmacy is also sponsoring the Young Carer of the Year Award. Young carers are absolutely extraordinary and these awards will ensure that the work they do is recognised and appreciated. A young carer is anyone under the age of 18 who is caring for somebody in their family. This can be anything to helping with cleaning or just making sure they have what they need. This is not an easy undertaking for any young person which is why CarePlus wants to ensure the work they do is recognised. Ms Cox said: “We are particularly pleased that CarePlus Pharmacy are sponsoring our Young Carer of the Year Awards this year for the first time. We cannot overstate how important this sponsorship is in terms of raising awareness of who family carers are and the tireless work that they do every-day in their homes often without recognition and with little support.” Adam Hyland is the Dublin Young Carer of the Year 2017 and he expressed what the award meant for him. He said: “It was an amazing day for me and my whole family. It made me feel so proud to be a young carer and help my mam care for my dad. Dad said it was his proudest moment to see me being recognised and thanked

for what I do and he doesn’t know what he would do without me. I felt seven foot tall that day.” The CarePlus Carer of the Year Awards will acknowledge the contribution of family carers throughout Ireland and the awards will highlight the sacrifices family carers make and the services they provide to the State. Last year's Carer of the Year was Paula Robinson, from Cootehill, Co Cavan. Aedine Browne, who is a CarePlus community pharmacist in Cootehill, County Cavan said: “I am always in awe of the carers who use our pharmacy for their dedication to the people they care for. As a pharmacist, we fulfil an important role in their lives and work as hard as we can to help them. But I often wonder whether I would have the strength to cope with some of the challenges they face every day. “I think the CarePlus Carer of the Year awards are a simple step in acknowledging that strength. I know the 2017 winner Paula very well, and she truly is an inspiration to everyone in the community in Cootehill. I know my CarePlus Pharmacy colleagues will be encouraging lots of nominations this year, to highlight their own local heroes”. Family Carers Ireland provides a range of services for family carers through its 26 resource centres nationwide. Nomination forms for the CarePlus Carer of the Year Awards are available online at www. familycarers.ie, Family Carers Ireland nationwide resource centres, CarePlus Pharmacies or via the Freephone Careline 1800 24 07 24. The Awards will be presented in Dublin in November. For further information on CarePlus Pharmacy, visit www.careplus.ie.

Carer Champion Eithne Mannering at Keane's CarePlus in Mullingar

Niamh Lynch, Commercial Director CarePlus Pharmacy with Marty Whelan, Mary Kennedy and Catherine Cox of Family Carer’s Ireland


News Vitamin D and rheumatic diseases Two new studies have shown that vitamin D deficiency is common in people with a range of rheumatic diseases. Research presented at the annual congress of the European League Against Rheumatism (EULAR) suggests that over half of all rheumatic patients have levels below the recommended threshold. In the first study, UK scientists from the University of Birmingham and University College London studied 180 patients with inflammatory joint diseases, osteoarthritis or myalgia. They found that 58 per cent of participants had vitamin D levels

below those considered to be acceptable.

patients who did take supplements of 800IU or more per day.

Meanwhile, Italian scientists looked at 1,191 patients with rheumatoid arthritis in order to compare vitamin D levels with measures of disease activity. Their study revealed that levels of 25-hydroxyvitamin D (a measure of vitamin D in the blood) were lower than normal in 85 per cent of patients who did not take supplements.

Analysis of patients who did not take supplements revealed that vitamin D levels were linked to individuals' degree of disability, mobility and number of swollen joints.

Vitamin D levels were also low in 60 per cent of rheumatoid arthritis

Dr Luca Idolazzi, from the University of Verona's rheumatology unit, commented: "We have seen in studies that vitamin D deficiency is common in patients with a range of rheumatic diseases, and our results have

confirmed this using several clinically accepted measures of disease activity. "What we need to see now is a range of long-term studies which examine the clinical response of patients to vitamin D supplementation." Vitamin D can be found naturally in some foods (salmon, mackerel, tuna, fish oils and eggs) and can be generated in our bodies by exposure to sunlight.

Christmas Cosmetic Gift & Trade Fair 2018 launched The Cosmetic Association Ireland is delighted to announce the return of the Christmas Cosmetic Gift & Trade Fair for 2018.

The fair will take place on May 20-22 at the RDS, Merrion Road, Ballsbridge, Dublin 4 and this year promises to be the most spectacular event yet. The Cosmetic Association was

formed almost 30 years ago to offer the pharmacy sector a onestop-shop for their Christmas trade. The Cosmetic Association Christmas Cosmetic & Gift Trade Fair came into being. As the years went by the trade fair grew as

more and more exhibitors took the opportunity of introducing their brands to Irelandâ&#x20AC;&#x2122;s pharmacies at the yearly exhibition. For buyers to experience full stands of cosmetics, displays of perfumes, jewelry ranges or a full quota of festive wrapping options in one convenient day has been a huge benefit to many community pharmacists in the country. As the years have passed, so has the success of the show which has

grown bigger each year. In 2007 the event moved out of its original home and into the much larger Main Hall of the RDS, Ballsbridge where it has remained ever since. The Christmas Cosmetics & Gift Trade Fair has continued to go from strength to strength and has now extended into Hall Three. Ireland is a small country but a large market and each year there the show continues to grow. Now the Christmas Show gives local buyers as much choice as many major US and European cities. This year will feature a significant number of new exhibitors, not to mention an even greater range of products and services for our buyers. The 2018 event will be the most colourful to date, bringing to life all of the glitz and celebration needed to entice your customers to start their Christmas shopping. This year guests have been asked to enter the RDS through the main gates on Merrion Road. For added convenience there is free parking in the RDS grounds and visitors will receive a full brochure, floor plan and a voucher for coffee and a pastry upon registration. The Cosmetics Association is confident that this will be the most successful Christmas show yet and will be delighted to welcome both buyers and exhibitors over the three-day event. For more information visit www.cosmeticassociation.ie


Help sufferers escape the misery of hayfever Nasacort’s unique formula provides 24 hour relief 1* of

Nasal congestion Sneezing Runny Nose

Itchy Nose Even works on eye symptoms

Key advantages: Once-a-day 2 Starts working from day one3,4 Stays where it’s sprayed3,5 The treatment of choice in patients with moderate to severe hayfever 2.


YOUR SANOFI PHARMACY REPRESENTATIVE NASACORT ALLERGY 55 MICROGRAMS/DOSE NASAL SPRAY SUSPENSION (TRIAMCINOLONE ACETONIDE) PRODUCT INFORMATION Presentation: 20 ml bottle, providing 30 actuations containing 55mcg triamcinolone acetonide per metered dose. Indications: Treatment of the symptoms of seasonal allergic rhinitis. Dosage and Administration: Patients aged 18 years and over: The recommended dose is 220 micrograms as 2 sprays in each nostril once daily. Once symptoms are controlled patients can be maintained on 110 micrograms (1 spray in each nostril once daily). If symptoms are not relieved within 14 days, a physician must be consulted. Not recommended in children and adolescents under 18 years of age. Contraindications: Hypersensitivity to the active substance or excipients. Precautions and Warnings: If adrenal function may be impaired, take care when transferring patients from systemic steroids. Localised infections of the nose and pharynx with Candida albicans has rarely occurred which may require local treatment and temporary discontinuation of Nasacort Allergy. Should be used with caution in recent nasal septal ulcers, nasal surgery or trauma, until healing has occurred. Systemic effects may occur, particularly at high doses prescribed for prolonged periods. Potential systemic effects may include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression. Treatment with higher than recommended doses may result in clinically significant adrenal suppression which may require additional systemic corticosteroid cover during periods of stress or elective surgery. Close monitoring in patients with a change in vision or with a history of increased intraocular pressure, glaucoma and/or cataracts. Contains benzalkonium chloride, an irritant, which may cause skin reactions. Interactions: No interaction studies have Date of preparation: March 2018 SAIE.SA.18.03.0073

*Once established on the product References: 1. Nasacort 24 hours data on file, 16th March 2016 2. Treatment of seasonal allergic rhinitis: 1998, MeReC Bulletin, 9(3), 9-12 3. Nasacort SPC 4. Gross G. et al. Annual of Allergy Asthma & Immunology 1996 5. Berridge MS. et al. The Journal of Nuclear Medicine 1998 been performed. Pregnancy and Lactation: should not be administered during pregnancy or lactation unless therapeutic benefits outweigh the potential risk to the foetus/baby. Adverse Reactions: commonly reported adverse reactions: flu syndrome, pharyngitis, rhinitis, headache, bronchitis, epistaxis, cough, dyspepsia & tooth disorder. Rare reactions: nasal septum perforations. Frequency not known: hypersensitivity (including rash, urticaria, pruritus and facial oedema), insomnia, dizziness, alterations of taste and smell, cataract, glaucoma, increased ocular pressure, nasal irritation, dry mucous membrane, nasal congestion, sneezing, dyspnoea, nausea, fatigue, decreased blood cortisol. Legal Category: P. Marketing Authorisation Number: PA 540/11/2. Further information is available from the Marketing Authorisation Holder: Medical Information Department, Sanofi-aventis Ireland Limited T/A SANOFI, 18 Riverwalk, Dublin 24, IE-medinfo@sanofi.com. Tel. 0845 372 7101. Please refer to Summary of Product Characteristics which can be found on IPHA at http://www.medicines.ie/ before prescribing. Date of preparation of PI: December 2016 Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Suspected adverse events can also be reported to Sanofi Ireland Ltd. directly by emailing IEPharmacovigilance@Sanofi.com or calling 01 403 5600.


Headaches and Migraines

By Andrew Jennings

Those who suffer from headaches or migraines will know they often have devastating and debilitating effects. Migraines in particular can be so painful and disorientating that people affected by them will try anything to get rid of them. This usually includes a trip to their local pharmacy or GP in an attempt to find treatment for the pain. of 12-15% of people. WHO data shows that migraines are three times more common in women then in men, while it is believed that about 60% of people inherit the condition. A migraine can last from four to 72 hours and is a very individual condition, with some people experiencing only one or two attacks per year while others suffer them on a weekly basis. The Migraine Association of Ireland has pointed to data showing that migraines affect almost half a million people in this country, or about 15% of the population. It is estimated migraines cost Irish businesses ¤252 million every year as a result of lost activity, with the average migraineur missing between one and a half and five days from work each year. Despite these figures, the association claims migraine remains a misunderstood and undermanaged condition which affects all age groups, citing that children as young as 12 months old have been diagnosed with the condition. Medical experts still do not completely understand what is happening inside a sufferer's head when a headache or migraine strikes. Although the causes of both can often be simple, they continue to be a serious issue for a large swathe of the population in Ireland. A public poll conducted last year highlighted that of the 1,001 Irish adults surveyed, almost one-fifth (19%) suffered from headaches on a weekly basis, while 37% suffered them once a month. In addition to this, of those suffering from headaches on a regular basis, 20% identified their headaches as being severe in terms of pain level. HEADACHE OR MIGRAINE? A headache is defined as pain located in any area of the head and occurs when pain-sensitive nerves in the scalp, blood vessels and other brain tissues send signals that register as pain in the brain cells. Headaches will typically last no more than a day. It is estimated that seven in 10 people have at least one headache each year,


which can often be mild, but in many cases can cause such severe pain that makes it difficult to concentrate at work and to perform other daily activities. The most common types of headaches are; sinus, tension, cluster, and migraine. The latter is the most severe and complex type of headache. A migraine is defined as a severe throbbing pain or pulsing sensation, most often on one side of the head. They are usually accompanied by nausea, vomiting and extreme sensitivity to light and sound. Experts believe migraines may be caused by changes in the activity of nerve pathways and brain chemicals, while genetic and environmental factors are also thought to affect a person’s susceptibility to them. The World Health Organisation (WHO) has classified migraine as the seventh most disabling disease worldwide - the fourth for women - and it is the most common neurological condition in the world, affecting in the region


migraine, the most common types of headaches are; sinus, tension, and cluster. Sinus headaches usually occur when there is infection or pressure in the sinuses. Tension headaches, which are the most common type, occur when the muscles in the head and neck tighten, and strike most frequently in women over the age of 20. Tension headaches are often described as feeling like a tight band around the head, while poor posture and stress are also contributing factors. Tension headaches usually last for only several minutes, but in some cases, they can last for several days. They also tend to be recurrent. But what makes the muscles tense, or causes some nerve endings in the brain to become so sensitive? According to the Harvard Medical School, the causes of tension headaches can vary from person to person, but some triggers include: • stress • lack of sleep

It is important that sufferers get a proper headache or migraine diagnosis to ensure the correct treatment for their condition. Both can be problems on their own, however they may also be a symptom of a more serious medical condition. The first thing a pharmacist or GP should do to diagnose a headache or migraine is to take a patient history to gain an insight into when and how headaches present themselves. Some questions they may ask include:

• fatigue

• How long does the pain last?

Many of the triggers for tension headaches can also lead to a migraine. Cluster headaches are non-throbbing headaches that can cause severe, burning pain on one side of the head or behind the eyes, and usually cause eyes to tear up and nasal congestion. These headaches can last for extended periods of time, some for as long as six weeks. Cluster headaches may occur every day and more than once a day. The cause is unknown; however, this

• Is the pain mild, moderate, or severe? • When does the pain occur? • What is the symptom of pain? • Where is the pain located? • Is there any nausea or vomiting? • What medications have been taken previously? As mentioned, other than

• hunger • caffeine withdrawal • abrupt cessation of medications that contain caffeine, such as some pain-relieving medications • weather changes • alcohol • certain foods and drinks, such as chocolate; processed foods that contain MSG

SOLUBLE TABLETS Paracetamol, Caffeine


Solpa-Extra 500mg/65mg Soluble Tablets (P) 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 dissolved in water every 4-6 hours. Max 4 tablets a day. Not suitable for children under 12 years. Contraindications: Hypersensitivity to the ingredients. Caution: 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. Interactions: Warfarin and other coumarins, cholestyramine, probenecid, chloramphenicol, metoclopramide, domperidone, sedatives, tranquilizers and decongestants. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions, TEN, SJS, drug-induced dermatitis, sterile pyuria. Unknown: neutropenia, leucopenia, nervousness, dizziness. PA 1186/017/001. MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. Date of preparation: 05/02/2018.

Feature • is accompanied by persistent nausea and vomiting or changes in vision

Frovatriptan; Sumatriptan; Eletriptan; Zolmitriptan; Naratriptan; Rizatriptan.

• is accompanied by seizures, mental disturbances, and loss of consciousness

In relation to preventative measures, the answer is generally for sufferers to try to avoid the causes of headaches in the first place. People should note their triggers first and write down the characteristics of your headaches, including their frequency, duration, intensity, as well the circumstances surrounding the headache or migraine, including:

• is associated with a fever or stiff neck • strikes suddenly with considerably more intensity than normal • wakes you from sleep or is worse when you lie down PREVENTION AND TREATMENT There is currently no cure for headaches or migraines, although a number of treatments are available to help ease the symptoms. Sufferers may need to take time to work out the best treatment for themselves and may need to try different types or combinations of medicines before they find the most effective ones. type of headache is rare and generally affects men age 20-40. Alcohol intake is a known trigger of cluster headaches. Nailing down causes of migraine is more arduous then any of the other categories of headache. The particular combinations of migraine are specific to each individual and the triggers may include: • stress or anxiety • certain smells • bright light, such as sunlight or flashing lights • certain foods, such as aged cheeses, avocados, bananas, chocolate, peas, pork, sour cream, nuts, peanut butter, yogurt, fermented and pickled foods • alcohol • fluctuations in atmospheric pressure due to changing weather • caffeine withdrawal • changes in oestrogen levels for women • taking certain prescription medications, or the abrupt cessation of medications that contain caffeine, • food additives, such as MSG and nitrates. • too little or too much sleep There are two basic types of migraines: migraine with aura and migraine without aura. Auras are visual disturbances that consist


of bright spots, flashing lights, or moving lines. In some cases, auras can cause a temporary loss of vision. Aura usually occurs about 30 minutes before the migraine begins and can last for 15 minutes. Migraines with aura tends to be less severe and disabling than migraines without aura. UNDERLYING CONDITIONS Although headaches and migraines can be painful and debilitating, they are usually not dangerous conditions. Sometimes, however, they can be a symptom of another more serious underlying physical condition. For example, sometimes a headache or migraine can signal that blood pressure is above what is considered a normal reading. High blood pressure is a risk factor for developing heart disease or stroke. Other more serious underlying conditions to watch out for with headaches and migraines include brain tumours and aneurysms, while meningitis may also cause a headache or migraine. Warning signs for this are a sudden onset of headache accompanied by fever, stiff neck, and visual problems. It is critical a patient seek emergency medical care if they experience a headache or migraine that: • gets worse over days and weeks • Is accompanied by impaired neurological function (e.g., loss of balance, weakness, numbness, or speech disturbance and double vision)

Many people who have headaches or migraines find that overthe-counter painkillers, such as paracetamol, aspirin, or ibuprofen, can help to reduce their symptoms. They tend to be most effective if taken at the first signs of a migraine attack and experts state that it is not advisable to wait until the headache worsens before taking painkillers as it is often too late for the medication to work. Sufferers may find they can't manage their migraines using over-the-counter medicines, so a GP may be required to prescribe something stronger. The Migraine Association of Ireland also believes treatment should be taken as early as possible in the headache phase of a migraine attack to prevent its escalation and to increase the drug’s effectiveness. adding that the two main types of acute migraine treatments used are analgesics and triptans. Analgesics, such as aspirin and paracetamol, work by reducing the person's perception of the attack, effectively numbing the painaffected area. Many of these are available over-the-counter. Nonsteroidal anti-Inflammatory drugs are often used for more severe attacks, these include ibuprofen, difene and naprosyn. Triptans are migraine-specific, prescription-only drugs which target specific groups of serotonin receptors in the brain that are known to be closely involved in migraine attacks. The seven triptan drugs available in Ireland are: Almotriptan;

• medications • diet • sleep patterns • activities • alcohol intake • menstrual cycle • environment • stress levels • physical problems Last year's poll offered the following tips for preventing headaches and migraines from occurring in the future: Hydration: Being dehydrated is one of the most common causes of headache and migraine. By drinking water throughout the day, people can avoid the risk of becoming dehydrated. Consuming alcohol can also cause people to become dehydrated. Sleep: Headaches are often an indicator that the body is weak due to a lack of sleep. Ensuring getting the recommended daily amount of sleep is a good way to prevent headaches and migraines. Nutrition: Headaches are often caused by low blood sugar levels experienced after not eating for a long period. By eating small but frequent meals, people can maintain a healthy blood sugar level and therefore prevent a headache or migraine. Weight: It has been proven that carrying extra weight can make people more likely to suffer from headaches and migraines. Caffeine: While a little hit of caffeine is known to have pain killing properties, over consumption of caffeine can be a major trigger of headaches and migraines for some people. By reducing caffeine intake it’s important to do so gradually as total withdrawal from caffeine can also cause headaches for long time coffee drinkers.

CPD 90: CHRONIC OBSTRUCTIVE PULMONARY DISEASE Biography - Deborah Lynch graduated from Queens University Belfast with a First-Class Honours degree in Pharmacy in 2008. She continued her training with Medicare Pharmacy Group in Derry for pre-registration. From there she qualified in 2009 and practised in Derry City for over 10 years in community pharmacy. Deborah has been working since March 2017 with the rapidly growing Chemist Connect in Bridgend, Co. Donegal.

Welcome to the Continuing Professional Development Module. CPD is mandatory professional requirements for pharmacists. Journal based education programmes are an important way of keeping up to date with personal clinical and professional development. This module can be used in your personal learning log and can be completed in the magazine or online by completing the reflection questions at the end of the module. You can also track your progress of you development by going to www.pharmacynewsireland.com/cpdtraining where you can register to record your learning.

Chronic Obstructive Pulmonary Disease What Is COPD? The World Health Organisation (WHO) defines Chronic Obstructive Pulmonary Disease (COPD) as not one single disease but an umbrella term used to describe chronic lung diseases that cause limitations in lung airflow. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used but are now included within the COPD diagnosis.1 There are four common symptoms of COPD resulting from mucus hypersecretion (chronic bronchitis) and tissue destruction (emphysema) which cause airway inflammation and fibrosis. 8 The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, a chronic cough1 and acute worsening of symptoms in relation to an infective exacerbation.8 However, COPD is not just simply a "smoker's cough" but an underdiagnosed, life threatening lung disease that may progressively lead to death.1 Epidemiology COPD is currently the 4th leading cause of death in the world and is expected to be the 3rd leading cause of death worldwide by 2020.2,3 More than 3 million people died from COPD in 2012, accounting for 6% of world deaths. COPD is a major cause of chronic morbidity and mortality, with people dying prematurely due to it and its complications. Globally the COPD burden is expected to increase in the coming decades due to increased exposure to risk factors and our ageing population.2,4 COPD is more common in older people; European studies in people aged >70 years showed a prevalence of COPD of 20% in men and 15% in women.5 More recent studies show that the prevalence

between men and women is now almost equal, possibly reflecting change in smoking patterns.2,10 According to the GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD, COPD is associated with a huge economic burden. 6% of the total healthcare budget within the European Union is spent on respiratory disease. COPD accounts for 56% within this category. Exacerbations of COPD accounts for the highest cost on the total COPD spend. Pathophysiology and Risk Factors It is a preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is caused by airway and/or alveolar abnormalities usually caused by exposure to noxious gases and particles.2 The most likely source of noxious gases and particles is tobacco smoke.1 Tobacco smoke is said to be responsible for 80% of COPD cases. 8 Others include indoor air pollution (such as biomass fuel used for cooking and heating), outdoor air pollution, occupational dusts and chemicals (vapours, irritants, and fumes).1 Inhaled cigarette smoke and other noxious particles cause an inflammatory response which induces parenchymal tissue destruction, (which causes loss of alveolar attachments to the small airways, decreasing lung elastic recoil)2 and narrowing of the peripheral airways leading to progressive airflow obstruction.5 This inflammatory response may result in mucus hypersecretion (chronic bronchitis), tissue destruction (emphysema) and

Reflection - Is this area relevant to my practice? What is your existing knowledge of the subject area? Can you identify any knowledge gaps in the topic area? Planning - Will this article satisfy those knowledge gaps or will more reading be required? What resources are available? Action - After reading the article complete the summary questions at www.pharmacynewsireland. com/cpdtraining and record your learning for future use and assessment in your personal log. Evaluation - How will you put your learning into practice? Have I identified further learning needs?

disruption of normal repair and defence mechanisms causing small airway inflammation and fibrosis (bronchitis). These pathological changes result in increased resistance to airflow in the small airways, air trapping and progressive airflow obstruction, all characteristic features of COPD. The structural and inflammatory changes in the airways of people with COPD increase with disease severity and persist even after smoking cessation.8 Lung function deteriorates progressively over several years, with increasing symptoms such as cough, sputum production and dyspnoea. Exacerbations of COPD, defined as increased cough, dyspnoea or sputum production, are triggered by factors including infection (bacterial and/or viral) and environmental pollutants. Frequent exacerbations are associated with a more rapid decline in lung function.5 Genetic risk factors involve a severe hereditary deficiency of alpha-1 antitrypsin protein.2 It protects the lungs from the destructive actions of common illnesses and exposures, particularly tobacco smoke. Alpha-1 antitrypsin deficiency (Alpha-1) results in an absence or low levels of AAT protein in the blood. These low levels prevent AAT protecting the lungs from the destructive damage of

positive family history). 5 Assessment of COPD severity is based on the severity of the spirometric abnormality (Table 1), the CPDand 90: the CHRONIC OBSTRUCTIVE PULMONARY DISEASE patient’s level of dyspnoea presence of complications. 16 Table StagesOF ofCOPD COPDBASED Based Severity TABLE 11STAGES ONon SEVERITY 16

Stage I: Mild COPD

Individual may not be aware that his/her lung function is abnormal. Mild airflow limitation (FEV1/FVC < 70%; FEV1 ≥ 80% predicted) and sometimes, but not always chronic cough and sputum production.

Stage II: Moderate COPD

Patients typically seek medical attention at this stage because of chronic respiratory symptoms or an exacerbation of their disease. Worsening airflow limitation (FEV1/FVC < 70%; FEV1 50% to 80% predicted), with shortness of breath typically developing on exertion.

Stage III: Severe COPD

Greater shortness of breath, reduced exercise capacity and repeated exacerbations which impact on a patient’s quality of life. Further worsening of airflow limitation (FEV1/FVC < 70%; FEV1 30% to 50% predicted). Quality of life is very appreciably impaired and exacerbations may be lifethreatening Severe airflow limitation (FEV1/FVC < 70%; FEV1< 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure).

Stage IV: Very severe COPD

An individual’s experience of functional impairment due to shortness of breath (dyspnoea) can be monitored using the scale Tabledefinition 2. A composite ofbyBody masssputum indexproduction, (BMI), airway neutrophil elastase resulting in lungin tissue of COPD asscore detailed frequent winter damage. Ireland has one of the highest NICE 2010; 'bronchitis’ or wheeze. obstruction (FEV1), dyspnoea and exercise capacity (distance walked in six minutes) is a better incidences in the world of people with this predictor of prognosis than any of Airflow the variables deficiency. Over 2,000 Irish individuals obstructionindividually. is defined as a reduced In addition to spirometry, patients require 7

have severe deficiency and over 200,000 a chest x-ray to exclude other conditions FEV1/FVC ratio (where FEV1 is forced are carriers. A further 10,000 Irish 16 expired volume in 1 second and FVC is such as lung cancer and tuberculosis. Table 2: MRC Dyspnoea Scale individuals are at risk of developing Additional investigations may include forced vital capacity), such that FEV1/FVC lung and liver disease from having the serial peak flow measurements (to is less than 0.7. 9 affected excludeexercise asthma, which is frequently Gradegenotype. 1 Not troubled by breathlessness except on strenuous indistinguishable from COPD), ECG and If FEV1 is ≥ 80% predicted normal a Gradelung 2 growth and development Short of breath whenof hurrying oronly walking up a slight hill echocardiography (to assess cardiac Reduced diagnosis COPD should be made statusbecause and alpha-1ofantitrypsin deficiency during gestation the presence of respiratory symptoms, Grade 3 and factors during Walks slowerinthan contemporaries on level ground (if early onset, minimal smoking history or childhood or adolescence that may affect for example breathlessness or cough. 5 breathlessness, or has to stop for breath when positive walking at own pace family history). lung development has the potential to increase of for breath Thereafter is no single diagnostic test100m for Gradean4individual’s likelihood Stops walking about or after a few minutes on level developing COPD.2,11 Smoking during Assessment of COPD severity is based on COPD. Making a diagnosis relies on ground pregnancy may also contribute to foetal clinical judgement based on a combination the severity of the spirometric abnormality growth therefore posing a risk to the baby (Table 1), the patient’s level of dyspnoea of history, physical examination and of development of respiratory disease and the presence of complications. confirmation of the presence of airflow and COPD. 2 obstruction using spirometry. The An individual’s experience of functional presence of airflow obstruction should Diagnosis of Chronic Obstructive impairment due to shortness of breath be confirmed by performing postPulmonary Disease (dyspnoea) can be monitored using the bronchodilator spirometry. All health scale in Table 2. A composite score of professionals involved in the care of Body mass index (BMI), airway obstruction Airflow obstruction is usually measured people with COPD should have access (FEV1), dyspnoea and exercise capacity using spirometry. Is a common test to spirometry and be competent in the Smoking Cessation (distance walked in six minutes) is a better used to assess how well the lungs work interpretation of the results. predictor of prognosis than any of the by measuring how much air is inhaled, variables individually. how much is exhaled and how quickly A diagnosis of COPD should be exhalation occurs. Spirometry is used considered in patients over the age of 35 to diagnose asthma, COPD and other Smoking Cessation who have a risk factor (generally smoking) conditions that affect breathing. and who present with one or more of The Health Information and Quality the following symptoms: exertional Authority (HIQA) for Ireland produced The following should be used as a breathlessness, chronic cough, regular

An individual’s experience of functional impairment due to shortness of breath (dyspnoea) can be monitored using the scale in Table 2. A composite score of Body mass index (BMI), airway obstruction (FEV1), dyspnoea and exercise capacity (distance walked in six minutes) is a better CPD 90: CHRONIC OBSTRUCTIVE PULMONARY DISEASE predictor of prognosis than any of the variables individually. 16 Table 2:MRC MRC Dyspnoea Scale TABLE 2: DYSPNOEA SCALE 16

Grade 1 Grade 2 Grade 3 Grade 4

Not troubled by breathlessness except on strenuous exercise Short of breath when hurrying or walking up a slight hill Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace Stops for breath after walking about 100m or after a few minutes on level ground

the HTA Report on Smoking Cessation Interventions in March 2017. This report states that approximately half of smokers in Ireland report making at least Smoking Cessation one quit attempt every year. The most popular cessation method is unassisted quitting (50%), followed by quit attempts involving e-cigarettes (29%) and nicotine replacement therapy (NRT, 12%). Less than 4% report using prescription only interventions such as varenicline or bupropion. The average quit rate for an unassisted quit attempt after 12 months from the attempt is 7.8%.15 There is huge potential for community pharmacists in Ireland to improve the quit rate. We have a responsibility to encourage our customers to want to quit. Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival. Therefore, smoking cessation should be the top priority in the treatment of COPD, as it is very cost effective and reduces the decline in lung function, reducing morbidity and mortality.12 An optimal approach to stopping smoking today should involve an adequate programme of support and counselling, either on a one to one basis or within groups. Typically, counselling should involve weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.13 Weekly interaction with our customer is key. This should be carried out in the pharmacy in a private consultation room, giving the customer time to listen to concise information about the benefits of quitting but more importantly, giving the customer time to voice their own worries and concerns about their health. Visiting the pharmacy should be seen to the customer as a positive experience each week. This programme should ideally continue for twelve weeks, with high doses of nicotine especially in week one, gradually reducing the dose of nicotine as the individual quitter sees fit.

Two nicotine replacement therapy products should be used concomitantly to achieve desired outcome. In the case of relapse, re-treatment should be offered. COPD patients need more support and encouragement than smokers without comorbidities. A multi-disciplinary approach should be adopted to ensure individuals receive maximum support.12 Management of COPD The World Health Organisation states that the goals of effective COPD management are to:

should know what triggers exacerbations and should know how to recognise an exacerbation. Common triggers include scented cleaning products, perfumes and aerosol sprays, smoke from surrounding smokers or fireplaces, pollen and cold winds.18 NICE recommends the following treatment in COPD; In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:

1. Prevent disease progression 2. Relieve symptoms 3. Improve exercise tolerance 4. Improve health status 5. Prevent and treat complications 6. Prevent and treat exacerbations 7. Reduce mortality17 Although COPD cannot be cured, its symptoms can be treated and managed resulting in improvement in quality of life. Management of COPD involves both a pharmacological and nonpharmacological approach. Smoking cessation should be offered to all patients with COPD. Pulmonary rehabilitation programmes are offered to patients with COPD and should include multidisciplinary interventions, which are tailored to the individual patient's needs. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention. Pneumococcal vaccination and annual influenza vacation is recommended for all COPD patients.7 Patient knowledge of their condition is a powerful tool in helping to control and manage symptoms. COPD patients

If FEV1 ≥ 50% predicted: either longacting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) If FEV1 < 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA. Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV1.7 Short acting β2 Agonist (e.g. salbutamol) Acts by being selective agonists at β2 adrenergic receptors on the airways smooth muscle, reducing smooth muscle tone and causing bronchodilation. Reduces breathlessness, improves lung function, enhances mucociliary clearance and reduces hyperinflation. Furthermore, decreases the release of inflammatory mediators into the airway lumen.19 Short acting inhaled anti-muscarinic, e.g. ipratropium Blocks airways muscarinic M3 receptors, inhibiting the main neural bronchoconstrictor pathway and allowing relaxation of the resting airway motor tone. Improves breathlessness and


health-related quality of life. Reducing the need for rescue medication and reduces airway mucus secretion and hyperinflation. Short-acting inhaled β2 agonists have an onset of action of 5 to 10 minutes and a duration of action of up to 6 hours. Short-acting inhaled antimuscarinics have an onset of action of between 30 and 60 minutes and a duration of action of between 3 and 6 hours.19 In some older people treated with beta 2 agonists, the stimulation of the beta2-adrenergic receptors can cause sinus tachycardia and can potentially cause cardiac rhythm disturbances.2 Long-acting β2 agonists (LABA), e.g. salmeterol, formoterol, indacaterol and vilanterol: Have a similar mode of action to short-acting β2 agonist are relatively lipophilic and therefore have a prolonged receptor occupancy. Have a duration of action of greater than 12 hours (salmeterol and formoterol) Long-acting muscarinic antagonists (LAMA) LAMAs, e.g. aclidinium bromide (Eklira Genuai®), glycopyrronium bromide (Seebri Breezhaler®), tiotropium (Spiriva®) and umeclidinium bromide (Incruse Ellipta®) are licensed for the maintenance treatment of patients with COPD.20 LAMAs have a similar mode of action to short-acting antimuscarinics but dissociate slowly from M3 receptors providing a longer duration of action. Any short-acting antimuscarinic must be stopped before starting a LAMA. Cardiovascular caution is required with all and there is a need to consider renal function with tiotropium and glycopyrronium. Offer once-daily longacting muscarinic antagonist (LAMA) in preference to four-times-daily short-acting muscarinic antagonist (SAMA) to people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, and in whom a decision has been made to commence regular maintenance bronchodilator therapy with a muscarinic antagonist.7 Inhaled Corticosteriods (ICS) NICE recommends that ICS should be prescribed for patients who have FEV1 <50% predicted and have had more than two exacerbations requiring antibiotics or oral corticosteroids in 12 months.7

Patients should be made aware of the risk of developing osteoporosis and other side-effects if prescribed high doses of inhaled or oral corticosteroids over a long period of time. General measures to counteract osteoporosis, such as regular exercise, smoking cessation and adequate dietary calcium are prudent.7 Oral Mucolytic Therapy

which interferes with daily activities. Patients requiring corticosteroid therapy should be encouraged to present early to get maximum benefits. Prednisolone 30 mg orally should be prescribed for 7 to 14 days. Antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum. Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline.7

This therapy should be considered for patients with chronic productive cough. Should be continued if improvement in cough or reduction in sputum. Not to be routinely used to prevent exacerbations.7

If clinical failure to first line antibiotics, previous amoxicillin exposure less than three months or severe symptoms consider hospital referral.21


Role of the Community Pharmacist

Theophylline is a non-selective phosphodiesterase inhibitor that causes an increase in cellular cyclic AMP in various cell types and organs. An increase in cyclic AMP in the lungs is implicated in the inhibition of inflammatory cells and immunomodulatory cells. Inhibition of phosphodiesterase also causes smooth muscle relaxation and airway dilation. The slow onset of action of theophylline and the need to titrate the dose to achieve suitable plasma levels can mean that the optimum benefit is not seen until several weeks after commencing therapy. The common adverse effects associated with theophylline therapy are tachycardia, palpitation, nausea and gastro-intestinal disturbances. Caution needs to be taken with the use of theophylline in older patients because of differences in pharmacokinetics, the increased likelihood of co-morbidities and the use of other medications. Lower doses may be appropriate.8 The dose of theophylline prescribed should be reduced at the time of an exacerbation if macrolide or fluroquinolone antibiotics (or other drugs known to interact) are prescribed.7

Community pharmacists are an important part of the multi-disciplinary team involved in caring for patients with COPD. Pharmacists are responsible for promoting self-care and ensuring COPD patients understand how to manage their condition. It is essential pharmacists are checking compliance and inhaler technique to ensure patients are getting maximum benefit from their treatment. We must ensure the patient is using a device that is suitable for them. In the case of non-compliance pharmacists can recommend other devices and refer the patient to the GP. Pharmacists can monitor prescription requests for rescue bronchodilators and determine if a patient is not managing their medicines properly. Also requests for OTC mucolytics and cough bottles may prompt the pharmacist to investigate further and thus recommend appropriate treatment and referral in the case of exacerbation. Pharmacists are responsible for encouraging the patient to get their annual influenza vaccine and administering the vaccine. Giving advice and providing support to the patient to help them to quit smoking is an extremely important part of the role of the pharmacist. Pharmacists are an integral part of the healthcare team and are expertly placed to identify symptoms of COPD to allow early diagnosis and make interventions where they have identified potential symptoms of exacerbation, possibly reducing hospital admission if treated promptly. Therefore, the role of the pharmacist in managing patients with COPD is hugely diverse and ongoing as the prevalence of COPD is ever increasing.

Management of Acute Exacerbations Symptoms of exacerbations include increased shortness of breath and /or wheezing, chest tightness or lung pain, increased cough either with or without mucus, a change in the colour, amount, taste or “stickiness” of the mucus, loss of appetite, fatigue or lack of energy.18 Increased breathlessness is a common feature of an exacerbation of COPD. This is usually managed by taking increased doses of short-acting bronchodilators. In the absence of significant contraindications, oral corticosteroids should be considered in patients in the community who have an exacerbation with a significant increase in breathlessness

References on request




Patch for 24 hour craving control

Hit cravings with great flavour†

from *Provides significant improvement in quit rates vs. patch alone. †216 person sensory study. NiQuitin Fresh Mint 2/4 mg Medicated Chewing Gum is to be used for the treatment of tobacco dependence by relief of nicotine withdrawal symptoms and cravings. Indicated in adults (18 years and over). NiQuitin Fresh Mint Medicated Chewing Gum 2 mg is suitable for who smoke who smoke 20 cigarettes or less. NiQuitin Fresh Mint Medicated Chewing Gum 4 mg is suitable for smokers who smoke 20 cigarettes or more. Gums should be chewed as directed whenever there is an urge to smoke, to maintain complete abstinence from smoking. Maximum 15 per day. In general, the use of the medicated chewing gum is 2-3 months then the use of gums may be reduced gradually. When daily use is 1-2 gums, use should be stopped. Abrupt cessation: Use a lozenges whenever there is an urge to smoke, maximum of 15 lozenges a day. Continue for up to 6 weeks, then gradually reduce lozenge use. Adolescents (12-17 years): only with advice from a healthcare professional. Contraindications: hypersensitivity to nicotine or any of the excipients and children under the age of 12 years. Precaution: Supervise use if recent MI, unstable or worsening angina, severe CA, uncontrolled hypertension or recent cerebrovascular accident, diabetes, renal/hepatic imapairment, phaeochromocytoma, uncontrolled hyperthyroidism, GI disease. Side effects: Allergic reactions, anaphylactic reactions, insomnia, irritability, dizziness, headache, lightheadedness, tremor, palpitation, tachycardia, atrial fibrillation, hiccups, sore throat, pharyngitis, cough, pharyngolaryngeal pain, dyspnoea, nausea, GI discomfort, sore mouth, vomiting, indigestion, mouth irritation, mouth ulceration, dyspepsia, abdominal upper pain, diarrhoea, dry mouth, constipation, flatulence, oral discomfort, stomatitis, erythema, urticaria, increased sweating, jaw pain, chest pain, arthralgia, myalgia, malaise, parageusia, metallic taste, taste perversion. Legal classification: GSL: PA 1186/19/1 & PA 1186/19/2 MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. RRP (ex. VAT): 30’s €9.99 100’s €24.99. SPCs: http://www.medicines.ie/medicine/17205/SPC/NiQuitin+Fresh+Mint+2mg+Medicated+Chewing+Gum/ NiQuitin 21 mg/24 hrs transdermal patches is indicated for the relief of nicotine withdrawal symptoms including cravings as an aid to smoking cessation. Indicated in adults and adolescents aged 12 years and over. NiQuitin patches should be applied once a day, at the same time each day and preferably soon after waking and worn continuously for 24 hours. Therapy should usually begin with NiQuitin 21 mg/24 hrs. Therapy schedule: Step1 NiQuitin 21 mg/24 hrs transdermal patches for 6 weeks, Step 2 NiQuitin 14 mg/24 hrs transdermal patches for 2 weeks, Step 3 NiQuitin 7 mg/24 hrs transdermal patches for final 2 weeks. Light smokers (e.g. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (14 mg) for 6 weeks and decrease the dose to NiQuitin 7 mg/24 hrs for the final 2 weeks. Apply a patch to non-hairy clean dry skin surface, a new skin site should be used every day. Contraindications: non-smokers, children under 12 years and occasional smokers. Precaution: Supervise use if hospitalised for MI, severe dysrhythmia or CVA, If haemodynamically unstable, susceptible to angioedema, urticara, discontinue if severe persistent skin rash. Renal/hepatic impairment, hyperthyroidism, diabetic, phaeochromocytoma, current/previous epilepsy. Pregnancy and lactation: oral formats preferable to patches unless nauseous. Remove patches at bedtime. Side effects: Transient rash, itching, burning, tingling, numbness, swelling, pain urticaria, heaviness, hypersensitivity reactions. Headache, dizziness, tremor, seizures, sleep disorders, nervousness, palpitations, tachycardia, dyspnoea, pharyngitis, cough, GI disturbance, dry mouth, sweating, arthralgia, myalgia, asthenia, malaise, influenza-type illness, fatigue and anaphylaxis. Legal classification: GSL: PA 1186/18/1, PA 1186/18/2 and PA 1186/18/3. MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. RRP (ex. VAT): 14 Day €37.73, 7 Day €20.94. SPCs: http://www.medicines.ie/medicine/6829/SPC/NiQuitin+7mg+24hrs+transdermal+patch es/, http://www.medicines.ie/medicine/4308/SPC/NiQuitin+14+mg+24hrs+transdermal+patches/, http://www.medicines.ie/medicine/4311/SPC/NiQuitin++21mg+24hrs+transdermal+patches/

Flexible dosing to suit a wide range of patients.1–3

Constipation relief for everyday people. MOVICOL®, MOVICOL® Liquid Orange Flavour and MOVICOL® Paediatric Plain. Prescribing Information REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC) BEFORE PRESCRIBING Presentation: Movicol Sachet of white powder which dissolves in about 125ml of water to make a lemon/lime flavoured drink. Each sachet contains: 13.1250g macrogol 3350, 0.1785g sodium hydrogen carbonate, 0.3507g sodium chloride and 0.0466g potassium chloride. Movicol Liquid A clear concentrated liquid, which is diluted in water to make an orange flavoured drink. Each 25ml of Movicol Liquid is diluted in 100ml of water before use and contains the following active ingredients: 13.1250g macrogol 3350, 0.1785g sodium hydrogen carbonate, 0.3507g sodium chloride and 0.0466g potassium chloride. Movicol Paediatric Plain Sachet of white powder, which dissolves in about 62.5ml of water. Each sachet contains: 6.5630g macrogol 3350, 0.0893g sodium hydrogen carbonate, 0.1754g sodium chloride and 0.0251g potassium chloride. Does not contain flavourings or sweeteners. Uses: Movicol: Treatment of chronic constipation and faecal impaction in adults, adolescents (aged 12 years or older) and older people. Movicol Liquid: Treatment of chronic constipation in adults, adolescents (aged 12 years or older) and older people. Movicol Paediatric Plain: Treatment of chronic constipation in children aged 2-11 years. For the treatment of faecal impaction in children from the age of 5 years. Dosage and administration: Movicol Chronic Constipation: Adults, adolescents (aged 12 years or older) and older people: 1-3 sachets daily in divided doses, according to individual response. For extended use: adjust dose down to 1 or 2 sachets. Children (below 12 years): not recommended. Alternative Movicol products are available for children. As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of Movicol treatment does not normally exceed 2 weeks, but can be repeated if required. Faecal Impaction: Adults, adolescents (aged 12 years or older) and older people: 8 sachets per day. A course of treatment for faecal impaction does not normally exceed 3 days. The 8 sachets should be taken over 6 hours (2 sachets per hour maximum in cardiovascular impairment). The 8 sachets may be dissolved in 1 litre of water. Children (below 12 years): Not recommended. Alternative Movicol products are available for children. Movicol Liquid Chronic Constipation: Adults, adolescents

(aged 12 years or older) and older people: 25ml diluted in 100ml of water 1-3 times daily in divided doses, according to individual response. For extended use, the dose can be adjusted down to 1 or 2 doses per day, each consisting of 25ml diluted in 100ml of water. As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of Movicol Liquid treatment does not normally exceed 2 weeks, but can be repeated if required. Movicol Liquid is not recommended for faecal impaction Movicol Paediatric Plain Chronic Constipation: The usual starting dose is 1 sachet daily for children aged 2-6 years, and 2 sachets daily for children aged 7-11 years. The dose should be adjusted up or down as required to produce regular soft stools. If the dose needs increasing this is best done every second day. The maximum dose needed does not normally exceed 4 sachets a day. Treatment of children with chronic constipation needs to be for a prolonged period (at least 6-12 months). Faecal Impaction: Escalating dose regimen starting with 4 sachets a day up to 12 sachets a day (at day 7) for children aged 5-11 years. Refer to Summary of Product Characteristics (SmPC) for full dosing recommendations. Not recommended in children with cardiovascular impairment or renal insufficiency. Doses for prevention of re-impaction should be as for patients with chronic constipation. For patients of 12 years and older it is recommended that Movicol is used. Contraindications: Intestinal perforation or obstruction due to structural or functional disorders of the gut wall, ileus and severe inflammatory conditions of the intestinal tract, such as Crohn’s disease, ulcerative colitis and toxic megacolon. Hypersensitivity to macrogol, or any of the excipients. Warnings and precautions for use: The fluid content of the re-constituted solution does not replace regular fluid intake and adequate fluid intake must be maintained. Diagnosis of impaction should be confirmed. If patients develop any symptoms indicating shifts of fluids/electrolytes the product should be stopped immediately. When using paediatric forms of Movicol to treat faecal impaction, use with caution in patients with impaired gag reflex, reflux oesophagitis or diminished levels of consciousness. Movicol Liquid contains benzyl alcohol. Do not exceed the maximum recommended daily dose.

macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride Interactions: There is a possibility that the absorption of concomitantly administered medication could be transiently reduced. Pregnancy and lactation: Can be used during pregnancy and lactation. Undesirable effects: Reactions related to the gastrointestinal tract are the most common and include: abdominal pain, abdominal distension, nausea, vomiting, dyspepsia, diarrhoea, flatulence, borborygmi and anal discomfort. Allergic reactions, including anaphylactic reactions, dyspnoea and skin reactions (e.g. angioedema, urticarial, pruritus, rash and erythema) can occur. Other effects can include electrolyte disturbances, headache and peripheral oedema. Licensing and legal category: Movicol Legal category: Subject to prescription; MA number: PA 0102/023/002. Movicol Liquid Legal Category: Subject to prescription; MA number: PA 1336/2/4. Movicol Paediatric Plain Legal Category: Subject to prescription; MA number: Number PA 102/23/4. For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, UK UB9 6NS +44 1895 826606 E-mail: medinfo@norgine.com Date of preparation: Jan 2018 Version number: UK/MOV/0118/0183

Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on +44 1895 826606. References 1. Attar A et al. Gut 1999;44:226–30. 2. Gruss HJ, Ulm G. Eur J Ger 2004;6(3):143–50. 3. Thomson MA et al. Arch Dis Child 2007;92:996–1000. Date of preparation: March 2018. Code: UK/MOV/0118/0186. MOVICOL, NORGINE and the sail logo are registered trademarks of the Norgine group of companies.

Pharmacy Show

McKesson and United Drug introduce the pharmacy of the future Community pharmacists were given a glimpse of the future at the United Drug Pharmacy Show which took place at the Aviva stadium last month for the 12th year in a row. Pharmacists and pharmacy workers were welcomed to the show by McKesson Ireland Sales and Marketing Director Pat Watt who was keen to introduce the parent company McKesson and the benefits to the new partnership would bring to the pharmacist as a customer. McKesson is a global leader with 180 years of experience, but the company are keen to emphasise how the company’s expertise benefits all of their customers in countless ways. Pat described how MRI technology in New York meant that an athlete could avoid painful

surgery; in Paris a simple skin analysis by a pharmacist allowed a patient to avoid a costly visit to the dermatologist and in Montreal a system co-developed by McKesson would trigger an adherence consultation, reminding a diabetes patient to take his medication. In the welcome video, Brian Tyler, Chairman of the management board of McKesson Europe AG describe how a fast-paced, modern marketplace compels the company to do smaller things faster, constantly making improvements along the way. McKesson has the advantage of decades of experience and expert knowledge of the supply chain.

Taking its cues from market leaders Amazon and Apple, in Ireland United Drug are not only meeting supply chain standards but surpassing them daily. The company gave special mention to its biggest asset – its workforce. Paul Reilly, Managing Director of McKesson Ireland, singled out Gareth Murphy who trudged for two hours through the recent snow to deliver vital medication to Beaumont Hospital, and Collette Meally who oversees totes that travel 15,000kms per day – that’s the same distance from Dublin to Perth, Australia. Strong emphasis was placed on the

Ann Crowley, Crowley's Pharmacy, Fergus McCauley, IQVIA

Ann Walsh and Jennifer Morrin, United Drugs

Anna Kelly, Anna Kelly Chemist, Fergal O'Shea, IQVIA

Audrey White, Corless Pharmacy, Brendan Phelan, Mylan IRE Healthcare Ltd, Mairin Holohan, Corless Pharmacy

Avril Farrell, Michelle Doyle and Conor O'Farrell, Boots Ireland

Brian Kissane, Graham Stafford and Richard Cronin, Ocean Healthcare

Brian Woods, Mylan IRE Healthcare Ltd, Nuala McCinna, Donabate Pharmacy, Martin O'Connell, Mylan IRE Healthcare Ltd

Camille Breuillac, Margaret Walshe, Ingrid Walshe, Sanofi

Catherine Gale and Patrick Whelan, Dunlavin Pharmacy


Pharmacy Show McKesson United Drug partnership as a local company with world-wide resources. United Drug customers will now reap the rewards of McKesson’s data insights, marketing initiatives, innovations and stronger purchasing support. Last year’s €40 million warehouse investment upgrade was just the beginning as the company plans to future proof the business in order to deliver world class service and services to their customers. The United Drug Pharmacy Show has always been a showcase for newest innovations not only in pharmacy and over the counter products, but also cosmetics, skincare, and pharmacy technology. Natalie Kelly of Ruth’s Pharmacy in Donegal said: “The Pharmacy Show is great for us. It’s the one chance you get to see all of the products and services in real life – not just as pictures or information online or in a catalogue.” This was also a very special year for United Drug as the company were proud to celebrate their 70th birthday in Ireland –


which happened to coincide with the 70th anniversary of the first Ireland Grand Slam. A fitting reminder of the same victory by the boys in green earlier this year. However, as celebrated as the company and country’s past may be, McKesson were firmly looking to the future with this year’s Pharmacy Show. The McKesson Experience The entrance to the exhibition itself plunged guests into darkness, but an innovative lighting concept guided visitors to a welcome video from McKesson Ireland Sales and Marketing Director Pat Watt who introduced the theme of this year’s show: Shaping the Future, Growing Together. Guests then continued to experience a glimpse of this new technology, as new services were showcased that can give a full diagnostic analysis with the click of a button in the McKesson Experience Cardiovascular Age Pharmacists were introduced to the Agedio, a machine that can, at the touch of a button, assess a patient’s cardiovascular age and

their particular cardiovascular risks. This technology can provide a full cardiovascular report for both patient and pharmacist in a matter of minutes – it can even assist pharmacists to provide a consultation on potential risk factors and how patients can improve their cardiovascular age. Skin Analysis Test This small device that almost fits in the palm of the hand can give an instant reading on the status of a customer’s skin. With just a few simple tests such as light readings and touch readings, any customer can be given an assessment of their hydration, sun damage, sebum levels and acne. The device is as small and as easy to use as a smartphone, making it a simple but effective addition to any pharmacy, significantly boosting any skincare service. United Drug also included the BetterLife Independent Living demonstration. This featured not just medical devices and mobility aids but also daily life aids to assist with housework and routines.

Christine Flynn and Nichola Carr, United Drug

Colin O'Dowling and Lorraine Prendergast, O'Sullivan's Pharmacy

Dave O''Connor and Caroline O'Connor, Brooks Pharmacy

Diane O'Reilly and Brenda Quinn, Foster's Pharmacy, Bryan Cribbin, McDevitt's Pharmacy

Eddie Campbell, United Drug, Mervyn Kneafsey, Reckitt Benckiser

Eddie Gibbons, Claudia Culliney and Martin Spillane, United Drug

Eimhin Gillman, Tiffany poludniak, Ann Marie Curran and Daragh Prendergast, Johnson & Johnson

Fergal Sheridan and Norma Doran, Doran's Pharmacy

Fergus Collis and Karen Collis, Ryder's Pharmacy, Treasa Breen, Magner's Pharmacy

Pharmacy of the Future Pharmacists were welcomed into a futuristic area for a multi-sensory experience. Thanks to the wonders of virtual reality technology, guests were given a 360-degree experience of the services and technology that pharmacies will be offering in the not-so-distant future. Modern consultation zones, touch-screen pharmacy ordering computers and customdesigned skincare were just some of the features of the pharmacy of tomorrow. Many

of the innovations and technology exhibited were then available for visitors to experience themselves throughout the show. Explaining the concept behind the Experiential Zone, Paul Reilly, Managing Director of McKesson Ireland and star of the welcoming video, said: â&#x20AC;&#x153;The modern pharmacy is changing rapidly. Today, customers expect more than just a prescription service. They want personalised guidance and expertise, so they have a deeper knowledge of their pre-

existing conditions or conditions they are at risk at developing. They also want advanced diagnosis of and treatment for common conditions in-store. The McKesson United Drug Pharmacy Show was, as usual, an unparalleled success. The themes this year of innovation and technology were certainly propelling the pharmacy industry into the path of the future

Fiona Taylor, Bayer, David Wilson, Local Pharmacy Group, Patricia Lawrence, Bayer

Gillian Skelton and Don Cronin, Reckitt Benckiser, Gayle Purcell, Kissanes Pharmacy

Jean Doyle, Pfizer, Joseph Haire, Gillian Skelton, Gayle Purcell, Kissanes Pharmacy

Jennifer Byron, Maeve Healy, Nicola Delaney, Tara Keating-Cahill, Jane Quinn, Allegro

John Cassidy, Rick O'Sullivan, Touchstore, Niall Cantwell, Dooley's Pharmacy, Simon Racklyett, Touchstone

John Feeney and Aidan Dwyer, Ultrapure Laboratories

Joseph Haire, Kissan's Pharmacy, Anne Marie O'Neill and Paul Flynn, Perrigo

Lorraine Tolan and Niamh Owens, Cottage Pharmacy, Norma Beggs and Maura Cronin, United Drug, Elaine Conlon, Bradlon Pharmacies

Louise Martin, Aoife Grimes, Claire Manning, Reckitt Benckiser

Mary Burke, Daly's Pharmacy and Brid Daly, Daly's Pharmacy

Mary Burke, Daly's Pharmacy, John Walsh, Studex, Brid Daly, Daly's Pharmacy

Mary O'Sullivan and Diarmuid O'Sullivan, Diarmuid O'Sullivan Pharmacy Ltd


Pharmacy Show


Mary Twohill and Joy Needham, Windzor Pharmaceuticals Ltd

Michaela Lynch and Jessica Melia, Sheridan's Pharmacy

Niall Tipping, Tipping's Pharmacy

Oliver Murphy Bourkes Pharmacy and Natalie Maginnis, IPN Communications

Olivia Brady, United Drug, Realtin Rollo, Swedish Nutra, Maire Bonar, United Drug

Peter Daly, Perrigo, Dympna Kennedy, Churchtown Pharmacy, Samantha Bakir, Smith's Pharmacy and Paul Flynn, Perrigo

Robert Buckley and Martin Lynch, Lynch Medical Supplies

Robert Byrne and Caroline Hogg, PharmaConsult

Serina Hickey, Sarah Whelan, Whelan's Pharmacy, Fiona Taylor, Bayer

Sinead Finucane, Avril Ryan, Colin Botha, Janes Clements, Paul Moran, Teva Pharmaceuticals

Stephen Wilson Downey and Therese Wilson Downey, Wilson's Pharmacy

The McLernons Team

Vivienne Smith, Freynes & Co, Paul Hatton, Perrigo, Sallyanne Freyne, Freynes & Co

Avril Farrell, Michelle Doyle and Conor O'Farrell, Boots Ireland

Dave Barrett GSK and John Arnold Total health

News Positive results from landmark IMPACT study on COPD GlaxoSmithKline plc and Innovia Inc have reported the results of the landmark IMPACT study – one of the largest ever conducted in patients with chronic obstructive pulmonary disease (COPD). The study revealed that Trelegy Ellipta gave significantly better results than two different classes of combined therapy, Relvar and Anoro on the primary endpoint of reduction in the annual rate of on-treatment moderate/severe exacerbations (p<0.001) and a range of other clinically important outcomes, including lung function and health-related quality of life. Results from additional secondary and other endpoints published today, include: • A statistically significant 34% reduction in COPD hospitalisations (severe exacerbations) for Trelegy compared to Anoro (0.13 vs. 0.19 per year; p<0.001) and a reduction of 13% compared to Relvar which was not statistically significant (0.13 vs. 0.15; p=0.064). • A significant reduction in the risk of on-treatment all-cause mortality was observed for both inhaled corticosteroid containing arms compared to Anoro. • A 42.1% reduction in the risk of on-treatment all-cause mortality was observed for Trelegy

compared to Anoro (1.20% vs. 1.88%; p=0.011). To fully understand the implications of the all-cause mortality observation, off-treatment data also need to be considered. Work is ongoing to investigate this further and will be presented at future scientific meetings. Dave Allen, Head, Respiratory Therapy Area R&D, GSK, said: “Reducing exacerbations to keep patients out of hospital is a key goal of COPD management alongside improving lung function and quality of life. The IMPACT study shows how Trelegy Ellipta can help patients with a history of exacerbation achieve these goals. We believe its publication in NEJM is an important addition to the evidence base that informs the management of this progressive and debilitating disease.” Dr. Ross, Consultant Respiratory Physician, Beaumont Hospital, said: “COPD is soon to be the third leading cause of death worldwide but at the same time remains hidden in plain sight in Ireland, with many people unfamiliar with the prevalence and impact

of the condition. Therapies that advance patient care and improve outcomes are dearly needed. The IMPACT study was performed in a large population of COPD patients with those in one arm on a once a day triple therapy inhaler, a therapy option which will help in the management of some COPD patients.” The safety profile of Trelegy was consistent with the safety profile of the individual components. The most common adverse events across the treatment groups were viral upper respiratory tract infection, worsening of COPD, upper respiratory tract infection, pneumonia and headache. Consistent with previous studies, the incidence of pneumonia as a serious adverse event was 4%, 4%, and 3% for Trelegy (FF/ UMEC/VI), Relvar( FF/VI) and Anoro (UMEC/VI), respectively. Results from IMPACT were submitted to the regulatory authorities in the US and EU in November 2017 and February 2018, respectively. Further regulatory submissions in other countries are expected in 2018.

Trelegy is the first COPD treatment to provide a combination of three molecules in a single inhaler that only needs to be taken in a single inhalation, once a day. It contains fluticasone furoate, an inhaled corticosteroid, umeclidinium, a long-acting muscarinic antagonist; and vilanterol, a long-acting beta2-adrenergic agonist, delivered in GSK’s Ellipta dry powder inhaler, which is used across the entire new portfolio of inhaled COPD medicines. Data from across multiple clinical programmes have demonstrated the benefit of the molecules in Trelegy both alone and in combination, for the treatment of COPD. Trelegy was approved for use in Europe in November 2017 as a maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist. The European Summary of Product Characteristics is available at: www.medicines.ie

Sam McCauley begins ¤50 million spree Irish pharmacy chain Sam McCauley has begun a €50 million pharmacy purchase project. The chain, which already has 30 retail pharmacies in Ireland, aims to double its size in the next three years according to the Independent. The company has already confirmed the purchase of two pharmacies – the Fermoy Medical Hall in Cork and Life Pharmacy in Clondalkin, Dublin – at a cost of ¤5 million. The individual price tags of the two pharmacies have not been disclosed, but it is estimated that the two together have an annual turnover of ¤5.5million. The Fermoy purchase will increase the number of Sam McCauley branches in Cork to four. It’s thought that this expansion plan is a direct challenge to the dominance of the two British pharmacy chains operating in Ireland – Boots and Lloyds. It’s thought that Sam McCauley intends to build its presence in

both cities and the countryside across Ireland. Last summer a private equity partnership of US giant Carlyle Group and Irish investment house Cardinal took over Sam McCauley’s with a reported investment of ¤40 million. The company’s annual turnover took a sharp rise to ¤78.8 million after the purchase. CEO of Sam McCauley Chemist Ltd Tony McEntee said the company was excited to be expanding its Cork operation. “The combination of our access to significant funding and our ability to promptly complete transactions puts Sam McCauley Chemists in a great position to continue to add to our portfolio over the next few years, with a number of other significant opportunities already under active consideration,” he said.

The company currently employs 600 people in Ireland, but more jobs are expected to follow as this acquisition spree continues.

Staff at Fermoy Medical Hall have already been assured that current jobs at the pharmacy will be supported.


Awards The Irish Pharmacy


The Irish Pharmacy Awards 2018 The winners’ trophy features the glittering figure of Raphael with his traditional medical staff. He is also adorned with wings, a historical symbol of healing and surrounded by two snakes, which have been considered a symbol of chemists and medical professionals for centuries.

The annual Irish Pharmacy Awards celebrate excellence in community pharmacy. The pinnacle of achievement for Irish pharmacists, the awards showcase the best of the profession from around the country.

Launched in 2008 by industry publication Irish Pharmacy News, the prestigious awards began with just a handful of categories. Now in its tenth year, we honour the industry - and the people who make it special across 16 categories.

The exclusive trophy also features the pharmacy cross as Raphael’s eye and he is surrounded by pills, representing the progressive development of medicine. The attractive trophy is sure to be a much sought-after memento of an unforgettable occasion.

Judged in a two-tier process by a selection of experts, the premier awards recognise service, innovation, business development and team work in both independent and chain stores. They celebrate the vital role of pharmacists as frontline providers of the nation’s healthcare. Competition for the Ireland Pharmacy Awards is fierce every year with an extremely high calibre of entries. What they make obvious is that the standards across the country in Irish pharmacy are high and remain so each year. This year sees the return of the Pharmaton People’s Pharmacist of the Year award. This is an extra special category which sees the general public vote for their favourite community pharmacist. The pharmacy professional who has taken their role to the next step to care for their patient. The nominees who have been shortlisted this year are testament to the professionalism


Community pharmacists and their customers are sure to appreciate the significance of the Raphael trophy.

in community pharmacy. They hail from all corners of the country, from cities, towns and villages. The one thing they share in common is their dedication to the health of their patients. You can the stories of the finalists on the following pages. The winners of the Irish Pharmacy Awards 2018 will be announced on Saturday, May 12, at a gala dinner at the Clayton Hotel, Burlington Road, Dublin. For more information or to book a table on the night, visit: irishpharmacyawards.ie or call 00353 (01) 6690562.

The winners in each category of the Irish Pharmacy Awards will receive an exclusive and specially designed gold Raphael trophy. Throughout history Raphael has been regarded as the patron saint of healing and this attractive specially commissioned figurine is a fitting reward for community pharmacy. Many people still turn to Raphael when healing their bodies from illness and injury. He is seen as the symbol of the promotion of good health in every area of the body.

For centuries Raphael has been considered a symbol of compassion for people who are struggling physically, mentally, emotionally or spiritually. These are the same qualities which are displayed every day by community pharmacists and their staff. He has also frequently been used a symbol who people turn to when trying to overcome addictions and to keep them safe when embarking on long journeys. The Raphael trophy stays true to the historical representations of the character while also modernising his depiction to represent the ever-changing and evolving world of medicine.

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Awards The Irish Pharmacy


Clinigen Group Community Pharmacist of the Year 2018

If there’s one thing that’s clear from the nominations in this category, it’s that the public is in safe hands. The calibre of entrants this year was outstanding. From Sligo to Cork, from Galway to Dublin, pharmacists are doing more and more to better serve their communities and actively look after the health and wellbeing of their patients.

Mike Walsh, Walsh's Pharmacy, Fermoy, Co Cork. Entry Overview: Mike Walsh’s dedication to his profession extends well beyond the pharmacy walls. He has pioneered numerous local initiatives, including mother-and-baby first aid sessions and defibrillator training for GAA club officials. A strong advocate for his community, Mike sponsors 40 local causes each year, hosts public health talks, and regularly contributes a column to his local newspaper. On top of these commitments, Mike has represented the profession on behalf of the Irish Pharmacy Union. As the pharmacy landscape shifts, Mike is always searching for new ways to engage his customers. He introduced an Atrial Fibrillation service in the pharmacy and set up a prescription delivery service for customers in rural areas. Living above the pharmacy, Mike has a reputation for answering late-night calls to respond to new parents and elderly customers in need.

Amy Kieran, Kieran's Avenue Pharmacy, Dundalk, Co Louth Entry Overview: With more than 20 pharmacies in Dundalk, competition in the bayside town is fierce. Amy, of Kieran's Pharmacy, won’t settle for anything less than being the market leader. With a reputation for first-class health care (and a good cup of tea for those who pop in to say hello), the pharmacy has built a loyal customer base over the years. After noticing the online presence for pharmacies in Ireland was lacking, Amy set up an online shop and delivery service to compliment her extensive in-store offering. This has proved a major success, giving customers access to health care products from the comfort of their own home. Amy uses her strong social media profile to grow her business and stand out in a competitive market.


Gillian Ryan, Keane’s CarePlus Pharmacy, Primary Care Centre Mullingar Entry Overview: Gillian Ryan has spent more than 25 years as a community pharmacist, proudly serving her Mullingar patients, empowering staff and coaching students. Gillian invests every effort to care for her patients and regularly dispenses out of hours. She is engaged with the local Family Carers Support Group and takes an active role - well beyond prescribing medication - in supporting families through the diagnosis of illness and disability. Her empathy has effectively allowed her to gain the trust of her patients, improving patient safety and building lasting relationships. “I have never met a stronger, more patient-focused, professional pharmacist,” said John Keane, owner of Keane’s Pharmacy, of Gillian. In an effort to spend more time on patient care, Gillian had installed a dispensing robot, Buzz. This move both improved efficiency in the dispensary and allowed her to focus on what she loves doing; counselling patients.

Ivana Forsythe, Hickey's Pharmacy, Harolds Cross Road, Dublin, Co Dublin Entry Overview: Ivana is the driving force behind one of the busiest dispensaries in the Hickey’s group. The modest Harold’s Cross store has established itself in Dublin as a pharmacy that never closes and offers a truly unique mixture of services under often-demanding circumstances. Ivana and her team run a community pharmacy service blended with nursing home care, acute step-down care, and palliative services. The late-night store also handles a large volume of discharge patients from A&E hospitals. Ivana has been credited with recently saving a woman’s life after responding to an emergency anaphylactic case in the bathroom of a local pub. Calm and professional, Ivana administered three adrenaline injections and stayed with the patient until paramedics arrived. Ivana, who has been with the Hickey's group for more than a decade, leads a committed team in a multifaceted pharmacy, and ensures her staff are all trained in preventive care treatment.

Gillian’s and the team in Keanes CarePlus Pharmacy PCC Kerrie Finnan, McCartans Allcare Pharmacy, Donaghmede, Co Dublin Entry Overview: It’s the little things Kerrie does that make the biggest impact in her customer’s lives. A compassionate and dedicated problem solver, Kerrie always goes above and beyond to support the vulnerable, whether it be young parents who can’t afford their medication or a patient suffering from dementia. When Kerrie sees a demand for something, she takes action. Off the back of a successful flu vaccine campaign, Kerrie organised a C.O.P.D clinic in Donaghmede and other stores in the McCartans chain. An advocate in her own time for the Irish Cancer Society, Kerrie arranged for a breast cancer nurse to spend a day in store to train staff and educate customers about recognising the warning symptoms and risk factors for breast cancer. Kerrie also lobbied to secure a 24-hour BPM for the pharmacy. She manages all this while running a very busy pharmacy with a high volume of prescriptions, and managing a team of 16 staff.

Susan Concannon, Adrian Dunne Pharmacy, Ashbourne, Co Meath Entry Overview: Susan’s fundraising initiatives have spanned 14 years, so it was no surprise when she and her staff teamed up with the ‘Support for Anna’ campaign in 2017. Anna, a seven-year-old girl from Ashbourne’s Polish Community, has Rhabdomyosarcoma, a progressive cancer that affects her sight. Unfortunately, Anna was blinded in one eye three days after being diagnosed. Susan hosted a huge Halloween fundraising event in the pharmacy which raised ¤1250 for Anna’s vital proton therapy. This is just one example of Susan’s charitable work over the years. Susan manages a rapidly growing dispensary and has achieved patient count growth of at least 10 per cent every month - an impressive achievement for any established pharmacy. Susan has a genuine interest in her patients and a love for what she does. A through-and-through people person, she thrives on being at the coal face every day and always goes above and beyond for her patients.


Awards The Irish Pharmacy


McLernon Computers Innovation & Service Development (Independent) Award 2018

How do we get better at doing what we do? That’s the pertinent question asked by the nominees striving for excellence in innovation and service development. There is tremendous work being done across the country to boost the business of pharmacy and improve our offering to patients. This was a category that proved particularly difficult to drill down to just three finalists.

Siobhan Rogers, Costigan’s Pharmacy, Co Tipperary Disillusioned with the style and layout of modern pharmacies, Siobhan decided to overhaul her store. In 2017, she found a new space and hired a small Dublin-based designer who had never fitted out a pharmacy. The plan was simple: strip back and redesign the shop so it would become a space where patients felt empowered and respected. Out went the plastic and the laminate and the white paint. In came grey dispensary units and soft lighting and a calming colour scheme. “Good design is powerful,” said Siobhan. “I felt strongly that there was another way for pharmacy to develop in Ireland, using the best of times past to build a new future.” Siobhan wanted the first impression on entering the new pharmacy to be that it was a professional healthcare facility, a sanctuary. Clever design gives customers the option of three levels of privacy – front counters with dividers, semi- private consultation areas, and fully-private consultation rooms. And, importantly for Siobhan, the floor isn’t cluttered with rows of beauty products. The result? Siobhan says her customers are visibly relaxed, respond better to care, and stay in store longer to ask questions.

Joanne Sheridan, Staunton's Link Pharmacy, Co Mayo Pharmacists can play a major role in achieving health targets for patients and staff. Since joining Staunton’s last year, Joanne has hosted regular in-store health promotion events. The first was a three-day Diabetes information and awareness campaign, which saw new participants receive free blood glucose checks, and diabetic and pre-diabetic patients given new blood glucose meters. Next, the pharmacy teamed up with the Irish Osteoporosis Society to host an information session about the bone disease. This year the pharmacy has hosted sessions ranging from weight management and heart health to cancer and autism. All events have been big hits with customers. “Pharmacists should become more active in health promotion,” said Joanne, “developing from the display of leaflets to the use of leaflets in response to requests for advice." The pharmacy is also active in promoting the mental and physical health of its staff. So far this year, employees have taken part in various swimming, walking and climbing challenges during their lunch breaks and outside of work hours (healthy prizes for the winners of each challenge have helped lure staff outside during the colder months).

Kieran Brennan, Haven Pharmacy, Mullingar, Co Westmeath Haven Pharmacy opened its doors at the tail end of the recession. Without a customer base and after years of financial turmoil dogging the retail sector, Kieran Brennan knew starting a business was a risk. But he had a clear vision: provide a second-to-none offering to customers and the pharmacy will flourish. “By ensuring the former, the latter would invariably follow,” he said. Haven's expansive product range caters for its wide and varied customer base, and its pharmacists are multilingual, a major drawcard for Spanish, Portuguese, Polish, French and Germanspeaking patients. In the four short years the pharmacy has been trading, Havens has enjoyed year-on-year double digit growth in almost every department. Kieran puts the success down to the team he assembled to serve the town of Mullingar and its hinterland. And, of course, his customers. “Without our customers we are nothing, and it is with this in mind that we have directed the focus of our business."


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Awards The Irish Pharmacy


The Nurofen for Children Baby Health Pharmacy of the Year Award 2018

The boom times might be over but the baby boom times are still in full swing. Ireland has the highest birth rate among all European Union countries, with the most recent figures showing almost 64,000 live births a year. That’s a lot of sleep-deprived parents.

Sheena Mitchell, Milltown Totalhealth Pharmacy It might be a quarter of a century old, but Milltown Totalhealth Pharmacy has thoroughly embraced the era of technology. Known for the WonderBaba parenting blog, the pharmacy this year relaunched the website to become a complete parenting healthcare destination. It offers more than 150 evidence-based articles and a confidential one-on-one online advice service with pharmacist Sheena Mitchell. The idea was born when, while on maternity leave, Sheena came across swathes of misleading and inaccurate parenting advice being disseminated online. Over the years - and often late at night - Sheena has answered thousands of online queries from vulnerable parents across the country who need quick, convenient and confidential access to support.

Martin Slattery, Headford CarePlus Pharmacy, Co Galway Is the town of Headford in the midst of its very own baby boom? Headford CarePlus Pharmacy has seen an increase in the number of babies born in recent years, and, in response, has tailored its services to meet the growing demand for parent-related supports. “Parents are always looking for common sense information and tips on the general care of their child, their child’s growth and development, what to do if their child has a problem, and who to get in touch with for more help and support,” says Martin. With an in-store Mum and Baby advisor, regular midwife talks, baby trade fairs, and a kids play area, it could just be that parents from all around the region are drawn to Martin’s pharmacy. The CarePlus group also has a baby whisperer (AKA a sleep expert) on call to offer advice to sleep sleep-deprived parents.

Keane's CarePlus Pharmacy, Mullingar, Co Westmeath It’s little wonder Keane's has become a destination of choice for parents in Mullingar. Before you even get to the extensive offering for mums and dads, the pharmacy boasts baby and child parking outside. Walk through the door and parents are greeted with a buggy-friendly shop layout. The shelves are stocked with the Nature Nurture baby range. Staff are on hand to provide a free baby weight measurement service. Keane’s have a team of specially trained Mum and Baby advisors on the floor who are there to answer your questions. The pharmacy hosts a parent-and-baby coffee morning, providing a safe and friendly meeting place, and holds regular baby massage classes. Local mothers groups are welcome. And if you decide to stay at home, the staff will deliver your medication to you.


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Awards The Irish Pharmacy


KRKA Counter Assistant of the Year Award 2018

The counter assistant is the unsung hero of any Irish pharmacy. Often the first point of contact for patients, the counter assistant must be both multi-tasker and team player. A good counter assistant will be an expert on all of the OTC products and service the pharmacy provides but also the vital connection between patient and pharmacist. The counter assistant is often the heart and human face of the pharmacy, consistently going out of their way to help others. This year’s nominations for best pharmacy counter assistant were oversubscribed - and every entrant was a worthy contender.

Danielle Hogan, Adrian Dunne Pharmacy In her short time with Adrian Dunne, Danielle has proven herself as a star performer. Her manager described her as dedicated, diligent, patient, caring, and compassionate - all attributes of a brilliant counter assistant. Danielle goes out of her way to help others. She’s often found encouraging and complimenting a regular adult customer who is learning to read. She has also shown great care and empathy while helping a woman who had dementia and who became lost in the store. “As a manager I have never worked with someone like Danielle,” said her boss. “Someone who takes on responsibilities simply because she doesn’t like to leave things undone.”

Phil Cahill, Adrian Dunne Trim Phil has been in the pharmacy business for three decades and her knowledge of the industry is unmatched. “Our business would not be the business it is today without Phil,” said her supervisor. “She is the essence of our pharmacy.” Adrian Dunne customers adore Phil - some pop in just to see her and say hello. New customers are always embraced, too; Phil takes the time to introduce them to the pharmacist and explain the services on offer. Going the extra mile is part of Phil’s nature. She is known for delivering prescriptions to customers in her own time. “We believe Phil deserves this award as she is extremely knowledgeable, caring, passionate and a selfless individual,” her colleagues said. “She completely embodies what a great counter assistant should be.”


Bernadette McNamara, Tully's Totalhealth Pharmacy Bernie treats every Tully’s customer like a VIP: she knows all their names and will get them anything they need. “Bernie is an expert at making people stay healthy and happy,” said her manager. “She radiates positivity and can brighten even the most unsuspecting patient that comes along.” Bernie’s colleagues struggle to remember a time when they haven’t seen her smiling. They describe her as a role model; someone who shows up to work every day with unrivaled energy and enthusiasm, which they find a little contagious. Bernie’s product knowledge is also second-to-none (there’s a rumour going around that she might have memorised where everything is on the shelves) and because she’s so approachable, customers will often seek her out for guidance.

Rosemary Bryne, Donnelly's Pharmacy, Strand Road, Portmarnock, Co Dublin With almost two decades at Donnelly’s Pharmacy, there’s nothing Rosemary doesn’t know about the store. She is the face of the Dublin pharmacy and a mother figure to all staff. Over the past 18 years, Rosemary has earned a long list of qualifications, but she is known for her approachable manner. She has found that perfect balance between a professional and personal relationship with customers, and has become a great friend to many in the local community. Her boss, while nominating Rosemary for this award, said, simply: “We don’t know what we will do when Rosemary retires.”

Lisa Nangle, Boots the Chemist Lisa began her career with Boots eight years ago as a temporary Christmas staff member and has worked her way up through various roles, from customer assistant, to healthcare advisor, to her current position as trainee dispenser. Lisa overcame her self-doubt and put her heart and soul into the dispenser programme, showing real energy, enthusiasm and commitment. She demonstrates great instinct and empathy in all her work, and provides customers with a fantastic level of healthcare. “Lisa is a great role model for fellow colleagues,” her manager said. “She completes her work to the highest possible standards and never walks past less than the best. She uses her knowledge and relationships with our customers to give the pharmacy team information and insights that may not immediately be apparent. This leads to the patient always receiving exceptional customer care.”

Sarah Keogh, McCartan's Pharmacy Portmarnock Sarah has become an integral fixture in McCartan’s Pharmacy since joining the team six years ago. The wellbeing of patients is always front of mind for Sarah, who regularly goes beyond her the call of duty to not only meet their needs, but exceed them. “Her willingness to complete any task or role asked of her with her full commitment and loyalty to the business is just one of many reasons why Sarah deserves this nomination and ultimately the award,” said her manager. Sarah is that rare type of staff member who, when called upon to fill in at other stores, is always fondly remembered and asked about by those she briefly worked alongside. Sarah’s background in event management and willingness to steer projects has been instrumental in guiding the pharmacy’s many initiatives, most notably the “Get Richie to Canada” fundraising drive and the launch of a pilot programme aimed at addressing the needs of vulnerable COPD patients.


Awards The Irish Pharmacy


GSK Self Care Award 2018

Pharmacists and their OTC staff have a fundamental role to play in an efficient self-care model. This award recognises those pharmacies who have made great strides in implementing health promotion.

Lloyds Pharmacy, Castletroy, Co Limerick Due to increased GP waiting lists, the Lloyds team were aware that many of their customer base were not even getting their blood pressure checked on a regular basis. Therefore, a clear need to inform the public was identified. The team decided on clear goals of making the public aware of hypertension and the associated risks, increasing awareness of the benefits of a healthy lifestyle and to involve the entire pharmacy in heart health awareness. The team have implemented clear initiatives to increase heart health awareness. Free blood pressures check – 17% of those measured were revealed to have hypertension. This imitative also fostered and improved the relationship between pharmacists and GPs. As well as heart health the team also focused on diabetes awareness and collaborated with local businesses in the area.

Meagher’s Pharmacy Group, Baggot Street, Co Dublin Meagher’s is a long-established pharmacy with an emphasis on new techniques and patient care. The pharmacy have clearly identified areas where pharmacists are ideally placed to provide comfort and can in a way that physicians and the health service are not. A good example of this is the area of dermatology and skin conditions. Meaghers have recruited their own consultant dermatologist to provide online consultations. The Meaghers pharmacists have also undergone team training and are constantly providing new services and products, giving their patients good solutions. The area of dermatology in Ireland is a very specialist one and is hugely undersubscribed in medicine. To complement the new services, the pharmacy has extended its range of specialist skincare in store, many of which are exclusive to Meaghers in Ireland. It is the pharmacy’s goal to improve the quality of life of its patients, bridge a gap between dermatologists and our patients and provide quality advice at the pharmacy counter. Throughout the year the pharmacy holds monthly awareness such as diabetes, osteoarthritis, smoking cessation and blood pressure and BMI checks.

McCartan’s Pharmacy, Maynooth, Co Kildare The McCartan’s Pharmacy team decided upon clear strategy to elevate the self-care and services of their pharmacy, with a focus on health promotion. The team have organised a series events clearly designed to involve and inform the general public. Events such as a COPD nurse visit to the pharmacy, an Alzheimer’s tea party and skincare events. Beauty therapist Niamh now volunteers with the Look Good, Feel Better charity and provides beauty workshops for women suffering from cancer. As well as events, the pharmacy identified a gap in their vitamins and minerals offering and now the team has undergone intense training on the subject, including a reference manual provided for all staff. The pharmacy also supports local community events through self-care. Runners in the local mini-marathon need only produce their runner number to be awarded with a goodie bag full of useful products for the amateur athlete. There is even a seminar planned for the prevention of headlice.






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COLODEX-MEDICAL.COM Facebook COLODEXIBS [insert Irish- FB here] Pharmed Ltd., Unit 3, Clonmore Business Park, Mullingar Co. Westmeath, N91 DK59 t: (044) 933 4602 • info@pharmed.ie • www.pharmed.ie

Awards The Irish Pharmacy


United Drug Business Development (Independent) of the Year Award 2018

The ability to create, innovate and advance are the key areas of the Business Development Award. This independent pharmacy will develop their own business development product with clearly defined objectives and, most importantly, clearly defined results. This is a challenging category for the independent pharmacy business but one that can put such a business ahead of the crowd with a better service for their customers and patients.

Kieran’s Avenue Pharmacy, Dundalk, Co Louth Established in 2014, Kieran’s Pharmacy quickly identified a need to reach out to a wider customer base beyond the immediate community. Kieran’s began to develop a website that would bring the wider community into closer aspects of their business. They identified several key objectives; their pharmacists underwent training in marketing and online business and they began to work with a web developer to create a site that retained the feel of a community pharmacy while opening the business to a wider customer base. Crucially, Kieran’s looked to their internal systems as well as the external ones. They ensured that online orders were dealt with swiftly, accurately and even personally – all orders were accompanied by a personal note from the pharmacist. Although Kieran’s is a single-store pharmacy, their website has increased customer loyalty, local employment and business for all stakeholders involved.

Remedi Pharmacy, IFSC, Dublin Undertaking any kind of business development project requires a lot of planning and preparation. With careful analysis of sales and stock and the benefits of individual stock the team aimed to improve the visual impact and product range of the entire first aid section of the pharmacy. To undertake such a large project a huge amount of detail was required. As well as product research and analysis, the team created a training seminar for not just themselves, but for their customers too. Most importantly as a team Remedi pharmacy have maintained their own roles and fixed goals. The team have found focusing on training is a real value to all staff and makes a real difference when it comes to performance. The team as a whole envaulted their own performance and identified the learning opportunities that came from it.

Mellerick’s Pharmacy, Fermoy, Co Cork The shopfront and interior design of Mellerick’s Pharmacy in Cork is a journey into the ultimate customer experience. The exterior of the pharmacy is a sophisticated design that still embraces 100 years of this pharmacy business. Inside the shop the pharmacy still adheres to its core values but offers so much more to customers. Great emphasis has been placed on the visual merchandising and custom displays of the pharmacy, with a holistic approach to all of the service available within. Well defined zones are on display for skincare and beauty, crockery, a waiting area and even a play space for the kids. This pharmacy hasn’t so much been designed as curated. Every aspect of this pharmacy has been attended to – even to the aromas with essential oils being burned every day and the in-house coffee bar.


01 463 2300


United Drug Wholesale, Magna Drive, Magna Business Park, Citywest Road, Dublin 24

Awards The Irish Pharmacy


4. Please give evidence of the impact this business initiative has had on the pharmacy bu

ClonmeltheBusiness community it serves:Development (Multiple) of the Year Award 2018

1. The key areas we identified from feedback from our team’s meetings where th arePlus Pharmacy Announces with We all know the pharmacy landscape Partnership is shifting. But what can - and should - we do about it? The entries in this year’s business development category are not just planning for the future - they’re lighting the path.KPIs: In order to a line our key performance indicators, we partner Developing Baby Sleep Expert Lucy Wolfe

Pharmapod which is an Incident Reporting and Learning System designed to dr standards of patient safety across the pharmacy and Real-world retail to ident financial analytics so our team could review week on week our performance b initiatives we had designed. These KPIs where:

CarePlus Pharmacy Group

• Dispensary errorsitself and to near missesa destination for parents. With CarePlus Pharmacy is positioning become an extensive baby range across national group, a need was identified to enlist • Complaints andthe compliments received experts to upskill staff. CarePlus operates an empowering Mum • front-of-store Medicines information queriesnow completed and Baby training programme, which counselled is spread over three modules and delivered in • Number of patients about their medication partnership with resident sleep expert Lucy Wolfe, midwife Dorothy Buck, and the • Number of education and training sessions carried out Irish Red Cross, who deliver paediatric first aid training. The programme is designed to provide dozens of specialist Mum and Baby staff with the tools and product Investment tech front of shop/Clean defined sections: Within the pharmacy information to2. deliver expert advice and customer care to expecting and new mums. So far, it has beento a major storeinvest and on socialinmedia. ensuresuccess that we incould in bays order to have clear defined sections

do this we partnered with Careplus and purchased stock pushers: which a faced off stock when someone took an item off the shelf, electronic shelf (SELs) which reduced paper waste and can be updated with the click of a butt Care plus’s support we developed very clear signage within our pharmacy.

Pictured L-R: Lucy Wolfe, Baby Sleep Expert, with Rebecca Hearst and baby Ruby Rose.

Plus Pharmacy is delighted to announce their partnership with renowned infant sleep consultant, Wolfe, who will travel the country with the 35 strong Irish pharmacy chain this year hosting free her and baby workshops, and offering expert advice on how to help your little one sleep through Stacks Careplus Pharmacy recognises its greatest asset is its employees. Drawing on night.

Stacks CarePlus Pharmacy


staff expertise, it has been able to grow its customer base and the services provided How? Simply by asking staff towith identify opportunities and weaknesses roadshowin-store. commenced in 2016 in Mullingar andits Limerick, over 100 parents in attendance, in the business. Swords team has been with senior management on a ssing on all-important tips forThe building healthy sleeping habitsmeeting with children. Following on from basis to puthave forward theirseven ideasmore for engaging customers growing the uccess of monthly these events, CarePlus scheduled events for 2017 with the and next event company. And it’s worked. idea that adopted was a communal area providing ng place on the 22nd of February in the One Middleton Park was Hotel, Cork. Attendance is free and freeplace tea and coffee, in a bid provide much-needed mother and baby support. As tration takes via the pharmacies or to through social media, but early sign up is advised to a result of this - and other initiatives - the pharmacy’s public profile has grown, it has d disappointment. continued to build customer loyalty, and employee engagement has skyrocketed. Win, win, win.as one of Ireland’s leading specialists on sleep-related parental advice, is a full , who is recognised

infant baby consultant and mum of four young children. Commenting on the partnership Lucy fe, Infant Sleep Consultant said: “I’m thrilled to be partnering up with CarePlus Pharmacy to m parents on good sleep practices with their little ones. Nobody plans to have a sleep problem, habits can become easily engrained and spiral quickly out of control and you can find yourself sleep ived, desperate and not too sure what to do. In this partnership with CarePlus Pharmacy, I will let Plus customers in on some good sleeping habits and answer any questions parents may have ut their child. I’m really looking forward to traveling around the country, working with the CarePlus up, and meeting mums and dads who are looking for tips to ensure a better nights’ sleep!”


O’Grady, Head of Marketing for CarePlus Pharmacy said: “We are delighted to have Lucy on board It can cost up to six times more to win a new customer than it does to retain an existing one. In an his roadshow. We will also have our own CarePlus baby experts at each event to answer all baby effort to zero in on customer recruitment and retention, Allcare pharmacy set up a loyalty programme, ed questions our customers may have. Supporting parents and their babies for is anits integral of In essence, customers earn 1% back on all front-of-store purchases and Reward, retail part section.

go in draws to win a range of prizes. Rewards gives Allcare a point of difference in a crowded market and also boosts connectivity with customers by increasing communication channels. Allcare Rewards has been a glowing success: within six months 40,000 customers are actively using the card, and more than a third of front-of-counter sales are purchased through the loyalty system. Importantly, it has also given Allcare a detailed analysis of customer buying behaviour. Building on the success of the program, the next step will be to expand the Rewards to pharmacy products.


LOOKING AFTER YOU AND YOURS SINCE 1970 Here’s to the next 40 years, when we look forward to serving patients in Ireland even further. For over four decades, Clonmel Healthcare has worked with GP’s and pharmacists to improve the quality of life for Irish patients, making us the longest serving Generic partner in Ireland. And with our commitment to the community – including a nurse specialist team – we’re also one of the most trusted names in Generic medicine. Our diverse product portfolio includes single source products that serve both the community and hospital markets, broadening our reach into every corner of Irish life. 2013/ADV/GEN/052 www.clonmel-health.ie

Awards The Irish Pharmacy


Cellnutrition Community Pharmacy Team of the Year Award 2018

Teamwork is at the heart of a successful community pharmacist and all of our finalists in this category thrive through adopting a collaborative approach. Once a pharmacy understands the value of the team approach then it can begin to play a full part in its local community and use their combined excellence to put customer satisfaction and safety at the heart of everything that they do. This is one of our most important awards because it recognises every member of the community pharmacy team, from the superintendent pharmacist to the counter staff who are the public face of the pharmacy for the public. Our finalists, chosen from a large number of entries in the most competitive of our categories, come from many different parts of Ireland which demonstrates that the values and importance of the pharmacy team are recognised widely in the profession today.

O'Connor's, Allcare, Moycullen, Co Galway Team lead: Managing pharmacist Lisa Moran Teamwork is at the heart of everything they do at O'Connor's Allcare Pharmacy in Moycullen, Co Galway. This pharmacy recognizes the importance of every member of staff, from managing pharmacist Lisa Moran to retail manager Elizabeth D'Souza and all the rest of their team and this ethos of mutual respect and support flows down to all of their relationships with customers. Every morning the staff take part in a 'daily huddle' where colleagues discuss the objectives and challenges for the day ahead. Their continual efforts to strive for improvement were shown at their annual review of store performance where they identified areas they had under-performed last year and determined that they would improve in 2018. All team members were involved in this process which culminated in a project plan for the pharmacy designed to increase sales and margins. This has led to a 6% increase in RX items dispensed and included significant changes in the layout & range on the retail side of the business, with old stock removed & new exciting ranges added. The pharmacy team are also dedicated to rolling out health activities in their local community and among businesses. Among the key services offered were blood pressure tests, inhaler & peak flow measurement, BMI measurement, flu vaccine and a diabetes point check.

McCartans Allcare Pharmacy, Donaghmede, Co Dublin Team lead: pharmacist manager Kerrie Finnan The team at McCartans Allcare Pharmacy in Donaghmede provide a one-stop shop for all of their customers in a busy retail area. They showed their dedication to the team ethos last year by running a number of outreach events which required all staff members to work together for the benefit of their community. Initiatives included charity fundraisers, a COPD clinic and a breast cancer awareness day. A good pharmacy team puts its patients and customers at the forefront of its priorities and the team at Donaghmede excel at this. Their long-term patient base show loyalty, due to the strong relationships which have been built up over many years. In addition to this, the pharmacy provides a top quality clinical service for its patients. Regular medication review, referral of patients and a great communication system within the dispensary and with local GPS ensure constant safe patient care. By carrying out reviews with staff, acknowledge their skills and encouraging progression this pharmacy has a successful and thriving collaborative ethos. They are responsive to changing needs and demands and continually improve the quality and safety of services to patients. They have demonstrated a working culture within the pharmacy that is patient-focused and which actively uses the views of patients and staff to improve services.


Boots, Letterkenny, Co Donegal Team leader: Jolene Barton and Roisin McCaffrey The team at Boots, Letterkenny are adept at being proactive and responsive to the changing needs and demands of their customers. The team has found the introduction of the Pharmacy Assessment Tool has been great, as it helped further cement team work and accountabilities. Each month the pharmacist completes the relevant section but the team come together to discuss the findings and everyone is encouraged to give their opinion and help find ways to improve the pharmacy. In the past year the team developed an action plan for increasing flu vaccination knowledge which led to the store vaccination 50% more customers than in the previous year. Despite the extra workload all of the team came together to ensure the vaccination service was a success. The team at Boots, Letterkenny are highly motivated team and know what can be achieved by working together. It’s an open environment where everyone feels comfortable offering an opinion. This often leads to innovative ideas allowing them to maximize potential and achieve great results not only in business but in care for customers.

Hickey's Pharmacy, Finglas West, Co Dublin Team leader: Eithne Duffy Continuity is the theme for the team at Hickey's Pharmacy in Finglas with most of the team working together for almost 20 years. This longevity has built a unique understanding within the team which transforms into excellence in healthcare with a smile. Last year the team won the company Vitamin Category Award in March 2017 through a company quarterly theme called Hickey’s Grand National. All team members collaborated to come up with different ideas and a plan was devised based on these. The team in Hickey's in Finglas West are known and loved by the community they serve. The team embodies the culture of the Hickey’s organization in the everyday selfless way they conduct themselves. During the recent snow, they managed to keep their store open to ensure their customers, as well as customers from neighbouring pharmacies’ medication needs were met. On their way home on each of the snow evenings they devised a route each and personally delivered medication to some of their elderly and needy customers who were housebound. On one of the days, the team were unable to enter the store and instead they opened the nearby Hickeys Cappagh branch to ensure no one from their community was left without medication. Their recent store refit means the team have over twice the previous store area and they are already eager to extend their clinical services portfolio; including rolling out methadone and vaccinations services which space constraints prohibited in the past.

McCartans Pharamacy Balbriggan, Co Dublin Team leader: Laura McIntyre, supervising pharmacist McCartans Pharmacy in Balbriggan has built a strong and loyal team where everyone pulls together for the benefit of the customers. On the shop floor, everyone pulls together to help each other out with staff members taking responsibility for any of their colleague’s areas if they are absent. The team are scheduled to become part of an exciting pilot scheme being run in conjunction with a prominent company in facilitating COPD patient care in May. It will focus on grading them using the GOLD standard for stages of COPD and assessing their current medications suitability with a goal towards improving patient care. Doctors in the area are already on board, and staff are excited to be part of a new initiative that aims to help patients. Over the years since the branch opened in 2006, there are still three of the original staff on the team. Many of the others are up to eight years here and even the younger staff on the team have been here up to three years. The staff that have joined the team along the way have blended in and forged very strong bonds also. The team have made a huge push over the years to increase their generic penetration in both the dispensary and the OTC. This helps increase margins, support Irish brands and deliver better value to the customer.

Lannon's Late Night Pharmacy, Co Sligo Team leader: Enda Lannon Lannon's Late Night Pharmacy is a busy community pharmacy where the staff possess a great sense of team spirit. This was demonstrated when the store has hosted and organized a number of in store loyalty nights, customer information evenings and a Charlene Flanagan Masterclass held in the Sligo Park Hotel and another held for a school Fund raiser in Enniscrone. These evenings which were a roaring success had over 200 people in attendance. This involved great team work across the stores while also maintaining excellence service for regular customers. Lannon's strives to be an active part of the community and give a helping hand to a number of organisations. One of which was 'Operation transformation' ran in conjunction with St, Johns football club. As part of the service the Healthcare Team offered subsequent aftercare on health and wellbeing offering weight management programmes, cholesterol testing and products to help the customers achieve their goals. The pharmacy team set weekly and monthly tasks to be achieved and often discuss how they deal with customers and give feedback to each other in order for to learn and continue to grow, while maintaining high standards of customer service. The pharmacy has only been open for four years in September and is still growing but the team has achieved a lot in a short time and have also developed a great rapport with the community.


Awards The Irish Pharmacy


JPA Brenson Lawlor Young Community Pharmacist of the Year Award 2018

The newest generation of community pharmacists represent the future and our shortlist proves that the profession is in good hands. All of our shortlisted candidates have made a huge difference in a short career so far, winning both the respect of their colleagues and the patients they serve every day.

Lorcan Gormley, McMeel’s Pharmacy, Skerries, Co Dublin Lorcan Gormley is a classic example of an enthusiastic young pharmacist who goes above and beyond the call of duty to improve services and access for patients and colleagues alike. Currently the managing pharmacist in McMeel’s, Lorcan is the first port of call for pharmacists in his group for the answers to legal and reimbursement questions and often uses his free time to help his colleagues figure out systems issues to ease dispensing. He proves his dedication by often working on his day off when a locum has failed to turn up and his commitment to understanding patients’ needs is reflected in his popularity among staff and customers. Despite his young age he has proven he is able to organise and manage a busy dispensary. He has combined his clinical background with a sound business sense and has led programmes in lean operations, data analysis and project execution and has led the way in rolling out new technology across the chain. The respect that his more experienced peers give to him is testament to his ability and dedication as a pharmacist.

Emma Sherwood, Lloyds Pharmacy, Blanchardstown, Co Dublin Pharmacy is very much in Emma Sherwood’s family but her individual energy, presence and desire to work in a team has already seen her build up a formidable reputation as a community pharmacist. Working in an extremely busy Lloyds Pharmacy, she has been adept at building relations with customers and other retailers in the area. Though her role is classed as support pharmacist, she has proven she has the ability to lead and manage a team, particularly when the regular supervising pharmacist went on long-term sick leave. Emma has a keen interest in palliative care as well as medicine usage reviews. This led to her giving informative talks in nursing homes which the pharmacy looks after. She also designed specific forms for nursing home orders for unusual products which are difficult to source, which has greatly reduced errors in information transfer and has led to timesaving for both nursing homes and the pharmacy. Emma is a shining example of a colleague who can be both a team member and a team leader and her desire to meet the needs of the patient as well as working in an ethical and professional way has earned her the respect and trust of her colleagues.


Fathimah Kara, Reidy’s Pharmacy, Rathcoole, Co Dublin Working as the supervising pharmacist in Reidy’s Pharmacy since 2012 Fathimah Kara has implemented a lot of new services including ABP monitoring and a ‘Flu Survival Kit’. She also undertakes regular CPD activities and uses the knowledge to support patients and to train other staff members to enhance patient care. Fathimah’s enthusiasm, youthful energy and innovative outlook have allowed new services to be introduced while also maintaining the smooth running of the pharmacy without disruption to customers. Her dedication to personal care and provision of individualised care appropriate to each patient ensures that values are upheld at all times. Fathimah is also regularly involved in fundraising activities and has helped to raise more than ¤8,000 for charitable causes as well as raising awareness of a number of good causes and bringing attention to services. Her commitment to her profession is evident and she always goes above and beyond. This can be through passing on knowledge to other staff members or delivering medication after work to patients who are unable to collect it. She has helped to update services while ensuring that the best all-round care and support is still available to all who need it.

Suzanne Goggin, Haven Pharmacy Scannells and Riverview, Co Cork Working in Haven Pharmacy, Suzanne takes a genuine interest in every patient. Despite her youth it is clear that she has made a positive difference in people’s lives, whether by directing them towards the services they need, supporting them in stopping smoking or improving their health and fitness. She always takes the time to help patients to understand their medication and can often be found visiting patients in their own homes. She has often travelled to other towns to source medication for patients in emergencies and her caring nature and extensive knowledge have been essential in helping people who have suffered from falls, allergic reactions or injuries. Suzanne has built a reputation as a leader and she constantly passes on her knowledge to her colleagues, mentoring new staff and taking time to answer all questions. She has even brought her expertise to local schools, teaching primary pupils about safety with medicines. Suzanne is always seeking ways to improve the future of pharmacy and she always ensures that she puts patient care at the heart of everything that she does.

Grace Grimes, Meaghers, Dublin Being exceptionally patient focused comes easy to Grace. She is a natural with customers and easily adapts her communication style to fit any situation. She approaches her job with an air of calmness and there can be no doubt that she thoroughly enjoys what she is doing, always going out of her way to help or support patients. When Grace finished her intern year with Meaghers there was no question that she would be retained as a pharmacist – she was an obvious choice. Grace is able to juggle the demands of a busy pharmacy with individual patient care. Her innovation has lead to several cost and time-saving measures involving everything to blister-pack preparation to diabetes management. She constantly searches for new ways to continue her education and has already started management training. In less than two years Grace has demonstrated a real flair for community pharmacy and a positive influence over her customers. She is clearly committed to a long career in community pharmacy.

Amy Moran, Blackglen Pharmacy, Co Dublin Having worked at Blackglen Pharmacy for less than two years, Amy has already made herself an indispensable part of the team. It hasn’t taken long for Amy to bring technology into her role and she has made several innovations using social media. Using WhatsApp she interacts with the patients on a daily basis, answering questions, updating patients on their prescriptions, streamlining the patient experience. This allows the patients more access to the pharmacist and gives near instant communication. Amy is constantly looking for ways to improve her knowledge. She is constantly attending talks, partaking in webinars as well as critically analysing articles in relevant journals. She is also constantly interacting with her peers in the pharmacy and elsewhere to see where she can improve. She understands exactly what is required of her to provide the optimum service to the patients. From the nuts and bolts of the business side of the job, to medication usage reviews with patients, Amy carries out the job faultlessly while maintaining an atmosphere in the pharmacy that everyone enjoys.


Awards The Irish Pharmacy


Teva Superintendent Pharmacist of the Year Award 2018

The superintendent pharmacist is a vital role in the success of a pharmacy. They are the key individuals who use their expertise to make their team a vital part of their local communities. All of our finalists have demonstrated outstanding leadership, innovation and ambition to ensure that in rapidly changing times, the ethos of high quality, safe and consistent service remains right at the centre of community pharmacies.

Tom Concannon, Hickey’s Pharmacy Tom Concannon is the personification of what a successful superintendent pharmacist should be. He has been a superintendent pharmacist for more than a decade and leads a growing team of 77 pharmacists across 34 stores, developing his role from a purely regulatory function to a position that now helps guide the strategic direction of the company. Tom has built a strong network of supervising pharmacists backed up by robust auditing systems and strong procedures. This year he is using new software to speed up the audit process and improve analysis of results, thus allowing him to focus resources where they are most needed. Tom takes his leadership role very seriously and makes time to personally work with each of his pharmacists to help them develop their roles and keeping them motivated by varying their responsibilities. He is also always available to them whether to hand out advice or answer a technical question. He leads by example and also makes time to chat with customers. He has also developed a positive reputation for introducing efficiencies, such as being the first to offer a prepared SMS service to launching their prescription orders online. His most recent initiative has been the StartRight prescription service which allows pharmacists to follow-up with patients who have started a new medication with a phone call 7-14 days later.

Dan Burns, Allcare Dan Burns is passionate about advancing the role of community pharmacists and pharmacy within the health system and is a firm believer that technology has huge potential to deliver more efficient, safer care. Dan has been instrumental in reminding, reassuring and promoting pharmacists as a vital resource in caring for their local communities and is adept at linking Allcare health promotional activities in tandem with national health campaigns. He organised training and resources to promote flu vaccination as a public health initiatives. He also has continued to scale up and improve Allcare’s Quality Management System, providing an open culture of continuous quality improvement and enhanced error and near-miss reporting and sharing of trends. He recently presented at the Health Services Research and Pharmacy Practice conference in Newcastle on the topic of ‘Shared Electronic Patient Records’ and is at the forefront of advances in this field. Dan was also instrumental in developing an operational survey on the ARCOS platform which is used across Allcare pharmacies. Dan continues to be at the forefront of volunteering to participate in pilots for new programmes and rolling these out to his community pharmacists and has an inherent ability to simplify these projects and adapt them for use.

Jack McPolin, Smith’s Pharmacy Group Jack McPolin is the Superintendent Pharmacist of the rapidly expanding Smith’s Pharmacy Group, consisting of 10 stores. Jack has demonstrated his understanding of patients needs when delivering healthcare in the community and has innovatively designed the Smith’s Pharmacy stores with patient care in mind. Jack has been the key driver of the business, has adapted the business model to embrace the evolving role of community pharmacy and ensures the frameworks are in place to deliver patient care. Jack is driven, motivated, not afraid to take a risk and a natural leader and influencer for the Smith’s team and has a proven record for going above and beyond for the patients in the community Smith’s Pharmacy serve.

Joanne Kissane, Lloyds Pharmacy Joanne is passionate in pursuit of great patient experiences and care within the Lloyds group and has been involved in designing, planning, implementing and monitoring a number of campaigns in the past year to promote increased levels of self-care amongst patients, leading to better outcomes. These initiatives have included their most successful ever flu vaccination campaign, asthma clinics and blood pressure campaigns as well as dealing with challenging situations such as pharmacy closures and adverse weather. She has also continued to work closely with HRA Pharma, the manufacturer of emergency contraceptive ellaOne in promoting the role of the community pharmacist in the provision of the morning-after pill and also to de-stigmatise the request by women for the pill. Joanne is also actively involved in the evolution of pharmacy CPD at an organisational and national level and has continued to be part of the PSI council which she joined due to her belief that if you are not prepared to change something then you relinquish the right to moan about it. Joanne remains committed to her role which she sees as assisting, influencing, guiding and supporting her colleagues and co-workers to ensure that high-quality, sage and effective and patient-centred services are delivered across all of the 90 LloydsPharmacy stores.


Awards The Irish Pharmacy


The Fixxa Category Development of the Year Award 2018

Running a successful pharmacist means much more than knowledge of top-selling products. The ability to optimise retail performance through a specific group of products managed as a distinct business unit shows an understanding and appreciation of the market and the ability to excel in these competitive times. All of our finalists in this category have demonstrated the measurable benefits from a specific project or initiative and have added value, profits, increased productivity and customer satisfaction. In short, they have shown they are always striving to do things better.

Meaghers Pharmacy, Baggott Street, Dublin The team at Meaghers have used their expertise to adapt a business strategy to improve sales and customer awareness of specialised dermatology in the pharmacy setting. Their research revealed real problems with waiting times for those accessing services for skin conditions in the Dublin area, leading to a partnership with a leading consultant dermatologist who provides expert opinion via an online consultancy facility on the Meaghers website. The dermatologist has also conducted in-depth dermatology training workshops with Meaghers’ pharmacists which empowers them to assess patient symptoms and diagnose skincare conditions before recommending treatment or referral. At all pharmacy counters some of the most common questions asked of pharmacists are around skincare conditions like psoriasis, eczema or asthma, yet often the profession receives little formal training in the area. Meaghers has shown leadership to empower their team to make a real difference to lives.

Remedi Pharmacy, International Financial Services Centre, Dublin A decision was taken at Remedi Pharmacy to develop and improve their First Aid section which included devising a number of training strategies and encouraging staff members to advise customers on their first aid needs. This led to an increase in first aid sales. Creating a specific plan designed to make shopping easier and promoting customer education initiatives resulted in a 20% increase in sales in the first three months of this year. Analysis of customer needs and shopping behaviour revealed that further customer educational initiatives were needed to facilitate sales of certain items. The initiative will be continued with staff working towards setting up a special first aid session for parents to focus mainly on kids and young babies.

CarePlus Pharmacy (Multiple) Remedies account for more than 40% of over the counter sales and the team at CarePlus Pharmacies, a network of independent pharmacies, knew the importance of a successful Remedies Planogram change in their stores. Training guides were provided for staff as well as workshops, both instore and regionally and point of sales packs to support the category were sent directly to the pharmacies. A new back wall was established which included a ‘OTC Hotspot’, a new solution to offset PSI restrictions and allow more product focus. Each pharmacy also had a dedicated ‘category champion’ whose responsibility it was to implement the new range change. The implementation of a new category or range change involves the support and delivery not only of the commercial team but also graphic design and marketing teams and the operation team being briefed weekly and the customer service team who support the operations team with the execution.


Awards The Irish Pharmacy


Innovation and Service Development (Multiple) of the Year Award 2018

The nominees in this category are taking active steps to transform the traditional pharmacy business. Each one deserves recognition for their respective programs, which, separately, benefit individuals, and collectively, raise the bar in our industry and improve patient care across Ireland. Well done to the finalists in this extremely competitive category.

LloydsPharmacy While community pharmacy has always depended on the knowledge of store assistants, the potential for academic study and subsequent career progression for these employees has been limited at best. Until now. LloydsPharmacy, in conjunction with the Institute of Technology Carlow, has tailored a level 6 “Certificate in Science for Dispensary Assistants” programme. The first of its kind, the course is designed to future-proof the business. The aim of the 15-month-programme is to train the next generation of dispensary assistants so they are equipped with the necessary skills and tools to provide an unrivalled quality of care to Irish patients. “To provide this best-in-class healthcare and lifestyle guidance, our dispensary assistants must be experts in their field,” Lloyds’ Shirley O’Neill said. Lloyds, which is funding the scheme, expects to place about 20 students a year in the programme, with an ambitious target of 100 graduates over the next five years. Already, the course has been noted as a benchmark in the sector and is being watched closely

Hickey’s Pharmacy In the era of convenience, we face the risk that the pharmacist-patient relationship is becoming increasingly transactional. Hickey’s Pharmacy is trying to counteract that. The company wants its customers to feel like they have a pharmacist, in the very same way they feel they have a doctor or a dentist. The group’s StartRight service sees pharmacists make follow-up calls to patients one week after consultations to assess how they're responding to new or adjusted medicines. “By following up on the transaction that is the dispensing, we aim to shift the relationship to one where patients view us as helping them to manage their medication,” Hickeys’ Tom Concannon said. Research shows many patients don’t take new medicines as prescribed, and given this is a relatively easy and cost-effective program to roll out, it makes perfect sense to take the time following up. Hickey’s said its StartRight service would result in more than 10,000 additional patient-pharmacist interactions over the next year. The response from patients so far has been very positive and pharmacists, too, are satisfied with the interventions they’re making. “Hickey’s have managed to create a wonderful, yet simple, service which works both for the pharmacy and for their patients,” Tom said.

McCartans Pharmacy Colm Clark and the team at McCartan’s Pharmacy piloted the launch of the first pharmacybased assessment clinics for Chronic Obstructive Pulmonary Disease, in a bid to improve disease and medication management for COPD patients. The purpose of the clinics was also to highlight the prevalence of COPD - which often goes undiagnosed - through a friendly, community-based setting. “Pharmacy is routinely recognised as the most accessible segment of the health service,” McCartans’ Colum Clarke said. Seven clinics were run across four McCartan’s stores, with more than 50 patients reviewed. Where appropriate, recommendations were made for GP referral. The company saw improved patient satisfaction and, as a result of the success of the program, it plans to extend it to four more stores in Ireland.


Awards The Irish Pharmacy


The Life Pharmacy Student of the Year Award 2018

This is one of the most exciting categories in this year’s awards because our nominees represent the future of the community pharmacy profession in Ireland. Already building a solid reputation among their peers, the shortlisted nominees have all displayed academic excellence combined with the professional aptitude necessary to fulfil a successful career as a community pharmacist. It is a timely boost for the exceptional young students as they take the first steps in their careers

Bridget O'Flynn - School of Pharmacy, University College Cork During her time at UCC Bridget has excelled and demonstrated all of the attributes necessary to be a successful pharmacist. She has shown excellence in clinical pharmacy practice and patient consultation and possesses good listening skills, empathy with the patient, ability to talk to the patient in a clear and understandable way as well as having a solid understanding of the legal and ethical responsibilities of a pharmacist. Bridget has also worked in Boots for three years and in her role, she puts into practice the knowledge and skills that she obtains during her studies. Outside of the academic, Bridget is an integral member of the UCC HealthVine initiative which aims to promote public health by students for students and the wider public. Bridget demonstrates an excellent understanding of the importance of a good relationship between pharmacists and patients through her work in Boots. Within her role, she provides trustworthy and accurate counselling to patients about their medication and ailments which is the key to maintaining the faith that many patients have for their pharmacy staff. She is also aware of the role that pharmacists can play in helping patients to be proactive about their own health; she carries out blood pressure monitoring, diabetes assessments, BMI calculations and both phone and online enquiries on a daily basis. In her work with UCC HealthVine, Bridget strives to promote the role of the pharmacist and the impact that the pharmacist can have on patient health.

Meabh Ryan - School of Pharmacy and Pharmaceutical Sciences, TCD Meabh has worked in a wide variety of pharmaceutical care settings over the past three years, seeking to develop her clinical knowledge and learn more about the relationship between pharmacists and patients. She has worked in two very busy community pharmacies located in Stephen’s Green and Dundrum Town Centre, and a more locally based community pharmacy in Dun Laoghaire. In addition to this, she spent five weeks working in Beaumont Hospital pharmacy department. Her experience in the hospital setting showed her how hospital pharmacists are limited in their opportunity to provide individual counselling to each patient on their discharge medicines and medication use. This highlighted the importance of counselling patients in a community setting to her. Meabh has learned that patients have a high degree of trust in their pharmacists, and community pharmacies are often the first point of contact a patient has with a healthcare professional. In addition to attending faculty assemblies and her involvement in the student union at TCD Meabh took on the responsibility of setting up a system where each week she sent an email to the class highlighting the main changes/ additions to the weekly timetable. She also included a ‘drug of the week’ in each weekly email, highlighting the major counselling points of some drugs which she believed to be relevant for future practice. Her aim was to ensure all classmates were constantly involved and informed of various lectures, tutorials and events so as to maximise participation and enjoyment of content.

Faiza Sefroun - School of Pharmacy and Pharmaceutical Sciences, TCD Fails balances the intense coursework at university with a perfect attendance and impressive results while also being a mother to three young children. Faiza is often seen attending the weekly postgraduate seminar programme in the School. Her enthusiasm, energy and joy is infectious and this has had such a positive impact on both students and staff alike. With her past experience working as a pharmaceutical technician Faiza has developed a proficient ability to communicate and interact with patients. Her decision to return to college as a mature student was not just centred solely on her career aspirations to practice as a pharmacist but ultimately to be able to contribute to the education of her own children. This decision has not been without its sacrifices for Faiza, both financially and personally, requiring as it does long hours of study in the library away from her family. She has an immaculate attendance record in college and even finds time to engage in extracurricular activity by attendance at the school's weekly seminar programme. Due to her endearing, warm and inviting nature friendships have blossomed throughout the school of pharmacy. Faiza is held in extremely high regard by all members of the academic staff. Her commitment to the course and her professionalism is universally acknowledged. When a member of staff suffered a serious cardiac episode and was confined to coronary care, each of Faiza’s children sent him their own personally drawn get well cards.


Awards The Irish Pharmacy


OTC Retailer of the Year Award 2018

The saturated OTC market continues to evolve at rapid pace. To stay on top of our game, we have to evolve, too. Investing in frontof-store. Specialist training for staff. Products tailored specifically for our target markets. These are just some of the initiatives that will provide a better customer experience, drive sales, and, in turn, ensure the longevity of our business. The finalists in this category are leading the way, and they’re already reaping the benefits.

Life Pharmacy - OTC Every policy decision Life Pharmacy implements is geared towards freeing up pharmacists’ time so they can spend more time focusing on customer service. The company believes this is the best way to increase OTC sales and drive the business as a whole. Extensive staff training initiatives over the past 12 months have equipped all employees with the skills and knowledge to confidently give customers professional advice about OTC. Life Pharmacy’s commercial buying team has developed a pack replacement supply process for OTC products in all stores, which prevents them from having to handle bulk orders and allows for more efficient stock control. Staff now spend less time sifting through boxes and more time with customers. Vitally, Life Pharmacy has engaged with its communities to drive health services, becoming a destination for OTC expertise.

Totalhealth Pharmacy Group - Paula Gallagher The biggest challenge facing Totalhealth is ensuring that its 70 independent pharmacies are operating at the same excellent standard in retailing, customer service, and staff knowledge. To achieve this consistency it embarked on a series of training initiatives, investing heavily in three programmes - Medicine Counter Assistant, Vitamins and Natural Remedies, and First Aid Training - designed for all OTC staff. The goal was simple: give staff across the group the confidence to handle any and all queries. To combat the staffing challenges faced by small community pharmacies, the training was rolled out in a module and exam-based e-portal that could be accessed any time (rather than sending staff away on training days). To date, 270 staff have completed the courses. The result? An increase in footfall, more OTC sales, growth in customer loyalty, and a €200,000 cost saving to members.

Boots Ireland Over the past 18 months, Boots has undertaken extensive research in a bid to find out what its customers want and how they want it delivered - both in-store and online. The chain’s focus is to grow loyalty and recruit new customers. Boots identified its key strengths range, value, advice, supported healthcare - and worked to them. “Our aim is to ensure our customers know how to get well and stay well,” Boots said. “The advice and information we provide at the OTC counter is key to improving the health and wellbeing of our customers.” One of the ways Boots does this is by offering customers solutions in the form of tips and hints around lifestyle changes. Another, is through training staff to normalise traditionally sensitive conditions and topics, such as women’s health, incontinence and hair loss, in an effort to help customers feel more comfortable.


Awards The Irish Pharmacy


Community Pharmacy Technician of the Year Award 2018

The growing demands of the modern-day pharmacy mean that the supporting role of the community pharmacy technician has become ever more important. Our finalists in this category have all displayed excellence in their work as well as demonstrating the depth and value that pharmacy technicians bring to community pharmacy in Ireland

Sarah Gilson, Adrian Dunne Pharmacy, Ballinteer, Co Dublin Sarah Gilson has used her own experiences to build empathy with patients in her job and also displays excellent knowledge of the healthcare system. Customers will often ask to speak to Sarah when discussing sensitive issues or uncertain situations. She has worked as a senior technician for the past two years and has shown great dedication to her job. She also attends a wide range of dispensary and shop-floor training, taking all opportunities to educate herself to provide a better service to her customers. Sarah is a highly motivated technician and an excellent trainer, helping new staff. She has exceptional knowledge of the HSE and the PCRS and is always keen to help her colleagues with new processes and administration rules.

Evelyn Daire, McSharry’s Pharmacy, Castlerea. Co Roscommon Evelyn combines the traditional pharmacy values of customer care with great pride in her work and compassion and great communication skills. Colleagues describe her as an ‘island of calm’ in a hectic workplace and her strength and confidence is an inspiration to everyone she works with. Evelyn understands the demands of working as a pharmacy technician but relishes the role and provides much needed support for the pharmacist and educating patients about their medication and running training sessions for staff. She has also been instrumental in organising and running various health and wellbeing promotion days in store and was a key member in the implementation of McSharry’s Pharmacy One2One Care which aims to enhance the delivery of patient-centred care. She understands the value of the plan and has worked hard to deliver the right service or product for the customer in every situation.


Mary Forde, Milltown Totalhealth Pharmacy, Co Dublin Mary Forde has tackled everything that working in a pharmacy can throw at you over the years. She has consistently demonstrated the depth and value that pharmacy technicians bring to community pharmacy in Ireland. Her skills as an organiser and natural leader have enabled her to become involved in every level of pharmacy business. She manages tasks, engages all of the team and instigates events, but all the while maintaining her faceto-face link with the customer who often turn to her when in need of assistance or advice. Mary always leads by example and has adopted a novel management structure for high need patients of the pharmacy, including the elderly, those with cognitive impairment and patients taking a large number of medicines. Maryâ&#x20AC;&#x2122;s strategies ensure that their needs are always met through careful stock management, advanced dispensing and even a delivery service. She is rightly viewed as a champion for pharmacy technicians in Ireland.

Mairead McTernan, Lannons Late Night Pharmacy, Co Sligo Mairead McTernan has helped to streamline processes since she arrived at the pharmacy for the first time in 2016 and this has improved the quality of dispensing and been of benefit to staff and colleagues alike. She has proven to be a real team player with a particular aptitude for training, driven by her great empathy with people. She is an all-rounder who can put her hand to anything from selling makeup at front of shop to being an expert healthcare provider. She helps with the local care homes, preparing their medications and completing audits and has devised a new time efficient way of organising the dispensary. Mairead is a vital part of the team at Lannons. She works well with all of the staff and treats each customer with professional advice and compassions. She has proven that she is always willing to go that extra mile for customer service.

Pamela Davin, Hickeyâ&#x20AC;&#x2122;s Pharmacy, Northside SC, Dublin Colleagues agree that Pamela Davin has raised the bar for pharmacy technicians in the group with her organisation skills, attention to detail, accuracy and decision making. She is able to run the dispensary which frees up the pharmacist for other duties. Pamela is consistent, reliable and caring as well as being generous with her time towards staff in training. Her determination to keep raising standards helps her to promote the ethos of continual improvement throughout the entire team. She is a natural leader and always among the first to embrace new innovations. Recently she has inspired the team to be top of group in the new RightStart Medicine service designed to increase patient engagement. She is driven to succeed and sees every target as a challenge to be pursued.

Lynsey Rigney, The Village Pharmacy, Co Dublin Lynsey has been a firm fixture in The Village Pharmacy for over a decade. Having started as a Saturday OTC assistant she completed her degree with DIT and then continued to gain her pharmacy technician qualification, all while remaining part of the team. Lynsey now takes care of the marketing and social media for the pharmacy and has developed her own specialist area in nutrition and exercise which she uses to influence not just patients but her co-workers too. Clearly dedicated to her job she taken advantage of every training opportunity to extend her knowledge and has effected real change with initiatives such as hypertension awareness evenings, answering questions on medication for the elderly and constantly encourages patients to improve their lifestyle. Here is a pharmacy technician who has whole-heartedly embraced the ethos of community pharmacy.


Awards The Irish Pharmacy


MRII Pharmacy Representative of the year Award 2018

The finalists for this unique award category are exceptionally ambitious and dynamic individuals working as Representatives of Pharmaceutical and healthcare suppliers in Pharmacies nationwide. Each of the three finalists this year has been nominated by a pharmacy customer, who has recognised each Representative as someone who really goes the extra mile for them. In their day to day roles, these finalists are working to showcase their products and grow new sales across their territories. They have each demonstrated an ability to meet and exceed their customers’ needs. The overall winner of this category will be decided by a specially selected judging panel, through a series of interview questions. The panel will be looking for examples and evidence of them achieving excellent results for their company, and what drives them to achieve when faced with obstacles. The winner will have demonstrated an exceptional capability to build strong working relationships with their customers and a genuine commitment to their profession.

Amanda Quinn MMRII, Perrigo Amanda Quinn MMRII, is Pharmacy Business Development Manager with Perrigo. Amanda told us “In my professional capacity, I am extremely fortunate to work in such a dynamic industry. I joined the industry in 2015 and currently employed with Perrigo. My role involves providing innovative products, educational support and adding value to community pharmacies and their patients. Every day is extremely interesting in my role, with exciting new products, forward thinking clients and without my valued customers, I would not be here. My business ethos, is to be as accommodating and supportive as possible to my customers and to deliver a superior quality service. It is through these relationships, that I have been fortunate enough to be nominated for this award. It is a real honour and I look forward to continued success, with all my valued customers.”

Orla Gleeson, Johnson & Johnson Ms Orla Gleeson is Pharmacy Territory Manager for Johnson & Johnson Consumer Division and has held this position full-time since March 2016 having previously completed a contract within the company in 2015. Orla who has worked in pharmacy sales for almost eight years having previously held employment at Sanofi, Quintiles, Continental Pharmaceuticals and Fannin Ltd. Orla is responsible for the sales development and management of the West Dublin/South Leinster territory. Her portfolio includes Johnson & Johnsons OTC and Consumer Health brands including Nicorette, Calpol, Benylin, Aveeno & Neutrogena. Having such a varied portfolio allows Orla great diversity in her day to day activities whilst always striving to provide exceptional customer service to her clients. Orla maintains that the most important element of her role is her relationship with her customers and having the ability to identify their needs in an ever-changing environment.

Scott Howard, PCO Manufacturing Scott has been working for PCO for two years. He moved into this industry from telecoms so pharmaceuticals was a new challenge for him. As Account Manager, it’s very important to Scott that he gives the best service possible to all of his customers. Scott told us “my favourite part of the job is relationship building with customers, on the phone and from when I visit them. I look after 300 accounts in Dublin, Limerick south and west Leinster and Connaught. With such a large number of pharmacies and contacts, the role always remains fresh and interesting.” Scott knows the importance of keeping up to date with products going short in the market and informing and updating his accounts with the current information on these lines. Overachieving sales targets is a strong priority for Scott.



Clinical Profiles ACCORD LAUNCH METHOFILL SOLUTION FOR INJECTION IN PREFILLED INJECTOR IN 5 STRENGTHS Accord Healthcare is delighted to announce the launch of Methofill in five strengths, 7.5 mg, 10 mg, 15 mg, 20 mg and 25 mg solution for injection in pre-filled injector. This new selfinject device will join Accord’s existing Methotrexate portfolio. This medicine is a pre-filled injector containing methotrexate and is indicated for active rheumatoid arthritis in adults. These presentations are now available from both Uniphar and United Drug. For further information please see enclosed SPC or contact your Accord representative, call Accord in Cork on 021-461 9040 or visit www.accordhealthcare.ie Your Accord Retail Representatives are: Richard Doherty, 087 667 1725, Cavan, Clare, Donegal, Galway, Leitrim, Longford, Louth, Mayo, Meath, Monaghan, Offaly, Roscommon, Sligo and Westmeath. John MacHale, 086 884 1114, Cork, Kerry, Limerick, Kilkenny, Tipperary, Waterford and Wexford. Louise Mooney, 086 044 3956, Carlow, Kildare, Dublin, Laois and Wicklow. Your Accord Hospital Representatives are: Ánna Barrett, 086 037 5953 Tracy Kivlehan, 086-8389829 Oliver Lawrence, 087 949 3918

JANSSEN ANNOUNCES FIRST HUMAN ANTICD38 MONOCLONAL ANTIBODY AVAILABLE FOR THE TREATMENT OF MULTIPLE MYELOMA Dublin, 16th April 2018: The Janssen Pharmaceutical Companies of Johnson & Johnson today announced DARZALEX® (daratumumab),


a first-in-class, fully human monoclonal antibody (mAb) that targets CD38, has been reimbursed in Ireland to treat patients with relapsed and refractory multiple myeloma, whose prior therapy included a proteasome inhibitor (PI) and an immunomodulatory agent and who have demonstrated disease progression on the last therapy.[i]

(PR) was reported in 17 percent of patients.8 The median time to first response was one month (95% CI, 0.9–5.6) with responses improving over time in 25.8 percent of patients.8 Safety data from the MMY2002 (SIRIUS) and GEN501 trials suggested that daratumumab (16 mg/kg) has a favourable and clinically manageable safety profile as a monotherapy.8,9

Reimbursement follows an accelerated assessment by the European Medicines Agency, a process reserved for medicinal products expected to be of major public health interest and therapeutic innovation.

Multiple myeloma is the third most common blood cancer in Ireland after non-Hodgkin’s lymphoma and leukaemia. [x] Approximately 1358 Irish people are living with multiple myeloma, with approximately 271 new cases diagnosed each year.[xi] The average at which myeloma is diagnosed is 65-70 years and just 2% of cases occurring in those under 40 years of age.[xii] On an annual basis, 173 people die from the disease.11

Multiple myeloma is an incurable blood cancer that occurs when malignant plasma cells grow uncontrollably in the bone marrow.[ii],[iii] It can be an incredibly complex disease to treat, as most patients eventually relapse or become resistant to standard therapies. Daratumumab is a first-in-class biologic targeting CD38, a surface protein that is highly expressed across multiple myeloma cells, regardless of disease stage. [iv] The novel mechanisms of action of daratumumab provide multiple approaches to promote myeloma cell death.[v] It binds to CD38 and then triggers the patient’s own immune system to attack the cancer cells.[vi],[vii] Daratumumab is manufactured by Janssen Sciences Ireland UC in Ringaskiddy, Cork. The approval of daratumumab was based on data from the MMY2002 (SIRIUS) study, published in The Lancet and GEN501 study, published in The New England Journal of Medicine.[viii],[ix] The pivotal open-label Phase 2 MMY2002 (SIRIUS) study showed treatment with singleagent daratumumab resulted in an overall response rate (ORR) of 29.2 percent (95% CI; 20.8, 38.9) with a one-year overall survival (OS) rate of 64.8 percent in patients who received a median of five prior lines of therapy, including a PI and an immunomodulatory agent.8 Stringent complete response (sCR) was reported in 2.8 percent of patients, very good partial response (VGPR) was reported in 9.4 percent of patients, and partial response

NEW NOVARTIS ANALYSES AT AAN SHOW SIPONIMOD’S EFFICACY ON DISABILITY AND COGNITION IN SECONDARY PROGRESSIVE MS PATIENTS Ireland, 25th April 2018: Novartis has announced new analyses from the Phase III EXPAND study of oral, oncedaily siponimod (BAF312) in patients with secondary progressive multiple sclerosis (SPMS). In pre-specified statistical analyses, treatment with siponimod consistently reduced the risk of confirmed disability progression in SPMS patients, with and without relapses1. In addition, new post-hoc analyses using more accurate methods to estimate the treatment effect on disability progression, now substantiate that the risk reduction with siponimod is largely disassociated from relapses. Siponimod also showed a significant benefit on cognitive processing speed, the key cognitive function impacted by MS, which frequently deteriorates in people with the disease2. These results are being presented at the 70th American Academy of Neurology (AAN) Annual Meeting, in Los Angeles, USA, April 21-27, 2018.

As previously reported for the overall study population, treatment with siponimod resulted in a statistically significant risk reduction in disability progression sustained for three- and six-months4. The new EXPAND study analyses, using a more advanced model-based approach, show an estimated risk reduction for disability progression, sustained at three-months that ranged from 14-20% compared to placebo (calculated by principal stratum analysis) for non-relapsing patients. For disability sustained at six-months, estimated risk reduction was even greater, spanning from 29-33%. Other complementary statistical approaches1 assessing the effect of siponimod on disability progression disassociated from relapses showed consistent results. In pre-specified and post hoc analyses, siponimod’s effect on cognitive processing speed was evaluated, as measured by the Symbol Digit Modalities Test (SDMT). SDMT is the only cognitive test with established clinical relevance of change in MS and is widely accepted by patients and physicians5. Other tests included the Paced Auditory Serial Addition Test (PASAT, assessing cognitive processing speed) and the Brief Visuospatial Memory TestRevised (BVMT-R, assessing memory)6,7. From baseline to month 24, treatment with siponimod showed a significant benefit on cognitive processing speed, compared to placebo, for all patients (SDMT, p=0.0004), and also in those who had relapses within two years before starting the trial (SDMT p=0.0151; PASAT p=0.0275) and those who did not (SDMT p=0.0099; PASAT not statistically significant)2. Treatment with siponimod did not result in significant differences in memory (BVMT-R)2. Novartis has initiated the submission of siponimod for US approval in SPMS in the first half of 2018. Filing for EU approval is planned to follow later in 2018.

Sunglasses 2018/19 • •

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• • • •

About the Range

High quality range of Sunglasses Full Sale or Return- return end of Sept ‘18 Credit will be applied to your Uniphar account and can be used to purchase any Uniphar products 7 Price points, RRPs ranging from €9.95 - €23.95 3 styles; • Classic, Sporty and Trendy Fully Merchandised stand or Counter display unit 20 piece replenishment pack


Merchandised Floor Stand

1 prefilled stand holds 100 (50 Styles) sunglasses GP 45% Artikel-Nr.: 85.956.9 Typ: Bodenständer Dimensions: Bestückung: 100 Sonnenbrillen • H. 184cm x w. 36cm x d. 36cm Maße Display: H. 184 cm x B. 36 cm x T. 36 cm Maße Verpackung: H. 186 cm x B. 39 cm x T. 39 cm Includes Mirror Platzierungsform: Saisonale Platzierung

Merchandised CDU

2 sided Counter display unit Holds 24 sunglasses each side GP 45% Dimensions: • H. 76cm x w. 38cm x d. 38cm

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Höhere Flächenproduktivität bei geringerer Standfläche - 36 x 36 cm Die hier dargestellten Brillen sind nur beispielhaft und entsprechen nicht unserer aktuellen Kollektion.

Number: Type: Quantity: Display dimensions: Packing dimensions: Type of placement:

85.956.9 Floor stand 100 sunglasses H. 184 cm x W. 36 cm x D. 36 cm H. 186 cm x W. 39 cm x D. 39 cm Seasonal placement

Higher space productivity with less stand space - 36 x 36 cm

Order Now: Contact your local Uniphar The glasses shown here are by way of example only Representative, our Telesales team and do not reflect our current collection. or order online at www.uniphar.ie


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Clinical Profiles ANOTHER DAY 1 FROM ACCORD HEALTHCARE - ACCORD LAUNCH EZETIMIBE 10 MG TABLETS Accord Healthcare is delighted to announce the launch of Ezetimibe 10 mg tablets in a pack size of 28 tablets available from Patent Expiry. Ezetimibe 10 mg tablets are indicated for the treatment of; Primary Hypercholesterolaemia, the Prevention of Cardiovascular Events and Homozygous Familial Hypercholesterolaemia. Please refer to the Summary of Product Characteristics (SPC) available at www.accordhealthcare.ie or www.hpra.ie for further information. Ezetimibe Accord is now available from Uniphar and United Drug. For further information please contact your Accord representative, call Accord in Cork on 021-461 9040 or visit www.accordhealthcare.ie Your Accord Representatives: Richard Doherty, 087 667 1725, Cavan, Clare, Donegal, Galway, Leitrim, Longford, Louth, Mayo, Meath, Monaghan, Offaly, Roscommon, Sligo and Westmeath. John MacHale, 086 884 1114, Cork, Kerry, Limerick, Kilkenny, Tipperary, Waterford and Wexford. Louise Mooney, 086 044 3956, Carlow, Kildare, Dublin, Laois and Wicklow.

GLOBAL I MMUNO-ONCOLOGY PARTNERSHIP ANNOUNCED APRIL, 2018 Boehringer Ingelheim and OSE Immunotherapeutics have announced a collaboration and exclusive worldwide collaboration and license agreement to jointly develop OSE-172, a SIRP-alpha antagonist targeting myeloid lineage cells. SIRP-alpha is a receptor expressed by myeloid lineage cells such as Dendritic Cells (DCs), tumour-associated macrophages (TAMs) and


Myeloid-Derived Suppressor Cells (MDSCs). In targeting SIRP- alpha, OSE-172 prevents the ligand CD47 from binding to and triggering the cellular inhibitory effects of SIRP-alpha. OSE-172 has the potential to enhance anti-tumor immunity by improving T cell activity through enhancement of DC antigen presentation functionality, potentiating the phagocytic and inflammatory properties of macrophages in the tumor microenvironment and enabling differentiation of MDSCs to an effector state. Boehringer Ingelheim has acquired the global rights to develop, register and commercialise OSE-172, a monoclonal antibody targeting SIRP-alpha which is expressed in myeloid lineage cells, as part of their continued commitment to research and innovation in immuno-oncology. Under the terms of the agreement, OSE Immunotherapeutics will receive a ¤15 million upfront payment from Boehringer Ingelheim, and potential additional shortterm milestones of up to ¤15 million upon initiation of a Phase I clinical study. OSE Immunotherapeutics stands to receive more than ¤1.1 billion upon reaching pre-specified development, commercialisation and sales milestones, plus royalties on worldwide net sales.

MOXETUMOMAB PASUDOTOX BLA GRANTED PRIORITY REVIEW 5 April 2018 AstraZeneca and MedImmune, its global biologics research and development arm, recently announced that the US Food and Drug Administration (FDA) has accepted the Biologics License Application (BLA) for moxetumomab pasudotox, an investigational anti-CD22 recombinant immunotoxin and a potential new medicine for the treatment of adult patients with hairy cell leukaemia (HCL) who have received at least two prior lines of therapy. The FDA has granted the moxetumomab pasudotox BLA Priority Review status with a Prescription Drug User Fee Act date set for the third quarter of 2018. The Phase III (‘1053’) moxetumomab pasudotox

clinical trial met its primary endpoint of durable complete response in adult patients with relapsed or refractory HCL, for which there is currently no established standard of care and few treatments available.i,ii Results from the 1053 Phase III trial will be presented at a forthcoming medical meeting. Priority Review is granted by the FDA to applications for medicines that, if approved, would offer a significant improvement in the safety or effectiveness of the treatment, diagnosis, or prevention of serious conditions.

US FDA GRANTS TAGRISSO MARKETING AUTHORISATION AS 1ST-LINE TREATMENT FOR EGFR-MUTATED NON-SMALL CELL LUNG CANCER AstraZeneca recently announced that the US Food and Drug Administration (FDA) has granted marketing authorisation to Tagrisso (osimertinib) for the 1st-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumours have epidermal growth factor receptor (EGFR) mutations, (exon 19 deletions or exon 21 L858R mutations), as detected by an FDA-approved test. The US authorisation is based on results from the Phase III FLAURA trial, which were presented at the European Society of Medical Oncology 2017 Congress and published in the New England Journal of Medicine. In Europe, Tagrisso has a marketing authorisation for the 2nd-line treatment of patients with metastatic EGFRm NSCLC, whose disease has progressed on or after a 1st-line EGFRTKI therapy and who have developed the secondary T790M mutation, as detected by a validated test method. Tagrisso is under regulatory review in the EU for use in the 1st-line treatment setting with regulatory decisions anticipated in the second half of 2018. Dave Fredrickson, Executive Vice President, Head of the Oncology Business Unit at AstraZeneca, said: “…(the) FDA approval of Tagrisso in the

1st-line setting is an exciting milestone for patients and our company. Tagrisso delivered unprecedented median progression-free survival data across all pre-specified patient subgroups, including patients with or without CNS metastases, and could prolong the lives of more patients without their tumours growing or spreading.” The FLAURA trial compared Tagrisso to current 1st-line EGFR tyrosine kinase inhibitors (TKIs), erlotinib or gefitinib, in previously-untreated patients with locally-advanced or metastatic EGFR-mutated (EGFRm) NSCLC. Tagrisso met the primary endpoint of progression-free survival (PFS) (see table below). PFS results with Tagrisso were consistent across all pre-specified patient subgroups, including in patients with or without central nervous system (CNS) metastases. Overall survival data were not mature at the time of the final PFS analysis. Safety data for Tagrisso in the FLAURA trial were in line with those observed in prior clinical trials. Tagrisso was generally well tolerated, with Grade 3 or higher adverse events (AEs) occurring in 34% of patients taking TAGRISSO and 45% in the comparator arm. The most common adverse reactions (≥20%) in patients treated with Tagrisso were diarrhoea (58%), rash (58%), dry skin (36%), nail toxicity (35%), stomatitis (29%), fatigue (21%) and decreased appetite (20%). In the US, Tagrisso has already received marketing authorisation for the 2nd-line treatment of patients with metastatic EGFRm NSCLC, whose disease has progressed on or after a 1st-line EGFR-TKI therapy and who have developed the secondary T790M mutation, as detected by an FDA-approved test. In 2017, Tagrisso was granted Breakthrough Therapy and Priority Review designations by the US FDA in the 1st-line treatment setting. Tagrisso is under regulatory review in the European Union and Japan for use in the 1st-line treatment setting with regulatory decisions anticipated in the second half of 2018.

TouchStore Sales Executive Introduction: TouchStore are currently seeking to hire a sales executive with pharmacy software knowledge along with sales skills to provide advice and support on a range of our products. This would be an ideal position for a pharmacy technician or pharmacist assistant who has experience using TouchStore Rx and is seeking a new challenging position. Typical work activities Include:

Congratulations to all on your continued success For further information please call Stephen on 014825424 or email pharmacy@cplhealthcare.com

• Searching for new clients who might benefit from company products or services • negotiating tender and contract terms and conditions to meet both client and company needs; • providing pre-sales technical assistance and product education; • working on after-sales support services and providing technical back up as required; • arranging and carrying out product training during installations; • supporting marketing activities by attending trade shows, conferences and other marketing events; Requirements: • Candidates must have full clean drivers licence and access to own vehicle; • Existing knowledge of TouchStore Rx and Retail 365 is a distinct advantage; Please send CV and Cover Letter to info@touchstore.ie

Sudocrem launches smaller pot to help tackle ‘Life’s Little Emergencies’ on the go Household staple for over 85 years now available in ideal size to fit in handbags, make-up bags, washbags, travel bags or any bag! Sudocrem, one of the nation’s best-loved household staples, announced the launch of the smaller, more convenient 15g pot for Life’s Little Emergencies. The handy pot is the ideal size to fit in handbags, make-up bags, washbags, travel bags or any bag to soothe, protect and restore your skin, on the go. The iconic Irish product has been taking care of Ireland’s little skin emergencies for over 85 years and is still made in Baldoyle, Dublin. For further information like us on Facebook at https://www.facebook.com/SudocremIreland or learn more about Sudocrem by visiting www.sudocrem.com

Breathe Easy: Introducing Marimer Nasal Hygiene, Health Inspired By The Sea New to Ireland, the Marimer Nasal Hygiene range is a competitively priced and completely safe seawater solution high in natural mineral salts and marine dietary elements, with a formula that makes for the easy, gentle discharge of nasal secretions. Products now launching in Ireland include: Marimer Isotonic (Daily Nasal Hygiene), RRP ¤8.45 - Marimer Isotonic is a sterile diluted 0.9% seawater isotonic solution designed for daily use to gently cleanse the nasal cavities, facilitate the evacuation of nasal secretions, bacteria, viruses, dirt and allergens in order to help prevent ENT infections. Marimer Hypertonic (Blocked Nose, Cold, Sinusitis), RRP ¤9.05 - A 100% sterile diluted seawater solution with 2.2% hypertonic concentration, Marimer Hypertonic is recommended in cases of chronic nasal congestion from colds and chronic rhinitis Marimer Baby Daily Nasal Hygiene, RRP ¤9.05 - Marimer Baby Daily Nasal Hygiene is a sterile diluted 0.9% seawater isotonic solution that uses an anatomical safety tip for gentle, non-invasive insertion, and works to gently clean and moisten the nasal cavity.

Nasacort Allergy Nasal Spray available from pharmacies in Ireland The prescription strength relief is available without the need for a prescription Nasacort Allergy Nasal Spray is available to buy direct from pharmacies for the first time in Ireland, without the need for a prescription. With up to 1 in 5[i] Irish citizens suffering with hay fever (seasonal allergic rhinitis), many will be pleased to hear that once established on the product they can get 24 hour relief[ii] from irritating symptoms, such as an itchy and runny nose[iii], without having to wait to see their doctor. Nasacort Allergy Nasal Spray has a strong prescription heritage and has been prescribed by doctors for many years to help manage hay fever. The unique thixotropic formula contains the active ingredient triamcinolone acetonide2, which thickens when sprayed onto the nasal tissues and ‘stays where it’s sprayed’ to stop it from running down the nasal passage and throat, allowing effective relief from seasonal allergies[iv]. The scent free and alcohol-free spray requires just one dose a day and allows non-drowsy relief from hay fever symptoms, without an odour or harsh taste2. Nasacort Allergy Nasal Spray costs ¤14.96 for 30 sprays, each delivering 55mg of triamcinolone acetonide and is available from pharmacies across Ireland2. Suitable for those aged 18 years and over. The recommended starting dose is 2 sprays in each nostril once daily2. Once symptoms are controlled the maintenance dose is 1 spray in each nostril once daily2. Contains triamcinolone acetonide. Always read the label. For trade enquiries please contact your Sanofi Sales Representative.

4fm Pollen Count sponsored by STÉRIMAR Listen out for the Pollen Count on Classic Hits 4FM, which is brought to you by STÉRIMAR from April to June this year. STÉRIMAR effectively relieves symptoms without the compromise of steroids, drugs and preservatives that can be found in other more medicated products.


Nasal Medical Allergy Filter is a drug free allergy prevention solution that prevents allergens and polluted air entering the nasal system and help sufferers enjoy the outdoors without enduring the debilitating symptoms of hay fever. Nasal Medical Allergy Filter is a discreet personal filter, anatomically engineered to fit discreetly and comfortably just inside the nose.

New from Nivea Men: Body Shaving Anti-Irritation Stick Compact and easy to use in the shower, this convenient stick allows for an efficient, fast and protected body shave without the irritation. Unlike traditional shaving gels, the specially developed formula is designed for use in the shower, meaning it won’t wash off mid shave. The transparent formula provides the ultimate precision shave without catching or irritating skin. Perfect for hand luggage or gym bags.

RRP 75ml ¤6.99

al +0 month

Daily nasal hygiene

/ Child


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Appointments Bernard Mallee, The Irish Pharmaceutical Healthcare Association (IPHA), which represents the research-based pharmaceutical industry in Ireland, has announced the appointment of Mr Bernard Mallee to a new post of Director of Communications and Advocacy. Mr Mallee will take up the position on May 21, 2018. The role, reporting to the Chief Executive Officer, is a strategic appointment aimed at helping the biopharmaceutical industry to tell an impactful story about the value it creates for patients, society and the economy, with innovation at the core. The new Director will have responsibility for building the industry’s reputation as a critical player in Irish healthcare and the economy, as well as leading engagement with public sector stakeholders, including at national and European levels, in the timely delivery of innovative medicines to patients.

Maire Geoghegan-Quinn, Minister of State for Training, Skills, Innovation, Research and Development, John Halligan T.D., has announced the appointment of former EU Commissioner for Research, Innovation and Science, Ms Maire GeogheganQuinn to the Board of Science Foundation Ireland. Ms Geoghegan-Quinn served as EU Commissioner for Research, Innovation and Science from 2010 to 2014 and was awarded the Légion d’Honneur by French president François Hollande in recognition of her role in the set-up of Horizon 2020. She went on to chair an independent expert group examining gender equality in Irish higher education institutions. Ms Geoghegan-Quinn was appointed to the Board of the Science Foundation Ireland following an open Public Appointments Service (PAS) process.

Dr Darrin Morrissey, Minister for Health Simon Harris TD has welcomed the appointment of Dr Darrin Morrissey as the new Chief Executive Officer for the Health Research Board. Dr Morrissey was appointed following an open recruitment campaign. Commenting on the appointment, Minister Harris said, “Dr Morrissey has a wealth of experience and a proven track record in leadership in the research and innovation environment. This is a key appointment in striving to develop our health research capability in Ireland. The HRB CEO has an important role in implementing the HRB’s Corporate Strategy and achieving the aim of excellent research which will generate relevant knowledge and promote its application in policy and practice. "The importance of health research has been well documented as being an essential element for health services.  It is fundamental to the safe and effective delivery of health services.    There is strong international evidence that a researchinformed health system with a research-aware workforce ultimately results in better outcomes for patients and I am committed to ensuring that health research is supported.”

Wiley’s launch innovation in eye care A company has launched an entire product line dedicated to eye care. Food supplement company Wiley’s Finest has created Bold Vision, a range specially formulated for vision care. In a move away from tradition, the company’s flagship product in this range is Bold Vision: Proactive, the first product created without Omega-3. Instead, the product contains Omega-7, a monosaturated fat which has emerging evidence of playing a beneficial role in eye health. As well as Omega-7, Bold Vision: Proactive combines FloraGlo Lutein, the most clinically studied form of eye health nutirient - with Anthocyanins from European


Bilberry, Astaxanthin from algae and Zinc, contributing to the maintenance of normal vision in an easy-to-take serving of two capsules. The essential nutrients Lutein and Zeaxanthin, which are concentreated in FloraGLO, help protect eyes from high energy blue light damage, thereby reducing eye strain and discomfort. “Our Bold Vision product is inspired by the success of using FloraGLO® Lutein in our awardwinning Elementary EPA, which is a flavoured liquid fish oil designed for children. While the mangopeach flavor was really popular

with kids, adults who tried it weren’t crazy about the flavour,” explained Wiley’s Finest Managing Director, Sam Wiley. “The real genesis is that eye vitamins tend to be thought of as ‘old people vitamins’ but the pervasive use of mobile phones has made it so important that people in their 20s, 30s, and 40s are taking care of their eye health,” continued Wiley. “That’s why we called it Bold Vision: Proactive. We wanted to bring all these basic nutrients backed by science and encourage people to be proactive about their eye health.”

Wiley’s Finest Proactive contains 20mg of Lutein and 4mg of Zeaxanthin in each serving, providing the daily recommended dose for optimal eye health support. Proactive is expertly formulated to be taken in conjunction with Wiley’s Finest #1 best-selling fish oil formula, Peak EPA, for a daily serving of Omega-3 plus eye health support. Like all Wiley’s Finest supplements, Bold Vision: Proactive is Contents Tested and Certified by NSF International.

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