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January 2019 Volume 11  Issue 1 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS: Pharmacy speaks out on Abortion Bill Page 6

REPORT: Minor Ailment Scheme for Ireland, what’s the delay? Page 14

LETTERS: Students suffering under MPharm programme Page 22

FEATURE: Supplementing the OTC market Page 24

CPD: Management of Lower Back Pain Page 31

TIME TO TREAT: Smoking Cessation Page 40


r gh Fo Cou Y AN Buttercup Bronchostop Cough Syrup contains thyme herb extract and marshmallow root extract. A traditional herbal medicinal product for the relief of coughs, such as chesty, dry, tickly, irritating coughs and catarrh, exclusively based upon long-standing use. Adults and children over 12 years: 15ml every 4 hours. Max dose 90ml per day. Not recommended for children under 12 years. Seek medical advice if symptoms persist after 7 days or if dyspnoea, fever or purulent sputum occurs. Contraindications: Known hypersensitivity to ingredients, rare hereditary intolerance to some sugars. Caution: Not recommended for use in Pregnancy and lactation. Contains methyl parahydroxybenzoate and propyl parahydroxybenzoate, which may cause allergic reactions. Side effects: Stomach disorders. TR 2006/1/1. TR Holder: Kwizda Pharma GmbH, Effingergasse 21, A-1160 Vienna, Austria. RRP (ex.VAT) 120ml €6.99 200ml €9.99 290ml €12.99. Date of preparation Apr 2018. SPC: http://www.medicines.ie/medicine/16380/SPC/Buttercup+Bronchostop+Cough+Syrup/ Buttercup Bronchostop Berry Flavour Cough Pastilles contains thyme herb extract. A traditional herbal medicinal product for the relief of coughs, such as chesty, dry, tickly, irritating coughs and catarrh, exclusively based upon long-standing use. Adults and children over 12 years: 1 – 2 pastilles every 4 hours. Max dose 12 pastilles per day. Not recommended for children under 12 years. Seek medical advice if symptoms persist after 7 days or if dyspnoea, fever or purulent sputum occurs. Contraindications: Known hypersensitivity to ingredients, rare hereditary intolerance to some sugars. Caution: Not recommended for use in Pregnancy and lactation. Contains 0.6 g fructose per 2 pastille dose – to be taken into consideration in those with diabetes mellitus Side effects: Stomach disorders. TR 2006/1/2. TR Holder: Kwizda Pharma GmbH, Effingergasse 21, A-1160 Vienna, Austria. RRP (ex.VAT) 10s €3.99 20s €5.99. Date of preparation Apr 2018. http://www.medicines.ie/medicine/16381/SPC/Buttercup+Bronchostop+Berry+Flavour+Cough+Pastilles/


Contents Page 4: Lifetime Membership for Fergus

So begins a New Year, bringing with it a plethora of opportunities and developments. Starting 2019 as we mean to continue, this issue is full of the latest news, exclusive reports and features. The purchase of Bradley’s Pharmacy Group by Uniphar was announced at the end of last year and we carry further details on page 4.

Page 5: More on how pharmacy-based services can save lives Page 9: Reflections of a Chairman; Cormac Tobin Profile

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Page 14: Where is Ireland’s Minor Ailment Service?

In other news, the need for a pharmacy-based Minor Ailment Service has long been established. In our special report on page 14 we detail the background, the questions on the delay and take a look at areas such as Scotland where the service has been running with great success. It is widely known that mental health issues rise to the fore during the winter months, for many and varying reasons. Pharmacy students across Ireland have voiced their concerns about the worrying levels of mental health strain being placed on them under the new MPharm programme.

Page 20: Sam McCauley’s open new Concept Store Page 22: Pharmacy students voice concerns over new MPharm programme PUBLISHER IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562 MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com EDITOR Kelly Jo Eastwood 00353 (87)737 6308 kelly-jo@ipn.ie ADVERTISING DIRECTOR Debbie Graham 00353 (87) 288 2371 debbie@ipn.ie ADVERTISING SALES Louie French 00353 (1) 6690562 louie@ipn.ie CONTRIBUTORS Paul Knox Frank Olden

Foreword

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20 Irish Pharmacy News is circulated to all independent, multiple Pharmacists and academics in Ireland.

IRISH PHARMACY NEWS

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 or transmitted in any form without written PHARMACYNEWSIRELAND.COM permission. IPN Communications Ltd. has taken every care in compiling the magazine to ensure that it is correct at the time of going @Irish_PharmNews to press, however the publishers assume no responsibility for any effects from omissions IrishPharmacyNews or errors.

Regulars

CPD: LOWER BACK PAIN

This month we feature an open letter, written by University students to the Pharmaceutical Society of Ireland in which they detail how unpaid placements are causing financial and health-crippling strain. Pharmacy students must now complete their four-month placement in year 4 and an eight-month placement in year 5 unpaid. “Contributing factors to the mental health status of Intern Pharmacists at present is not limited to the financial strain,” the letter states. “It is also because we are unmotivated whilst at placement. If you look up the definition of extrinsic and intrinsic motivation you will understand what we are referring to. Receiving payment for the work which we do would contribute towards building the self-esteem, work ethic and work morale of student pharmacists. Receiving payment would also make us feel more competent and thus contribute to our intrinsic motivation.” Turn to page 22 for the full letter. The Pharmaceutical Manufacturers Institute held their Annual Charity Lunch in December of last year, celebrating their 2-year partnership with Hugh’s House. This extremely worthwhile charity, established by Stack’s Pharmacy MD Ade Stack and her husband, carries out vital work for families of terminally ill children. Irish Pharmacy News is delighted to offer a new ‘space for your time’ initiative in support of their work and urge all pharmaceutical companies and their teams to volunteer their time. Full details can be found on page 42.

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FEATURE: UNDERSTANDING ASTHMA P48

PRODUCT PROFILES:

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FEATURE: ECZEMA MANAGEMENT P36

FEATURE: EXPANDING THE FAMILY P52

CLINICAL PROFILES:

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News news brief EPRESCRIBING WILL DRIVE BENEFITS

Uniphar complete purchase of Bradley’s At the end of last year, Uniphar completed their purchase of the Bradley’s Pharmacy Group. Uniphar, which has annual sales of €1.3bn and 1,500 employees across the UK/Ireland/ Benelux have taken on all 20 of the Bradley’s pharmacies from examinership. a good platform to further strengthen Uniphar’s retail symbol offering and invest in our symbol support teams. Market demand is growing for this new model and with the Bradley group acquisition, Allcare is now the largest branded group in the Irish market with 102 sites. Looking ahead, we will invest in both digital, e-Commerce solutions and on-line training portal for both our Allcare and Life brands and there will be additional capital expenditure on IT, new store fit-outs and branding.”

The Health Information and Quality Authroity (HIQA) has published a National Standard on information requirements for ePrescribing in a community setting, which has been said will have ‘considerable benefits’ for not only pharmacists but patients and prescribers. This National Standard defines the information requirements for the implementation of community-based ePrescribing and dispensing in Ireland. Information requirements are a minimum set of data items that are recommended for implementation in information systems that create and transfer information to support the delivery of safe and quality care to patients. The inclusion of data in the minimum set of data is determined by its clinical relevancy and the potential for the data to improve patient safety in a collaborative care environment. HIQA’s Director of Health Information and Standards, Rachel Flynn, said, “A national, community-based ePrescribing programme can deliver significant benefits for patients, prescribers and pharmacists. It can improve patient safety considerably by reducing cases of incorrect dosage, incorrect medication and adverse drug interactions.” The Sláintecare Implementation Strategy published in August 2018 prioritises the implementation of communitybased ePrescribing to support information sharing, patient empowerment and the development of digital services. Ms Flynn continued, “A national ePrescribing service can also benefit prescribers by enabling the safe electronic sharing of prescription information. Prescribers can receive notifications when a patient collects a prescription from a pharmacy. Electronic prescribing can improve the efficiency of process within pharmacies thus allowing pharmacists give to more time with patients. "The National Standard published today is a key building block in the development of ePrescribing in Ireland and will ultimately help improve patient safety.”

Uniphar Retail Services, Managing Director, Dermot Ryan The news is seen to offer a single end-to-end solution and a competitive advantage for Uniphar across the supply chain. It is believed as the market demand for its retail ‘symbol’ model grows, the added volume of 20 Bradley’s stores will also improve buying power with manufacturers, and also give Uniphar the opportunity to grow own brand sales.

across counties Louth, Meath, Monaghan, Dublin, Wicklow and Kerry - which in turn provides

Uniphar believes further consolidation of retail will gather pace over the next three years and that it needs to protect its wholesale customer base while also availing of scaling opportunities.

Speaking to Irish Pharmacy News, Managing Director of Uniphar Retail Services, Dermot Ryan said, “The acquisition of the Bradley group is a strong fit for Uniphar Group plc. It delivers a strong core of pharmacies with a good geographical spread

Lifetime Honour for Fergus Fergus McAuley, IQVIA has been honoured with Life Membership of the Pharmaceutical Manufacturer’s Institute (PMI). The accolade was presented recently during the PMI Annual Charity Lunch. With only 13 Life Membership’s presented in 30 years, this is the highest honour to be bestowed on a member, with no-one more deserving. Fergus has been a member of the PMI for over 28 years and has served on the Institute’s Committee in a variety of roles for over a decade, most recently as Honorary Secretary. “His dedication, commitment, warmth and generous sharing of his time and knowledge has ensured Fergus is an essential part of the Institute’s team,” said a PMI spokesperson. They added, “We have been honoured to work alongside Fergus and look forward to welcoming him to many more events in the future as our newest Life Member.” Turn to page 42 for details on Irish Pharmacy News latest initiative in association with Hugh’s House – ‘Space for your Time.’

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Fergus McAuley, IQVIA


News Pharmacy-based hypertension service could save lives Community pharmacists and their teams can deliver ‘an extremely positive benefit’ in terms of prevention, detection and initial management of suspected hypertension and atrial fibrillation, the results of a new report have shown. Launched by the Irish Pharmacy Union (IPU), the report outlined the results of a pilot to detect people at risk of hypertension and atrial fibrillation in the community. Carried out during the summer of 2018 in 68 community pharmacies throughout Ireland, the pilot aimed to identify people 50 years of age and over who had high blood pressure or an irregular heartbeat or both. Over 1,100 people were checked in a 2-month period. Speaking at the launch of the report on the pilot programme, President of the Irish Pharmacy Union, Daragh Connolly, said that the results of the pharmacist-led health check pilot showed, “27% of participants were identified with high blood pressure while an irregular pulse was detected in 5.5% of participants, with 2% of participants showing signs of both. 26% of all participants checked were referred to their GP as a result of the study and 4% of those were started on medications to treat the conditions.” “These findings are particularly important, especially when Irish data suggests that 64% of people over the age of 50 have high blood pressure and that nearly half of

those are undiagnosed. Regarding atrial fibrillation, research suggests an overall Irish prevalence estimate of 3% atrial fibrillation in the over 50s,” he said. The service was seen as highly beneficial by both participants and pharmacists and easy to implement within the pharmacy environment. Overall, the majority of participants (83%) were happy with the information they were given by the pharmacist who undertook the health check. The pilot also raised participants’ awareness of blood pressure and pulse readings, as 91% of participants said they were more aware of blood pressure and atrial fibrillation as a result of taking part in the pilot. Virtually all participants (98.5%) said they would recommend the health check to a friend and 99% said they were happy to have taken part in the pilot. In conclusion, Mr Connolly said, “The pilot demonstrated that, by carrying out a standardised population health check for hypertension and atrial fibrillation in the community pharmacy, a highly accessible healthcare location, community pharmacists can deliver an extremely positive benefit to

participants in terms of prevention, detection and initial management of suspected hypertension and atrial fibrillation. The pilot objectives aligned perfectly with Government priorities for the health service and we believe that the findings strongly support the roll-out nationally of an HSE-funded cardiovascular health check service.” Pfizer Healthcare Ireland supported the pilot study with an educational grant and the Irish Heart Foundation provided support materials and training for the pilot. Around 8,000 people will be hospitalised due to stroke in Ireland each year, with an average age of onset of 74 years. At least 1,800 stroke patients will die, with 1,000 being discharged to nursing home care and the remainder returning home. It is estimated that over 30,000 people are living with a stroke related disability in Ireland. The Cost of Stroke in Ireland study carried out for the Irish Heart Foundation by the ESRI estimated a total direct cost of stroke to the economy of up to ¤557 million per annum. It is also estimated that stroke incidence will increase by 59% by 2030.

Call for Ireland to be in top quartile for speed of access to new medicines Ireland remains among the slowest countries in western Europe to deliver the latest innovative medicines, with the result that Irish patients often don’t have access to treatments available to their European counterparts. bodies present at a recent Guaranteed Irish roundtable discussion raised a number of challenges facing the industry, including the slow access to new medicines. Guaranteed Irish’s members made a series of recommendations, including: • Appointing a Chief Innovation Officer to identify suitable new treatments and make them available • Funding models that enable pharmaceutical companies to deliver new medicines to Irish patients at the same pace as other European countries Ger Brennan, Managing Director, MSD Ireland, Martin Shanahan, CEO, IDA Ireland, Brid O'Connell, CEO, Guaranteed Irish, Matt Moran, Director, BioPharmaChem Ireland and Todd Manning Managing Director Abbvie

To this end, members of Guaranteed Irish, the not-forprofit business membership organisation championing 500+ homegrown and international businesses in Ireland, have called on the Government to set a target for Ireland to be in the top quartile of European countries for speed of access to the latest medicines. The last decade has seen significant capital investment at pharmaceutical facilities across the country. However, industry leaders and representative

• Increasing the number of clinical trials to attract greater research and development • Introduce more manufacturing apprenticeships, similar to those in Germany and Switzerland, as many roles do not require third-level qualifications Guaranteed Irish has developed the outcomes of the roundtable event into a submission paper for Government, outlining the support required to ensure the pharmaceutical sector remains in robust health in Ireland. Members of Guaranteed Irish in the pharmaceutical and healthcare sectors include MSD Ireland, AbbVie, Hollister, Ipsen, Tosara Pharma Ltd, PPL Biomechanics, KCI Medical Ireland and Nutricia Ireland.

news brief PHARMACY GROUP LOSES HIGH COURT BID An Irish pharmacy group, which sought to enter into a community pharmacy contract (CPC) Agreement with the HSE in respect of a new pharmacy in Dublin, has had its application for judicial review refused in the High Court. The HSE last April refused the application by Darastream Ltd for a CPC for Smith’s Pharmacy at Quarry Road, Cabra, in light of inquiries by it, including whether there was claiming on the double for prescriptions, at two other Smith pharmacies operated by companies with the same beneficial ownership as Darastream. Due to inspections carried out at two other pharmacies owned by the group which alleged, inter alia, duplicate cross pharmacy claiming, the HSE refused its application to enter into a new agreement. Finding that the HSE enjoyed discretion to consider the inspections in making its decision refuse the application, Mr Justice Garrett Simons was satisfied that the HSE did not have a duty to enter into a contractual arrangement with any particular individual pharmacist. The HSE was entitled to have regard to matters including financial probity and professional qualifications of the party seeking to enter a contract with it and to the fact all three pharmacies would have the same superintendent pharmacist, he also held. Without preempting the results of the HSE’s inquiries, it was sufficient to note the issues raised, if correct, are “serious matters” and could lawfully ground a decision to refuse to enter into a CPC agreement, he said. Mr Simons noted the HSE had proposed to defer its decision whether to issue a CPC for the Cabra pharmacy until its inquiries were concluded and only made the disputed refusal decision after the applicant insisted a decision be made in advance.

PHARMACYNEWSIRELAND.COM | 5


News news brief EXPANSION OF FLU VACCINE In the majority of healthy people, the flu is unpleasant. Symptoms such as fever, headaches, coughs, muscle aches and pains can suddenly occur and last up to seven days or a fortnight in some cases. Other groups are at-risk of harmful or even life-threatening complications from the flu, particularly those with compromised or developing immune systems, including pregnant women, the elderly, and young children. The flu vaccination is free of charge for patients over the age of 65 and at-risk patients aged between 18 and 64 who hold either a Medical Card, Doctor Visit Card, or have HAA eligibility. LloydsPharmacy has expanded the flu vaccination service to 52 stores nationwide, increasing from 32 in 2017. Vaccinations will be administered by a trained LloydsPharmacy pharmacist in a private consultation room from the end of September, and throughout the winter period. Colleagues are also available throughout winter to provide professional advice on appropriate over-the-counter medication in the treatment of coughs, colds and flu, and the proactive steps patients can take to stay healthy during the winter months. Commenting, Denis O’Donnell, Superintendent Pharmacist at LloydsPharmacy says, “Incidents of flu peak in winter. A severe case of flu can result in self-limiting symptoms such as fever, headaches, cough and fatigue that can last for up to two weeks. “In more extreme cases among elderly and at-risk categories, the flu can be more serious and sometimes even result in death. “Last year, the HSE announced 92 flu related deaths reported to the Health Protection Surveillance Centre (HPSC). “We encourage all our patients to be winter health aware and prepare for the season ahead. We encourage adults over 18, regardless of their risk status, to visit their local LloydsPharmacy to discuss their eligibility for the vaccination and if they are entitled to receive it for free. For opening hours, especially during evenings and weekends.”

Health Minister on collision course over Abortion Bill? A Bill to legalise abortion services in Ireland passed all stages in the Dáil at the end of last month (December). TDs voted in favour of the legislation by 90 votes to 15, with 12 abstentions. It followed hours of debate and more than 60 amendments. The Regulation of Termination of Pregnancy Bill will now proceed to the Seanad (Irish senate). Conscientious objection was a major contentious point during the debate, over Minister Harris’ plans to introduce GP-led abortion services from January 2019. IPN understands that community pharmacists are concerned about failures by the Health Minister Simon Harris TD to engage with them, stating that he has denied them a consultation. The Irish Pharmacy Union had previously called on the Minister to specifically recognise the right to freedom of conscience for pharmacists in the practice of their profession in the health Bill before the House. Speaking to Irish Pharmacy News, an IPU spokesperson said, “Following the referendum to repeal the constitutional prohibition on termination of pregnancy, the IPU wrote to the Minister for Health seeking an explicit right of conscientious objection for pharmacists in the context of the Health (Regulation of Termination of Pregnancy) Bill. “The Code of Conduct for Pharmacists already provides for conscientious objection by requiring pharmacists to ensure that, in instances where they are unable to provide prescribed medicines or pharmacy services to a patient, they must take reasonable action to ensure these medicines/services are provided and the patient’s care is not jeopardised. As such, a pharmacist who, for religious or ethical reasons, cannot provide a specific service to a patient must direct that patient to someone who will. “Nevertheless, as the principle has already been established that medical professionals should have the right of conscientious objection, the IPU has written to the Minister for Health and health spokespersons, proposing that the provisions regarding conscientious objection should be extended to pharmacists to ensure that they would not be compelled to participate in a service to which they have fundamental, religious or ethical objections, should the manner in which the service is to be provided changes in the future.” A recent PharmaBuddy poll of pharmacists registered in Ireland showed that 60% of respondents supported the extension of

6 | PHARMACYNEWSIRELAND.COM

Michael Collins, Independent TD freedom of conscience protection to the pharmacy sector. Pharmacists will play a critical role in the implementation of any future abortion policy. Independent TD Michael Collins, in addressing a debate on the Bill stated, “The Health (Regulation of Termination of Pregnancy) Bill 2018, as currently drafted, does not provide for the conscientious objections of pharmacists. Pharmacists will therefore play a critical role in any foreseeable abortion regime as all the methods of abortion provided for in the Bill involve prescribing, dispensing and administering medication. Although their conscience prevents them from intentionally ending the life of an unborn baby, they will be required by law to collaborate in this very act. The legislation in its current form interferes with the exercise of pharmacists' professional clinical judgment and denies their right to freedom of conscience.” He added that an ‘alarming aspect of the legislation is that our legislators believe that the only people in the health service who have consciences are doctors and nurses.’ “At this stage, the Minister has made no reference in the legislation as to how his abortion proposals will work in practice. He has proposed a GP-led regime which a majority of GPs oppose and most GPs believe is unworkable. He has failed to consider the most basic practical issue of how the medications used in abortions will be manufactured, provided and dispensed. He has not consulted pharmacists on this fundamental change in healthcare ethics and practice and has, to date, displayed a combination of disregard and contempt for the conscience rights of the dedicated pharmacists and healthcare workers who conscientiously oppose abortion. Pharmacists have a human right to freedom

of conscience, religion and belief. Their right to freedom of conscience must be included and protected in the Health (Regulation of Termination of Pregnancy) Bill 2018,” he added. Meanwhile, a senior pharmacist has criticised Minister Harris for misleading comments in relation to the protection of conscience rights in his draft abortion legislation. Responding to comments made by Minister Harris to media outlets, Dr James Carr, a Chief Pharmacist from Louth, said, “Mr Harris has either failed to read his own legislation or he misunderstands the profound meaning of conscientious objection.” Dr Carr added, “Minister Harris told reporters that no doctor, nurse or midwife would be forced to participate in abortion services if they have a conscientious objection to them. This is simply untrue and is flatly contradicted by section 24, sub-section 2 of the legislation, which revokes the right of conscientious objection under a range of un-defined circumstances. Even without such circumstances being invoked, the accommodation of conscience rights provided for in section 24, sub-section , is eviscerated by the morally and logistically oppressive obligation to refer outlined in sub-section 3. Furthermore, the Minister continues to ignore the conscience rights of Pharmacists, Health and Social Care Professionals, and other healthcare staff, which will be violated if the legislation passes in its current form.” Dr Carr concluded, “Maybe the concept of conscience is somewhat remote to the practice of politics but, for the practice of healthcare, it is a vital touchstone. Even if Minister Harris doesn’t fully understand it, he could at least accord it some respect. Civilised co-existence in a pluralistic republic demands no less.”


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Profile

In the Chair with Cormac Tobin Cormac Tobin is somewhat of a pharmacy legacy within Ireland. With a background which begins in SuperQuinn, he swiftly climbed the career ladder efficiently and diligently. Having worked since he was only 13 years of age, he decided in 2017 it was time to hang up his Managing Director title and focus on family. Never one to shy away from offering his opinion on pharmacy and its prospects, both within Ireland and a struggling NHS, Cormac served as Managing Director with Celesio for ten years, before announcing his retirement in November 2017. “Cormac has been an energetic and trusted leader of our UK and Ireland businesses. He has built a strong leadership team for Celesio UK and his warm and engaging personality made him many friends across community pharmacy and beyond,” said Brian Tyler, Chairman of the Management Board of McKesson Europe which owns Celesio at the time of the announcement. “There is a genuine affection for him amongst our colleagues who value his ability to understand customers and patients and put them at the heart of everything we do. “I am grateful for the dedication that Cormac has shown over the last few years and his leadership through an ever-changing external environment. I wish him every success for the future.” Despite his retirement however, he is still putting his acute business acumen and sharp mind to good use, serving as Chairman on a number of Boards, including Cara Pharmacy, Fallon and Byrne, From me 2 you gift card Company and My Clinic on line doctor. On his decision to leave Celesio, he reflects that the time was ‘quite simply just right’ for him to return to Ireland. “Having lived away for so many years I missed out on a lot with regards to my family. It is with very mixed emotions that I left but I had five incredible years and enjoyed every bit. Paying tribute to Celesio he says it has “an unrivalled and talented team

Cormac Tobin, Chairman of Boards

who will continue to provide innovative and compelling patient and customer outcomes and experiences. “I started working in retail at the age of 13, packing bags and doing general housekeeping for Superquinn. Here, I rose through the ranks to become the youngest store manager in the group by the age of 23. In 1991, I was selected to tour the world for 6 months to improve my retail skills by working for associates of Senator Feargal Quinn, founder of the Superquinn supermarket chain. Soon after, I became manager of Superquinn’s flagship store in Blackrock where I oversaw a ¤4 million refit and delivered a 10% sales increase, which led to a Supermarket and Manager of the Year award. “I have been in business a long time and it’s time to relax.”

Technology is a vital part of community pharmacy’s future, and is what younger patients in particular want to see developed in pharmacy Looking back at his career highlights he says, “I took over Celesio UK to develop a new integrated strategy, accelerate business performance, comprising the following brands: AAH Pharmaceuticals Ltd, LloydsPharmacy, Online

Doctor, Evolution Homecare, Betterlife at Lloyds Pharmacy, John Bell & Croyden. “In 2015, I was appointed to the Celesio Europe Leadership Team and also became responsible for the Republic

PHARMACYNEWSIRELAND.COM | 9


Profile of Ireland. The Leadership team’s key responsibility is to formulate and execute strategy, policy and operational excellence across Europe. The UK Board increased profitability of the UK business overall by 45% and 4 turnover by 35% LfL. In all of our markets, we achieved considerable increases in market share where the company was either at a number 1 or number 2 position.”

effectiveness and efficiency of technology with the human intimacy and understanding. People want digital solutions but they also want physical engagement, so it’s very important to us in the products and the services that we provide that we build it around that.”

Future is Digital

In the future personal monitoring devices talk to one another and professionals will interpret people’s personal data collected real time, on blood pressure readings, for example, and take action as a result. “I’m really excited about that for pharmacy”, he said. “Pharmacy is in a position to do that, because they know so much about the patients.

Technology is the key that will unlock community pharmacy’s potential, Cormac believes, saying it would "release the genius of our pharmacists", taking the pressure off and giving them the time to do more "clinical work". "We are not responding in the right language to our patients’ needs. We are responding in a language that's locked in the 20th century," he said. There should also be “crosssector collaboration” between GPs, trusts, pharmacy bodies and pharmacists, he continued. "Everybody needs to understand each other's needs and come up with a compromise so that patients' experiences can be transformed to being meaningful in the modern era."

Younger people in particular don’t always want to go into a pharmacy, he adds.

“Pharmacists are geniuses,” he says. “They are passionate, talented, committed and highly skilled people. The personalised care they provide in their communities is so valued. Amazonisation is by no means the way forward for pharmacy – but “patientisation” most certainly is. He uses the term a lot. What does it mean?

Technology is a vital part of community pharmacy’s future, and is what younger patients in particular want to see developed in pharmacy, he says.

“It is about making sure patients are at the centre of how we do things. Technology can help smooth over the friction points of the service we provide. A good example would be delivering someone’s medicines to their place of work – if that is most convenient for them – using an online doctor service.”

“It’s very important that the technology in healthcare becomes more apparent, because technology will be one of the ways that we can solve the challenges the health service faces: using the speed,

Inevitably, conversation turns to the pharmacy cuts. He makes the point that the funding squeeze has hit the entire sector hard, no matter the size or ownership of the pharmacy business. LloydsPharmacy has

In the future personal monitoring devices talk to one another and professionals will interpret people’s personal data collected real time, on blood pressure readings, for example, and take action as a result 10 | PHARMACYNEWSIRELAND.COM

certainly borne its share of the pain, and earnings across the Celesio group even took a hit. “Costs are up, prescription volumes are rising, they key is to keep making efficiencies where you can. The danger for the sector is that this is becoming increasingly difficult to do without compromising patient safety,” he warns. The cuts, which he calls “draconian and counterproductive”, not only threaten pharmacy’s future, but hit at the very heart of what makes the sector an integral part of the communities and people it serves. “I said at the time that the lack of consideration of the bigger picture and shortsighted manner in which the cuts were imposed left a bitter taste. There is no line of sight to enable us to run our businesses progressively and invest in the future.” Cormac continues, “The leadership of the healthcare ec-system must wake up at

every level and put aside its professional and territorial differences. It is the custodian of this healthcare system and being so, it must provide inspiring leadership to authoritive, passionate and knowledgeable colleagues and teams. “They can provide seamless, innovative and relevant leadership at the intersection point of the digital and physical world we live in to provide compelling solutions and experiences to patients in multiple ways and touchpoints – where, when and how people need healthcare. “Taking a fresher approach, this will ensure more efficient caring and effective patient outcomes at a cost the State can afford.” However, there is much to be positive about with regards to the future of pharmacy, he says. “The future is bright right across the profession and as for me right now, well I’m just living the dream.”

Leaving a Reputation Cormac joined Celesio UK in 2013, overseeing a unique set of healthcare brands, from leading wholesaler AAH Pharmaceuticals to renowned community pharmacy chain LloydsPharmacy. His vision for Celesio UK was all about creating a healthcare eco-system which operates at the intersection point of the digital and physical worlds so customers and patients can live life to the fullest. This includes leading the way in innovation whether that’s reinventing the role of community pharmacy, establishing an omni-channel business or revolutionising off-site dispensing through new PAS systems. Cormac led the way with his commitment to providing compelling services for that inspire people to live more positive lives. This approach was evidenced by many successes under his leadership. Prior to joining Celesio, Cormac enjoyed a successful seven year period leading DocMorris and Unicare Pharmacy in Ireland. Prior to that, he held several management roles at Irish retailer, Superquinn. Starting there at the tender age of 13, Cormac rose through the ranks to become a board member in 2002. He holds an MBA in Retailing and Wholesale from Stirling University, Scotland.


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News news brief MEDICINE SUPPLY MUST BE TOP PRIORITY Contingency planning for the supply of medicines must be a top government priority as ongoing uncertainty makes a no-deal Brexit a real possibility. This warning was issued by the Irish Pharmacy Union (IPU) who has said that for Irish patients who receive over 75 million prescriptions each year the impact of a no-deal Brexit could be profound. The testing of medicines may also be severely impacted without a negotiated Brexit deal according to IPU Secretary General Darragh O’Loughlin. “Typically, every batch of medicine imported into the EU undergoes ‘batch testing.’ This involves confirming by laboratory analysis that it has the correct composition. Medicines from the UK which did not require batch testing in 2018 will require this process in 2019, risking delays in the delivery of medicines to wholesalers, to pharmacies and, ultimately, to patients. This would generate additional costs for suppliers, which would inevitably be passed onto patients and the State. “There are over 15,000 medications authorised in Ireland. Given the sheer scale of work that could be required to retain this supply of medicines, information about what contingencies are being put in place is long overdue. Without comprehensive answers from the Government, pharmacists cannot reassure patients that they will not have to change their medications or get new prescriptions from their doctors.” Mr O’Loughlin said stockpiling is not a feasible solution to any medicines supply difficulties post Brexit. “Even if pharmacies and wholesalers had the physical storage space to do so, this would still only be a shortterm measure. Minimising the impact on patients and ensuring a continuing supply of medications must be an absolute top priority for Government in the coming weeks.”

GSK and Pfizer enter giant Joint Venture GlaxoSmithKline plc has reached agreement with Pfizer Inc to combine their consumer health businesses into a new world-leading Joint Venture, with combined sales of approximately £9.8 billion ($12.7 billion). GSK will have a majority controlling equity interest of 68% and Pfizer will have an equity interest of 32% in the Joint Venture.

A GSK spokesperson told Irish Pharmacy News, “GSK announced that we have agreed with Pfizer to create a new world-leading Consumer Healthcare Joint Venture, which will include the world’s largest OTC business, and which GSK intends to separate to create a publicly-traded, UK-based company. Subject to approvals, we would expect to close the deal in the second half of 2019. The separation is expected to take place within three years of this so we will have a lot of time to understand the implications, if

any, for our sites in Ireland. Until then, it is very much business as usual and we will continue to keep our employees informed over the coming months and years as things progress.” It is understood painkiller brands Panadol and Anadin will be bought under one roof. Other brands involved in the deal include Aquafresh toothpaste and Chapstick lip balm. The deal still needs approval by shareholders and regulators. Shares in GSK rose 7% on the news.

GSK's consumer healthcare division used to operate as a joint venture with Swiss firm Novartis, but it acquired full control of the business nine months ago. The proposed transaction is subject to approval by GSK shareholders and conditional upon the receipt of certain anti-trust authority approvals. Subject to these approvals, the transaction is expected to close in the second half of 2019. The Board intends to recommend that shareholders vote in favour of the proposed transaction.

Brexit clock continues to tick With the Brexit clock ticking down, the Irish Pharmaceutical Healthcare Authority (IPHA) has hosted a roundtable to outline the steps the industry is taking to minimise any potential disruption to the continued supply of medicines to patients in Ireland. These preparations, which have primarily involved ensuring regulatory and supply chain readiness and compliance, have been under way for some time ahead a final determination of how the UK leaves the European Union, with or without a deal. The scale of the Brexit preparedness task the pharmaceutical industry faces is significant. Ireland has a critical reliance on the UK as a source of medicines. Up to 70% of medicines on the Irish market either come from, or transit, the UK. As well as that, up to 60% of medicines marketed here share common labels with the UK. Every month, around 45 million packs of medicines leave the UK destined for patients in Europe. Some 37 million packs transit the opposite way. That amounts to around one billion packs of medicine crossing the border between the UK and the European Union every year.

12 | PHARMACYNEWSIRELAND.COM

In preparing for Brexit, the industry been working closely with the Irish medicines regulator, the Health Products Regulatory Authority (HPRA), health authorities, customs officials and other State agencies. As Irish Pharmacy News was going to press, MPs in Westminister were due to vote on the Brexit Withdrawal Agreement. The Revenue Commissioner is committed to actively engaging with businesses to help in identifying and understanding the potential customs implications of Brexit and how the challenges can be addressed. They presented to IPHA and it is understood plans are underway between them and the pharmaceutical industry for emergency medicines coming into Ireland be ‘fast-tracked at customs entry points’ post-Brexit. Ireland is the world’s seventh-largest producer of pharma and chemical goods,

representing a ¤33.3bn market, and it is a hot spot in Europe for biopharmaceutical manufacturing. HPRA has said, “The HPRA recognises that there is still uncertainty over the outcome of the Brexit negotiations but we are planning on the basis that the UK becomes a third country in April 2019. This approach will allow us to manage all eventualities from a soft to a hard Brexit. “However, it is critical that companies also engage in this process. The HPRA’s commitment to supporting stakeholders is dependent on companies engaging with us on a timely basis. We are willing to use existing resources and increase resources to meet the commitments expressed above, but to deliver on this industry will need to give regulators timely and advance notice of their plans so we can prepare accordingly.”


Special Report

Report: MAS for Ireland – No sense in Delay Community pharmacists have been urging the Government to introduce a minor-ailment scheme that would allow patients with medical cards to be treated for common illnesses in pharmacies, without the need for a doctor’s prescription, for several years now. In 2016, the IPU and the HSE collaborated on a successful three-month pilot Minor Ailment Scheme in four towns - Kells, Roscommon, Macroom and Edenderry. An evaluation of this pilot scheme concluded that expanding it nationwide would be cost-effective for the Exchequer, would alleviate pressure on GP surgeries and would potentially prevent unnecessary use of Emergency Department Services. However, the scheme was never implemented, even though most IPU members said they would welcome it. "It is ironic that the HSE is now actively encouraging patients to visit their local pharmacy and avoid overcrowded GP surgeries while, at the same time, little effort has been made to introduce an initiative that the public overwhelmingly wants and which would offer immediate benefits to the public and to the HSE. Such a move, which would apply to conditions such as dry eye, dry skin, scabies, threadworm infection and vaginal thrush, would seriously alleviate pressure on overworked GPs, who could then see more seriously ill patients who may otherwise find themselves in hospital emergency departments. Similar schemes already operate successfully in other jurisdictions, including Scotland and Northern Ireland, and could help reduce pressure on the rest of the healthcare system. In November last year the subject was debated in the Dáil as Deputy John Brassil questioned the Health Minister as to when a decision will be

taken on the nationwide rollout of a scheme following a successful pilot in 2016. He also asked when the Minister will publish the HSE report that has already been submitted to his Department. Minister Simon Harris referred to the 2016 pilot but stated that ‘no meaningful clinical or outcome data emerged.’ “While the study successfully tested operational and administrative procedures, the patient take-up was small (121 consultations) and no meaningful clinical or outcome data emerged. If this is to be progressed, more extensive trialling, with defined outcome measurement, would be required in order to assess

14 | PHARMACYNEWSIRELAND.COM

whether a publicly funded minor ailments service represents an effective health intervention for medical card patients. “The report has been submitted to my department and is being examined by my officials. “Any expansion of services should address unmet public health needs, improve access to existing public health services delivered elsewhere or provide better value for money or patient outcomes if delivered through pharmacy. Expansion of publicly funded pharmacy services will be considered in the context of available resources, the potential for health gain and Government priorities for the health service,” he said.

"While more patients are getting sicker and GP surgeries and EDs are getting busier, it makes no sense to delay any further," IPU Secretary General Darragh O'Loughlin says. In this Report, we take a look at the necessary need and examine how such a service is running successfully elsewhere with documented support. With examples of success and reductions in both time and money, it must be asked why the HSE are stalling despite the evidence in favour. Reducing Time and Cost Twenty four million consultations are reported to take place in Irish general practice each year and over one million consultations in the out-of-


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Special Report The Story in Scotland

It is ironic that the HSE is now actively encouraging patients to visit their local pharmacy and avoid overcrowded GP surgeries while, at the same time, little effort has been made to introduce an initiative that the public overwhelmingly wants and which would offer immediate benefits to the public and to the HSE hours co-ops (NAGP OOH Co-Ops, 2013). With Irish GPs receiving ¤551.57 million from the HSE in 2017, this implies a cost of ¤22.98 per consultation. Analysis commissioned by the Irish Pharmacy Union (IPU) estimates that full implementation of a comprehensive Minor Ailment Scheme would save almost a million GP consultations per year (947,806 in 2016), freeing up approximately ¤22 million worth of valuable GP capacity in an overloaded GP service. A spokesperson for the IPU told Irish Pharmacy News, “Healthcare policy shows a clear commitment to a decisive shift towards primary care, and pharmacists have a key role to play in this. Sláintecare outlined the severe pressure on the health service and the need for it to be reoriented towards primary care. “Pharmacists are ideally positioned to expand the services they offer, taking pressure off GPs, and ensuring the public has access to professional, trustworthy and accessible healthcare in the community. There are a lot more services that can be provided in Irish community pharmacies. In Canada and the UK, for example, pharmacies provide additional services like a pharmacy based Minor Ailment Scheme, New Medicine Service, extended vaccination services and chronic disease

management, which are shown to deliver significant benefits to both patients and the State and to take pressure off other parts of the healthcare system, including GPs and hospitals.” Systematic reviews have found that consultations and prescribing for minor ailments by GPs decreased following introduction of the pharmacistled minor ailments service (PMAS). This is consistent with results from an earlier systematic review by the National Public Health Service for Wales in 2007, which also found a reduction in GP consultations for ambulatory conditions. Preliminary evaluations exist to suggest that PMAS will provide GPs with more time to care for patients with more serious illnesses. The IPU has already collaborated with the Department of Health and the HSE on a pilot Minor Ailment Scheme, which enabled medical card patients to receive treatment for common illnesses, free of charge, directly from their local community pharmacy in a timely manner and without the need for a visit to the GP. A review of the pilot found 91% patient satisfaction with the service and 91% resolution of symptoms. Feedback from participating pharmacists and GPs was also positive. The IPU spokesperson continues, “Pharmacists want

16 | PHARMACYNEWSIRELAND.COM

to extend the care and services they provide to patients and add even more value to the healthcare system. The future of the healthcare system rests in the advancement of pharmacists’ roles and the extension of the range of services that are provided. “Over the past number of years, the IPU has made several policy proposals to the Department of Health, which offered pharmacy-based solutions to primary healthcare deficits. These proposals include a Minor Ailment Scheme, an internationally recognised extended pharmacy service, which allows pharmacists to improve public health access, shape future services and broaden pharmacy roles to deliver quality patient care and improve health outcomes. “At present, private patients who want to access nonprescription medicines for ailments such as hay fever, migraine or skin conditions, consult with their local pharmacist on the best option for them, and pay for their over-the-counter medication. Medical card patients with the same ailments can only access the same medicines if they visit their GP and get a prescription. If a Minor Ailment Scheme were introduced, public patients would no longer have to make and wait for GP appointments, saving time for both the GP and patient.

Scotland serves as an appropriate comparison to Ireland, having similar sizing with regards to both population and community pharmacies. The national MAS was introduced in Scotland in 2006, but only children, people aged over 60 years, people with a medical exemption certificate and people on certain benefits can use it. The service in Scotland was originally developed to save GP appointments.It was designed to deter people from going to the GP simply to get a free prescription if they were exempt from charges and were unable tobuy medicines over the counter. It was well tested on paper and then electronically before being rolled out nationally. The Governmentfurther announced in September of last year that theyare to create an expanded community pharmacy minor ailments service available to everyone across Scotland.It is expected that a new national service would also cover a wider range of conditions that the current MAS. Clearly, this roll-out would not be forthcoming were it not for MAS demonstrating its ability to offer cost savings. This news followed on the back of a successful pilot scheme operating in a part of Glasgow. Although the Government is yet to decide on the details of how exactly MAS will run, it is a positive step forward. Speaking about the establishment and set-up of the new service, Deputy Director of the Royal Pharmaceutical Society in Scotland, Aileen Bryson told us, “For the past few years we have been at a strange place in that prescriptions are now free for everyone but only those who would have been exempt from charges previously are eligible for the eMASservice. “Our direction of travel is now to roll this out for everyone, making pharmacy the first port of call for common clinical conditions. The service has


“For patients there is no doubt it improves access to treatment and healthcareadvice. It reduces GP workload. Some practice managers have estimated that approx. 6% of GP appointments could be dealt with in the pharmacy and this is also true of A&E appointments. “The service started theprocess of pharmacist prescribing which is positive as the public see the professional side of pharmacy and not just a supply function. Aileen Bryson, MRPharmS, Deputy Director, Royal Pharmaceutical Society Scotland

expanded using PGDs to treat impetigo and simple UTIs and in some areas other skin infections and COPD exacerbations are also treatable. We are very pleased that the Scottish Government is recognising the potential of community pharmacy to play a bigger part in NHS treatment. “We will want to see the details in due course, but we are very pleased to see government commitment and would like this to continue, recognising the expertise available from pharmacists to improve patient outcomes in the community pharmacy sector,” she said. “It is about making sure that the patient sees the right health professional at the right time and we need to have good referral systems across the primary care team to ensure patient safety and continuity of care.” Reflecting on the challenges she adds, “The service has never been advertised outside of pharmacies and GP practices so many people do not know that it is available to them. The administration has proved a challenge at times in various different ways over the years but we hope this will be addressed in the expanded service.The initial thorough piloting and testing was essential as this had to be a smooth electronic process in order to be efficient.” However Aileen is adamant the benefits outweigh any obstacles and would also urge the Irish Government to follow their lead.

“We would recommend learning from what we have done here already, including the pilots and evaluations and the further developments now in the pipeline for “Pharmacy First”. The Community Pharmacy Management of Minor Illness (MINA) study, conducted by the University of Aberdeen, NHS Grampian and the University of East Anglia in January 2014, found that pharmacy minor ailment consultations were less expensive than GP consultations, and more than one in ten GP consultations were for a minor ailment that could have been treated in a community pharmacy. The study also narrowed down the primary reasons why patients tend to seek care from a community pharmacy: convenience; not having to travel too far; and thinking that their illness was not serious enough to warrant a visit to the GP. Kathy Maher, a Haven Pharmacist in Duleek also believes that pharmacists can support people with minor illnesses so that there is less

overcrowding in doctors’ surgeries. “We can filter people if they come to the pharmacy to see if an antibiotic is needed or not. We can also help them to manage viral illnesses with overthe-counter medicines, advice and self help,” she says. Pharmacy First in Northern Ireland Across the border, the Department of Health have been attempting to put pharmacy first. A Minor Ailments Scheme was introduced in Northern Ireland in 2008.It provides free prescriptions for a variety of everyday conditions such as ear wax, cold sores and mouth ulcers.It also provides treatments for other ailments including diarrhoea, head lice, Athlete's Foot and fungal infection free of charge. It was recently announced that a new Pharmacy First service, launched last winter, will enable patients to have a consultation in a private area with their community pharmacist for advice and treatment for sore throats, colds and flu-like illness. The service is available from participating community pharmacies from 1st December 2018 until 31st March 2019 and represents a £2.1m investment in pharmacy services from the Department of Health as part of the transformation of health services. Joe Brogan, Head of Pharmacy, Health and Social Care Board says, “Community pharmacists have an important role to play

as the ‘high street medicines expert’ and this service will reinforce that role “This service will utilise the skills and expertise of the community pharmacist to provide advice and treatment for a range of common conditions to support self-care. This will help support GP practices, GP out-of-hours services and Emergency Departments over the coming months when winter ailments occur more frequently.” Research from the Proprietary Association of Great Britain (PAGB) shows that up to 40% of GP time in the UK is taken dealing with patients suffering from common conditions. All patients registered with a GP in Northern Ireland are eligible to avail of this service, with the exception of temporary residents and patients living in nursing or residential homes. In conclusion, and with anticipation of a speedy resolution, the IPU told us, “We would now like to see the development and roll-out of a comprehensive national Pharmacy Minor Ailment Scheme which would generate economic savings, provide immediate enhancement of health service capacity, and improve ease of access for patients. Full roll-out of a Minor Ailment Scheme is ready to go from the perspective of community pharmacists, and should be rolled out to ensure equity and efficiency, and to ease pressure on the health service.”

The Community Pharmacy Management of Minor Illness (MINA) study, conducted by the University of Aberdeen, NHS Grampian and the University of East Anglia in January 2014, found that pharmacy minor ailment consultations were less expensive than GP consultations, and more than one in ten GP consultations were for a minor ailment that could have been treated in a community pharmacy

PHARMACYNEWSIRELAND.COM | 17


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Concept Launch Concept Pharmacy launch at Charlemont Sam McCauley Chemists is continuing its expansion plans as they recently opened their newest McCauley Pharmacy in the very exciting Charlemont Square development in Dublin 2.

The greenfield city centre location provides a unique offering, and falls into line with the company’s plans for further development with a focus on the greater Dublin area. The group has recently announced the relocation in early 2019 of it’s support office to Citywest in Dublin. Majority-owned since last year by private equity group Carlyle Cardinal Ireland, it is believed the new Charlemont store has seen a ¤700,000 investment in a location that will include 300,000 sq. ft of offices, 200 apartments and shops.

continue to grow to between 70 and 100 shops.

¤12m, bringing annualised turnover for the group to ¤95m+.

Following the significant investment by the private equity fund Carlyle Cardinal Ireland (CCI) in 2017 Mc Cauleys acquisitions comprise Life Pharmacy in Clondalkin, Fermoy Medical Hall, two Nolans Haven pharmacies in Navan, Doyles Pharmacy in Athy, French’s Pharmacy in New Ross along with a green field opening in Enniscorthy. The new stores have a combined turnover of approx.

“As an ambitious business, we are excited to be expanding our presence in and around the country and look forward to serving the people of those communities. Both acquisitions are part of a growth strategy for the business that will see McCauley Chemists grow its presence in Dublin and larger provincial locations throughout Ireland,” Tony says.

The store has unique offerings, including 7am-7pm opening hours to the benefit of their catchment area in the busy centre, and aims to provide services which combine the traditional setting of the community pharmacy dispensing medications and offering OTC services alongside a vast beauty and hair department; award-winning hairdresser and celebrity favourite, Ceira Lambert, has opened a salon within the store. This exciting store is the first store in the group boasting the completely rejuvenated Mc Cauley brand. Tony McEntee, Chief Executive of Sam McCauley, says the group are “actively considering” other acquisitions and greenfield developments, and having grown from 30 to 38 outlets in the last 12 months it has ambitions to

20 | PHARMACYNEWSIRELAND.COM

“Whilst we will be opening green field sites, we believe that the bulk of our growth plans will be delivered through acquisitions. 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.”


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News Financial and mental strain being placed on Pharmacy students Pharmacy students across Ireland have, exclusively to Irish Pharmacy News, highlighted difficulties under the new MPharm programme and have voiced their concerns on a lack of payment for placements. “These astronomical fees never had to be paid by a student in the past. This integrated degree was developed to benefit us, the students. We have yet to experience any of this benefit. All we are experiencing is financial strain, stress and unhappiness. In a previous email you stated that the new integrated 5-year degree will inflict 'short term financial consequences on students'. This statement undermines the consequences of this financial strain, with a worrying amount of young Intern Pharmacists experiencing various mental health issues as a result, including anxiety and depression.

Under the terms of the new integrated Masters of Pharmacy programme, 4th year pharmacy students are presently undertaking a four month unpaid placement. “We work 9-5.30 four days a week, carrying out the same tasks as a pharmacy technician,” A 4th year pharmacy student, who wished to remain anonymous, told Irish Pharmacy News.

paid up to 14 euro an hour, at the discretion of the employer. The new course, introduced in 2015, is a five-year integrated masters programme under one of the three schools of pharmacy in Ireland – UCC, TCD, RCSI. As a result, pharmacy students must now complete a four-month placement in year 4 and an eight-month placement in year 5 – both unpaid.

“Furthermore, as 5th year students we are expected to undertake an 8 month unpaid placement, with an increased cost of fees from ¤3000 to ¤7,500 in UCC, ¤8,500 in TCD and ¤9000 in RCSI. As a result, each pharmacy student faces an approximate deficit of at least ¤25,000.”

“Some students are having to work nearly seven days every week to financially support themselves and to be able to attend placement. One third of pharmacy students are currently in receipt of the SUSI grant. However, it is unclear whether the fifth year will be covered by this, thus students may have to take a year out between fourth and fifth year to work to afford their fees.

Many students are experiencing financial strain as well as mental health issues associated with their study. University Students Ireland (USI) alongside pharmacy students have therefore written an open letter to the Pharmaceutical Society of Ireland. The letter states, “The old course consisted of a 4-year undergraduate programme followed by a one-year internship,

“The Department of Education refuse to fund fifth year and the Pharmacy Schools and the PSI are against intern pharmacists being paid for their work. We would like clarification on who used to cover the costs of the NPIP year in the past. We would like to know what we are paying for and why?

22 | PHARMACYNEWSIRELAND.COM

“Contributing factors to the mental health status of Intern Pharmacists at present is not limited to the financial strain. It is also because we are unmotivated whilst at placement. If you look up the definition of extrinsic and intrinsic motivation you will understand what we are referring to. Receiving payment for the work which we do would contribute towards building the self-esteem, work ethic and work morale of student pharmacists. Receiving payment would also make us feel more competent and thus contribute to our intrinsic motivation. “You also mentioned that 'the opportunity presented by the new programme for careful teaching and professional mentoring would be an invaluable asset' in this email. Could you explain to the pharmacy students of Ireland how so? What is the program for careful teaching and professional mentoring? Will the preceptors be receiving a new training plan to educate them as to how they are to deliver this ‘professional mentoring’ during the 8 months? If so, is it possible for this training plan to be circulated to the students of all three schools of pharmacy so that we can see exactly what the astronomical fifth year fee is funding? What additional education shall we be receiving for this new fee? How will it be an invaluable asset to us?

“You also mentioned that 'the 5th year placement is not designed for pharmacy students to act as technicians'. We would like to inform you that regardless of what your intentions were when designing the new course, it is inevitable that we will be acting as technicians during our 8-month unpaid placement. We will be performing all the same tasks and duties in the pharmacy as a pharmacy technician would be doing. Examples of these activities are putting away the drugs order, putting prescriptions through the software, generating labels, gathering the drugs for final checking by the pharmacist, getting the claim ready at the end of the month, performing extemporaneous compounding etc. “This new integrated degree was designed to enhance students’ learning. We urge you to listen to us, the students. Please consider our opinions and respond promptly to them. Our learning is not being enhanced. We are not benefiting from this new course in any way. We are not learning more or gaining anything different from those students in the year ahead of us who are in the old 4 + 1 model. We are suffering financially but more importantly, and alarmingly, we are suffering mentally. “In the real world, you learn on the job. The notion that a student can sit on placement for 4-months and simply ‘learn’ and not work is incredulous. Working and learning are not mutually exclusive. They go hand in hand. This new degree programme has generated a lot of upset for students, with very little educational gain. We should be looking forward to our careers as Pharmacists. Instead we will emerge disappointed and in low spirits. It is the duty of the PSI to take our feedback into account and listen to our concerns to ensure the course can be improved for the future pharmacy classes to come. If not, it appears the pharmacy degree will become a course solely reserved for the ‘elitist’.”


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Prospects and Emerging Trends in the Supplements Market Increasing numbers of people are taking a proactive approach to their health and the wellbeing trend is sweeping the nation. the acquisition of health giant Merck by Procter & Gamble in April 2018. Prior to this move, Procter & Gamble divested part of its beauty and personal care line to Coty, with the company now well positioned to grow its presence within consumer health in Ireland and abroad. The experience that P&G has from its beauty and personal care lines indicates that the company is likely to aggressively market the consumer health care brands it gained through the Merck acquisition. There has also been considerable investment by several brand to get their product endorsed by brand ambassadors. Emerging Trends Keeping up with consumers or even getting a bit ahead of their desires is the name of the game. In the ever-changing and extremely fickle vitamins, minerals and supplements (VMS) category, it is even more vital to stay on pace or ahead of the curve with those visiting their local pharmacy, many of whom are demanding the next greatest product from this category to allow them to maintain a healthy lifestyle. Consumer demands for the next best thing from the VMS category always has put a burden on manufacturers to keep the new product pipeline going, and for pharmacies to have a sizeable selection of products that meet as many needs as possible. Globally, the over the counter (OTC) drugs and dietary supplements market is driven by improvement in lifestyle and ageing of baby boomers, rise in consumer awareness related to preventative healthcare, and proliferation of distribution channels. In addition, increase in trend of self-directed consumers and self-medication for the treatment of primary health conditions have fuelled the market growth. However, stringent regulations by FDA and other governing bodies related to the safety and efficacy of OTC medications have delayed the approval restricting the market growth.

Locally, according to Euromonitor International’s report, ‘Vitamins in Ireland’ published in November 2018, vitamins sales are expected to continue growing as consumers increasingly look towards preventative measures over cures. A growing number of consumers are expected to monitor their health through blood tests, which will result in greater awareness of vitamin and other deficiencies. The report highlights some key facts: • Vitamins retail current value sales grow by 2% to reach ¤16 million in 2018 • With higher disposable incomes, consumers can afford to supplement their diets with vitamins • Vitamin D leads growth in 2018, with retail current value sales rising by 5% • Vitamins is expected to post a retail value CAGR of 1% at constant 2018 prices over the forecast period, with sales reaching ¤17 million in 2023 Prospects Vitamins sales are expected to continue growing as consumers increasingly look towards preventative measures over cures. A growing number of consumers are expected to

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monitor their health through blood tests, which will result in greater awareness of vitamin and other deficiencies. While many fitness conscious consumers monitor macronutrient levels (ie fat, protein, carbohydrates), there is expected to be a gradual shift towards focusing on micronutrients also, which will benefit the area. However, there is also likely to be stronger demand for multi functionality products that contain both vitamins and other supplements that complement each another. Vitamin D is set to drive sales growth over the forecast period. Awareness of the importance of supplementation due to limited sunshine is increasing. It is strongly recommended that consumers supplement their diets with vitamin D, particularly babies and small children in winter time. Ireland’s weather is not likely to improve considerably. The country’s geographical position provides long hours of daylight in summer but short periods of daylight in wintertime. With Ireland also having a moderate climate where it rains a lot, sunshine is not relatively common sometimes even in summer. This will continue to be the case, thus fuelling demand for vitamin D over the forecast period. Competition in vitamins could become more intense following

Decisions in purchasing Consumers purchase VMS for reasons often driven by their age. The rise in health technology is starting to show effect as younger consumers are turning to VMS to self-treat symptoms or meet certain fitness requirements. Older generations are often using VMS to avoid sickness and the development of chronic health conditions. Demographic segmentation Whilst male VMS represents the smallest segment of the market, it has been experiencing the fastest growth. The majority of products targeted at men have a clear focus on sports nutrition, while products for the everyday male consumer are less represented, presenting an opportunity for businesses. Similarly, there is potential to capitalise on the growing demand for sports related supplements for older generations, targeting against muscle wastage and maintaining healthy joints and for active females. Fun and innovative formats New product development has led to an increase in innovative delivery formats, including powders, chews, transdermal creams and sprays, helping the brand stand out and broaden the category to include children and teenagers. Powder based VMS products, which consumers can add to their food or drink to


Feature

improve its nutritional content, are often perceived to be more 'natural', and as such are a key focus area for many brands. Own label brands however remain heavily focused on launching conventional pill methods which are regularly seen to be the most convenient format. Powder based VMS products which consumers can add to their food or drink to improve its nutritional content, are often perceived to be more 'natural', and as such are a key focus area for many brands. The Lifestyle Effect Increasingly hectic lifestyles and busy work schedules mean we are a current population who eats out more often, with this in turn often leading to over-indulgence in meals which are often unbalanced in terms of nutrition. Alternatively there are many who just don’t have the time to eat adequately. There is also an adverse effect on health and wellbeing with tiredness and stress being two of the more pressing concerns. Nutrients that are of concern include: Vitamin D: Studies by scientists at University College Cork report one in 8 Irish people have vitamin D deficiency. Bones can become frail and soft if they are lacking in vitamin D. Severe cases of vitamin D deficiency can cause rickets in children and osteomalacia in adults. Vitamin D deficiency has been linked to other health

issues such as cancer, asthma, depression, Alzheimer’s, type-II diabetes, high blood pressure and such autoimmune diseases as multiple sclerosis, type-I diabetes and Crohn’s. From October to early March, people should rely on getting their vitamin D from certain foods and vitamin supplements. Iron: one in 10 women are anaemic, yet many have no idea, even though their iron levels might be so low that their body’s producing less red blood cells, meaning they have full-blown iron-deficiency anaemia.This can have a significant impact, as iron is essential in the production of red blood cells, which are responsible for carrying oxygen around the body, keeping various tissues and organs in working order. But while the symptoms, including tiredness, shortness of breath, palpitations and a rapid heart rate, headaches, paleness, hair loss and brittle nails, can have a significant effect, they’re often ignored, or dismissed as an inevitable sideeffect to hectic, modern lifestyles. Haemochromatosis affects around one in 200 people across Europe, but it’s particularly prevalent in Ireland, affecting one in 83 people. Those with haemochromatosis take in too much iron, leading to an overload which can result in symptoms such as tiredness, depression, joint and abdominal pain and loss of sex drive. Haemochromatosis can only be

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developed if both parents are carriers of the gene. As part of its awareness drive the HSE has said that research indicates early diagnosis should see the manageable condition being no barrier to a normal life. The element iron is required for the body to produce hemoglobin in red blood cells to transport oxygen around the body. Those with haemochromatosis have a mutation in this function in that they keep taking in too much iron after this process.As public awareness of the condition is low, symptoms (which include fatigue, depression, joint and abdominal pain and loss of sex drive) are often confused with other health issues. Magnesium: The average healthy adult requires around 270-400mg of magnesium per day, but research has shown that threequarters aren't getting a good enough fix. In fact, magnesium deficiency is one of the most common nutritional deficiencies in adults today, and this is associated with an increased risk of conditions such as diabetes, poor absorption, chronic diarrhoea, coeliac disease and 'hungry bone syndrome'. Experts have even dubbed it the 'invisible deficiency', because it is so often overlooked. Studies have shown that when magnesium levels are too low, it’s harder to stay asleep. Magnesium also has a role in hormonal regulation and may also help blood

sugar balance which can help with mood issues such as depression and anxiety. Selenium: up to half of adults and teenagers do not meet the recommended intake. This nutrient doesn’t get the same ‘buzz’ as vitamins C and D or calcium. It is needed in much smaller quantities than many other nutrients, but there are many ways selenium benefits the body, playing a role in reproductive health, thyroid function, DNA synthesis, and it’s also an antioxidant. Women and men need 55 mcg per day of selenium, which is considered a trace element. (Women who are pregnant or breastfeeding need 60 and 70 mcg, respectively.) Most people do get adequate amounts in their diet, though those who smoke, drink alcohol, or take birth control pills may run low in the mineral. Folic acid: Current guidelines state that all women thinking of having a baby should have a folic acid supplement, as should any pregnant woman up to week 12 of her pregnancy. Folic acid can help to prevent neural tube defects. Pregnant and breastfeeding women are also at risk of vitamin D deficiency and should take a daily supplement containing 10 micrograms – a point pharmacy teams could raise with expectant mothers. Fish oil supplements should be pregnancy-specific to avoid high doses of vitamin A, and breastfeeding women should continue with vitamin D and fish oil supplementation.


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Feature Consumption Safety New guidelines on how many vitamins and mineral supplements can be safely consumed were published in June of last year by Ireland’s food regulator, alongside warnings about the dangers of over consumption. The new report from the Food Safety Authority of Ireland’s (FSAI) Scientific Committee outlines the process that the burgeoning food supplement industry can use to establish maximum safe levels for 21 of the 30 vitamins and minerals permitted in food supplements in Ireland. The report sets out tolerable upper intake levels of these nutrients for the population of Ireland which can be used by the food supplement industry as a guide to ensure that the daily dose provided by supplements containing vitamins and minerals is safe when placed on the Irish market. Ageing population Nutritional issues play a key role in a wide range of age-related diseases and debility. The potential for good nutrition and physical activity programmes to improve health outcomes in later years are so far under-exploited, yet are urgently called for, as the Irish population ages. Within the next 40 years, approximately one in four Irish people will be over 65 years of age compared with less than one in nine currently. Without the implementation of strategies to address nutritional issues affecting this age group, such a demographic shift will pose enormous challenges for Irish society and its healthcare system. Although still under-detected and undertreated, malnutrition has been recognised by Governments across Europe, including Ireland, as an urgent public health issue that needs to be addressed, although a national action plan Supplements, such as a daily multivitamin, can provide an effective strategy for maintaining health, supporting nutrient intakes, plugging dietary gaps and helping to address the nutritional challenges associated with ageing. Due to weaker digestive systems in older age, it is difficult for the human body to absorb the required nutrients from food. Among the geriatric population, loss of appetite and the weakening of bones are common issues. In many cases, the diet does not contain sufficient calories or the essential nutrients that the body needs. With the growing interest in healthy ageing, B vitamins, fish

oils and zinc have all been shown in randomised clinical trials to support cognitive function, while vitamin D is recommended across the board for the over 65s. Managing the Category There is a plethora of conflicting information about the advantages and benefits to be had of certain supplements over others, in addition to a variation in the quality of products with the same ingredients. Ultimately, the decision will come down to what is seen as convenient and best suited for the purchaser. What is deemed an important quality by one customer may be an entirely different issue for another. Pharmacists should highlight products that have some research behind them and are manufactured with high quality control. It may also be beneficial to purchase from companies that are investing in promotional campaigns that could draw more customers into pharmacy, as well as companies that offer in-store support material and training for pharmacy staff. It is always important that a customer walks away from their pharmacy feeling like all their specific health needs were met. More often than not they will come away from the experience with more knowledge through the education given to them during their visit. Therefore pharmacists and their staff should provide customers with clear advice and guidance on the variety of products available. When it comes to stock, keep in mind that there will always be the need for the basic vitamin and mineral essentials such as calcium, vitamins B, C and D and magnesium.

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Whilst the setting of maximum safe levels of vitamins and minerals in food supplements is provided for in EU law, the precise levels have not been established yet. The FSAI will be working with the food supplement industry to establish guidance for the marketing of safe vitamin and mineral supplements in Ireland. Dr Pamela Byrne, CEO, FSAI states that under food law, all food supplements marketed in Ireland for the first time must be notified to the FSAI. The number of food supplements notified to the FSAI as being on the Irish market has been increasing year on year and it is incumbent on the food supplement industry to take on board this new guidance, reformulate their products accordingly and provide labels that are easy for consumers to understand. “The numbers of food supplements that have been notified to us has risen from 700 in 2007 to over 2,500 in 2017 – an increase of over 300%. Of those notified, the number of products that require more detailed examination to assess if they pose a risk to consumer safety is also continuing to rise, with over 95% of food supplements requiring this due to high vitamin or mineral content. We are concerned about the growing number of these products and, in particular, the safety of vulnerable groups of the population in Ireland including children, pregnant women and older people. This comprehensive report enables us to provide robust advice and guidance to the industry on the levels of nutrients for their products by age and gender groupings. “Our advice for the general public regarding taking food supplements is that it is not necessary to take food supplements to maintain a healthy lifestyle. The FSAI recommends a wellbalanced diet with plenty of fruit and vegetables and, plenty of exercise. The only food supplements that the FSAI recommends are 400µg folic acid per day for women who are sexually active and a 5µg vitamin D3 only supplement per day for all infants from birth to 12 months”, added Dr Byrne. People in Ireland are becoming more aware of the importance of a varied and balanced diet for good health which is positive; however, some are using food supplements in their diet and there can be a mistaken belief that ‘more is better’,” says Professor Albert Flynn, Chairman of the FSAI Scientific Committee. “There can be adverse health effects when people take too much of some vitamins or minerals. “This is particularly true when it comes to children and adolescents who may be taking the same amounts of vitamins and minerals from food supplements as adults, despite having different needs and smaller body sizes. We know from recent surveys of dietary practices in Ireland that most people are getting more than enough vitamins and minerals from their diet alone,” he added.


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CPD 98: MANAGEMENT OF LOWER BACK PAIN Biography - Paul Knox earned his higher diploma in Community Pharmacy from Cloughjordan Pharmacy with Distinction and started in Coffeys Pharmacy Roscrea in 2013. There he was quickly promoted to Managing Pharmacist before he and his wife Tanya took over the Pharmacy in October 2016. Paul also holds a masters degree from Trinity College Dublin.

Management of Lower Back Pain INTRODUCTION

• Low back pain

Lower back pain is a nebulous term covering a myriad of physical and, in some cases, psychological maladies. It is the most common musculoskeletal condition affecting the adult population with up to 80% of persons being affected by it one way or another during the course of their lifetime. In fact, most of us can probably think of at least one person in our lives who suffer or have suffered from this debilitating complaint. The problem can persist for days, weeks, and intermittently for years and have a real economic cost directly and indirectly. Chronic low back pain is, as the name suggests, a chronic pain syndrome in the lower back region persisting for at least twelve weeks. Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing , avoiding this close time criterion – this definition is significant as it underlines the concept that chronic low back pain has well-defined underlying pathological causes and that it is a disease in its own right, not merely a symptom.i

• Lumbago – generalise pain in the muscles and joints of the lower back

This article hopes to shed some light on how our role as pharmacist can assist in the initial diagnosis, referral, treatment, management and/or recovery of this condition. DIAGNOSIS AND CLASSIFICATION Given the complexity of the condition, the diagnostic evaluation of patients with lower back pain can be very challenging and requires complex clinical decision making. Ultimately, the answer to the question ‘what is the pain generator?’ among the several structures inovolved is the key factor in the management of these patients, since a diagnosis not based on on specific pain generator can lead to therapeutic mistakes. Low back pain, without symptoms or signs of serious medical or psychological conditions associated with clinicial findings of – 1. Mobility impairment in the thoraic, lumbar or sacroiliac regions 2. Referred or radiating pain into a lower extremity, 3. Generalised pain is useful for classifying a patient into the following International Statistical Classification of Diseases and Related Health Problems (ICD categories):

• Lumbosacaral segmental/somatic dysfunction – a clinical diagnosis for a spinal joint complex disorder presenting with pain and/or altered function • Low back strain

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?

• Spinal instabilities • Flatback syndrome – a condition in which the lower spine loses some of its normal curvature resulting in the patient becoming inbalanced and hence may tend to lean forward when standing or walking • Lumbago due to displacement of intervertebral disc • Lumbago with sciatica – pain affecting the back, hip, and outer side of the leg, caused by a compression of the spinal nerve root in the lower back, often owing to degeneration of an intervertebral discii LOW BACK PAIN EPIDIEMIOLOGY As mentioned above, lower back pain represents a major social and economic problem. The prevelance of acute and chronic lower back pain in adults doubled in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups. Evidence does suggest, however, that females are more likely to be affected than males when all factors such as age, and other co-morbidites are taken into account. The condition has a significant impact on functional capacity, as pain restricts occupational activites and is a major cause of absenteeism. Its economic burden is represented directly by the high costs of health care spending and indirectly by decreased productivity.ii WHERE IS THE PAIN COMING FROM? Lower back pain symptoms can derive from many potential anatomic sources such as nerve roots, muscle, fascial structures, bones, joints, intervertebral discs and organs within the abdominal cavity. Moreover, symptoms can also spawn from aberrant neurological pain processing

neuropathic lower back pain – thus the diagnositc evaluation of patients with lower back pain can be very challenging. Nevertheless, the identification of the source of the pain is the most important aspect of diagnois and will determine the ultimate therapeutic appraoch. However, one must not discount psychological factors such as stress, depression and/or anxiety. History should also include substance use exposure, an holistic health history, work, hobbies and activities, and psychological factors.i The type, location and severity of low back pain depends on the cause – • Local cause • Nerve root involvement e.g Sciatica – leg pain which may be acute/chronic, mild severe, burning or shooting in nature and may extend up to the ankle or foot. It may be constant or intermittent and may be worsened by coughing, sneezing, straining, breath holding, walking or rest, and micuraion and defecation. • Local back strain or sprainiii Other more serious underlying causes may also have to be considered and these ‘red flags’ are listed below – • Recent significant trauma or milder trauma age > 50 years • Unexplained weigh loss • Unexplained fever • Immunosupression

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CPD 98: MANAGEMENT OF LOWER BACK PAIN • History of cancer • IV drug use • Osteoporosis, prolonged use of corticosteroids • > 70 years • focal neurological deficit with progressive or disabling symptoms. • Caudaequina Syndrome – type of automnomic root involvement whichr requires immediate medical or surgical intervention.iii Clinical information is the leading element that drives the initial impression, while MRI should be considered only in the presence of clinical elements that are not definitely clear or in the presence of neurological defects or other medical conditions. The recommendation is not to do imaging for lower back pain with the first six weeks unless the red flags (see above) are present. Conventionally the cause of the pain can be divided into non-spinal and spinal causes respectively.iv There is an importance of avoiding the common mistake of diagnosing “simply low back pain” thus resulting in improper treatment of a definiton and not a complex disease – it is an important distinction. A multidiscipliary diagnosis and multimodal treatment is necessary. ANATOMY OF THE LOWER BACK While this is not particularly relevant for us as pharmacists, it is important to have a basic knowlegde of the area about which the patient is complaining.

Low Back Pain Low Back Pain

The lumbar spine consists of five vertebrae (L1-L5) as shown above. The complex anatomy of the lumbar spine is a combination of these strong vertebrae, linked by joint capsules, ligaments, tendons and muscles with extensive innervation. The spine is designed to be strong to serve is protective function but it is also flexible with the abilty to move in many different planes.i PATHOPHYSIOLOGY OF SPINAL PAIN Pain is mediated by nociceptors, specialised peripheral sensory neurons that alert us to potentially damaging stimuli at the skin by transducing these stimuli into electrical signals that are relayed to higher brain centers. Nociceptors are pseudo-unipolar primary somatosensory neurons with their neuronal body located in the DRG . They are bifurcate axons: the peripheral branch innervates the skin and the central branches synapse on

second-order neurons in the dorsal horn of the spinal cord. The second-order neurons project to the mesencephalon and thalamus, which in turn connect to somatosensory and anterior cingulate cortices in order to guide sensorydiscriminative and affective-cognitive features of pain, respectively. The spinal dorsal horn is a major site of integration of somatosensory information and is composed of several interneuron populations forming descending inhibitory and facilitatory pathways, able to modulate the transmission of nociceptive signals. If the noxious stimulus persists, processes of peripheral and central sensitisation can occur, converting pain from acute to chronic. Central sensitisation is characterised by the increase in the excitability of neurons within the central nervous system, so that normal inputs begin to produce abnormal responses. It is responsible for tactile allodynia, that is pain evoked by light brushing of the skin, and for the spread of pain hypersensitivity beyond an area of tissue damage. Central sensitisation occurs in a number of chronic pain disorders, such as temporomandibular disorders, LBP, osteoarthritis, fibromyalgia, headache, and lateral epicondylalgia.v Despite improved knowledge of the processes leading to central sensitisation, it is still difficult to treat.vi Peripheral and central sensitisation have a key role in LBP chronification. In fact, minimal changes in posture could easily drive long-lasting inflammation in the joints, ligaments, and muscles involved in the

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stability of the low back column, contributing to both peripheral and central sensitisation. Furthermore, joints, discs, and bone are richly innervated by A delta fibers whose continuous stimulation could easily contribute to central sensitisation. DIFFERENTIAL DIAGNOSIS Clinicians should consider diagnostic classifications associated with serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when; 1. The patient’s clinical findings are suggestive of serious medical or psychosocial pathology 2. The reported activitly limitations or impairments of body function are not consistent with conventional guidelines, 3. The patient’s symptoms are not resolving with interventions aimed at normalisation of the patient’s impairments of body function.ii DIAGNOSISTIC METHODS (NON-INVASIVE) 1. Neurologic exam incorporating gait; motor sensory and reflexes 2. Regional exam of spine and leg – inspection for scoliosis or skin rash, palpitation for bone tenderness. 3. Sciatic and femoral nerve 4. Strength tests


CPD 98: MANAGEMENT OF LOWER BACK PAIN THE PATIENT AND THEIR PAIN As lower back pain is such a complex malady with a constellation of symptoms, the patient is obviously the key component in the diagnosis and their future therapy. The images below describe quite effecienly how to glean relevant information from a patient regarding their pain.iv Lower back pain is considered to be non-specific, and the misconception the the cause of 80-90% is unknown has persisted for decades.vii

History Aggravating/Relieving Factors What Makes Better

What Makes Worse

Muscle tension and spasm are among the most common reasons for LBP, for example, in patients with fibromyalgia. In other cases, LBP can be attributed to different pain generators, with specific characteristics, such as • Radicular paini- Radicular pain is pain evoked by ectopic discharges emanating from an inflamed or lesioned dorsal root or its ganglion; generally, the pain radiates from the back and buttock into the leg in a dermatomal distribution. Disc herniation is the most common cause, and inflammation of the affected nerve rather than its compression is the most common pathophysiological process. Radicular pain is pain irradiated along the nerve root without neurological impairment. If a patient’s history and physical examination findings indicate lumbar disc herniation with radiculopathy, the most suitable noninvasive test to confirm this could be an MRI. This is particularly important if it is necessary to proceed with an invasive treatment or to better define the neurological impairment. The next most appropriate test to evaluate the presence of lumbar disc herniation is computed tomography (CT) or CT myelography, which would be suitable for those individuals unable to have an MRI because it is contraindicated or those for whom MRI is inconclusive. • Facet joint syndromei- The lumbar zygapophyseal joints are the posterior articular process of the lumbar column. They are formed from the inferior process of upper vertebra and the superior articular process of lower vertebra. They are supplied by the medial branches of the dorsal rami (MBN). These joints have a large amount of free and encapsulated nerve endings that activate nociceptive afferents and that are also modulated by sympathetic efferent fibers. Unlike radicular pain above, history and clinical examination remain fundamental steps in the diagnosis of facet joint syndrome • Sacroiliac joint paini - Sacroiliac joints (SIJs) are dedicated to providing stable but flexible support for the upper body. SIJs are involved in sacral movement, which additionally directly influences the discs and almost certainly the higher lumbar joints. Its innervation is still not well known but has been reported to be by branches from the ventral lumbopelvic rami; however, this has not yet been confirmed. SIJ pain is often underdiagnosed. It has to be considered in every situation in which the patient complains of postural LBP that worsens in a sitting position and with postural changes. Furthermore, it is possible that SIJ pain is often strictly related to facet joint syndromes as both are related to postural problems. Finally,it is important to consider that SIJ

BEWARE OF THE PATIENT THAT SAYS NOTHING MAKES PAIN BETTER!

pain could also be a sign of rheumatic disease. MRI findings of articular effusion and inflammation (especially if bilateral) can alert the clinician to consider this condition. • Discogenic paini - Disc degeneration (DD) has been estimated as the source of CLBP in 39% of cases. Its symptoms are aspecific, axial, and without radicular radiation and they occur in the absence of spinal deformity or instability. DD is often a diagnosis of exclusion among other types of CLBP. Pathologically, it is characterized by the degradation, within the disc, of the NP matrix with accompanying radial and/or concentric fissures in the annulus fibrosis. Despite numerous recent advances, the main issue is how inflammation is initiated and sustained to lead to CLBP. A possible explanation could involve the growth of nerves capable of signaling pain deep into the annular structures. Imaging MRI can detect changes in the endplates and in the vertebral bone marrow, such as edema in the vertebral bodies (Modic type 1). Clinical trials have demonstrated that some patients suffering from LBP have improvement following amoxicillin-clavulanate. Moreover, diabetes increases the risk of developing painful DD because advanced glycation end products (AGEs) induce catabolism and promote inflammation. • Lumbar Spinal stenosisi - Lumbar spinal stenosis (LSS) can be congenital or acquired (or both). It could be determined by inflammatory/scar tissue after spine surgery or, even in absence of previous surgery, by disc herniation, thickening of the ligaments, or hypertrophy of the articular processes. The majority of cases of LSS are degenerative, related to changes in the spine with aging. LSS is determined by a progressive narrowing of the central spinal canal and the lateral recesses and consequent compression of neurovascular structures. LSS is generally diagnosed based on a combination of history, physical examination, and imaging. The most useful findings from the history are age, radiating leg pain that is exacerbated by standing up or walking, and the absence of pain when seated. The gait and posture after walking may reveal a positive “stoop test”, performed by asking the patient to walk briskly. As the pain intensifies, patients may complain of sensory symptoms followed

by motor symptoms, and if they assume a stooped posture, symptoms may improve. If patients sit in a chair bent forward, they may have the same relief. MANAGEMENT OF LOWER BACK PAIN General considerations – • Primary therapy related to aetiology • Patient expectations • Patient education and related to pain treatment • Cost effectiveness • Prevention of back pain exacerbations • Prevention of unnecessary surgery and suffering (Failed-back-surgerty syndrome)iv NON-PHARMACOLOGIAL INTERVENTIONS Self-management Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include: • information on the nature of low back pain and sciatica • encouragement to continue with normal activities. Exercise Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within for people with a specific episode or flare-up of low back pain with or without sciatica. Take people's specific needs, preferences and capabilities into account when choosing the type of exercise. Orthotics Do not offer belts or corsets for managing low back pain with or without sciatica. Do not offer foot orthotics for managing low back pain with or without sciatica. Do not offer rocker sole shoes for managing low back pain with or without sciatica. Manual therapies Do not offer traction for managing low back pain with or without sciatica.

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CPD 98: MANAGEMENT OF LOWER BACK PAIN Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy. Acupuncture Do not offer acupuncture for managing low back pain with or without sciatica. Electrotherapies Do not offer ultrasound for managing low back pain with or without sciatica. Do not offer percutaneous electrical nerve simulation (PENS) for managing low back pain with or without sciatica. Do not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain with or without sciatica. Do not offer interferential therapy for managing low back pain with or without sciatica. Psychological therapy Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica but only as part of a treatment package including exercise, with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage). Combined physical and psychological programmes Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica: • when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or • when previous treatments have not been effective. Return-to-work programmes Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica. However, the effect of work on the condition should not be discounted. Psychological factors are even more important in people with chronic back pain. Dissatisfaction with a work situation, conflicts, or boredom contribute greatly to the onset and persistence of back pain.viii PHARMACOLOGICAL INTERVENTIONS (PRESCRIBING RECOMMENDATIONS) • Consider oral non-steroidal antiinflammatory drugs (NSAIDs) for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age. • Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective. • Do not offer paracetamol alone for managing low back pain. • Do not routinely offer opioids for managing acute low back pain

• Do not offer opioids for managing chronic low back pain. • Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain. This is interesting as we often see prescriptions for tricyclic antidepressants, particularly amitriptyline and anecdotally they seem to be effective. However, the proximal prescribing for their initiation may be to treat the depression associated with lower back pain, while its distal reason may be due to the drug’s effectiveness in treating neuropathic pain. • Do not offer anticonvulsants for managing low back pain. INVASIVE TREATMENTS FOR LOW BACK PAIN

In general, 90% of patients will recover within two months without the need for any invasive procedure. The management of lower back pain without sciatica or neurological deficit calls for a conservative approach with analgesics and no bed rest.iv PREVENTION OF LOW BACK PAIN • Exercise • Correct posture adoption while sitting • Address sleep posture and sleep hygiene • Wear low-heeled shoes • Avoid smoking • Eat a balanced diet with a view to avoiding osteoporosis – calcium, phosphorate and vitamin D. • Manage stressiv

Spinal injections

CONCLUSION

Do not offer spinal injections for managing low back pain.

Lower back pain is one of the most common symptom and conditions motivating individuals to seek medical consultation. In many ways it is in a nebulous term encompassing a constellation of symptoms. It is usually acute and self-limiting but chronic back pain has a huge impact on society both epidemiologically and economically. Treatment of an acute episode of back pain includes relative rest, activity modification, NSAIDs, and physical therapy.

Radiofrequency denervation Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when: • non-surgical treatment has not worked for them and • the main source of pain is thought to come from structures supplied by the medial branch nerve and • they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral. Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block. Do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation. Epidurals Consider epidural injections of local anaesthetic and steroid in people with acute and severe sciatica. Do not use epidural injections for neurogenic claudication in people who have central spinal canal stenosis. SURGICAL INTERVENTIONS Surgery and prognostic factors Do not allow a person's BMI, smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica. Spinal decompression

Chronic lower back pain must always be addressed as a complex disease in which it is mandatory that an accurate diagnosis of pain generators is determined before starting any treatment. Leaving aside serious underlying pathology such as cancer or osteoporosis, the guidelines for the treatment of back pain stress the importance of a multimodal and multidisciplinary approach in order to solve the problem and not simply alleviate symptomatic pain. Patient education is also imperative to improve understanding of their condition and their willingness to acquiesce to an often complex treatment programme, and to prevent relapse. REFERENCES i

Clinical Pracice Guidelines: Low Back Pain Journal of Orthopaedic and Sports Physical Therapy 2012 Volume 42 Number 4

ii

Hamidreza Shemshaki et al What is the source of low back pain Journal of Craniovertebral Junction and Spine 2013 Jan-Jun; 4(1): 21-24

iii

Islam Nazul Basic of Back Pain Shaheed Suhrawrady Hospital Bangladesh Presentation 2011

iv

Dubin AE, Patapoutian A: Nociceptors: the sensors of the pain pathway. J Clin Invest. 2010;120(11):3760–72. 10.1172/JCI42843

Julius D, Basbaum AI: Molecular mechanisms of nociception. Nature.2001;413(6852):203–10. 10.1038/35093019

v

Consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms.

vi

Nijs J, Malfliet A, Ickmans K, et al. : Treatment of central sensitization in patients with 'unexplained' chronic pain: an update. Expert Opin Pharmacother.2014;15(12):1671–83. 10.1517/14656566.2014.925446

Spinal fusion

vii

Spratt KF, Lehmann TR, Weinstein JN, et al. : A new approach to the low-back physical examination. Behavioral assessment of mechanical signs. Spine (Phila Pa 1976). 1990;15(2):96–102

viii

George E. Ehrlich Low Back Pain Bulletin of the World Health Organization 2003, 81 (9)

Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial. Disc replacement Do not offer disc replacement in people with low back pain.

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Feature Pharmacist role in effective Eczema management Eczema (or atopic dermatitis) is a common, inflammatory skin condition characterised by red, dry, itchy skin. Those with eczema can experience acute worsening of their condition, which are referred to as flares. During flares the skin becomes red which can sometimes weep, become blistered, crusted and thickened. of eczema. It is a non-contagious inflammatory skin condition and is recognisable by red, dry, itchy skin which can sometimes weep, become blistered, crusted and thickened. Itch is the most troublesome symptom and can affect quality of life. “Globally it is estimated that 230 million people have symptoms of AD, affecting 1 in 5 children and 1 in 12 adults in Ireland. It can start at any time in life but is most common in childhood. AD involves a complex interplay of the following, skin barrier dysfunction owing to a deficiency in the structural protein filaggrin, abnormal immune system responses and an imbalance in the skin microbiota.

The symptoms of this skin disorder can range from mild to severe, and all forms of eczema can have a significant impact on the quality of life for the person with eczema, caregivers and their loved ones.

important in its development, these include an inherited (genetic) predisposition to have a weakened skin barrier, as well as altered inflammatory and allergy responses.

One area for which there is a considerable demand in primary care for advice and support is dermatology and some evidence suggests that many people with skin problems manage their condition through self-care.

Atopic eczema can run in families and frequently occurs alongside other atopic conditions, including hayfever and asthma. Although there is no cure for eczema yet, treatment are available to manage the condition.

Pharmacists have the potential to facilitate effective self-care for patients with dermatological problems. Furthermore the chronic nature of many skin conditions emphasizes the need for medicine management support to improve outcomes for those with conditions such as eczema.

Eczema is recognizable by the presence of red, dry, itchy skin, which can sometimes weep, become blistered, crusted and thickened. However, the appearance of eczema, and the locations of the body affected, can vary greatly depending on the age of the person.

Eczema can have a significant impact on a person's quality of life. It is important for all community pharmacists and their teams to refresh your knowledge of the condition's symptoms, treatments and self-care advice in this learning article so you can pass on expert knowledge to customers.

A recent article in Nature Reviews/ Disease Primers reviewed the current knowledge on atopic dermatitis (AD), established treatments and the study of changes in the skin that results in this skin condition.

Eczema affects approximately 1 in 5 children and 1 in 12 adults in Ireland. While the exact cause of eczema is not known, certain factors are thought to be

Michelle Greenwood is a Dermatology Nurse at Tallaght Hospital. Here she gives an insight into the most common form. “Atopic dermatitis (AD) or atopic eczema is the most common form

36 | PHARMACYNEWSIRELAND.COM

exposure to a number of environmental irritants or allergens. Common irritants include soap, bubble bath, shampoo, laundry detergents, fragrances, clothing that feels ‘itchy’ next to the skin (e.g. wool), changes in temperature, or allergens like animal dander, the house dust mite or pollen, but sometimes no cause can be identified. Stress Emotional stress can aggravate eczema. Finding ways to reduce stress may lessen the frequency and, hopefully, the intensity of the flare-ups. Whilst stress is associated with flares of atopic eczema, it is not yet fully understood.

“Filaggrin (a skin protein), ties skin cells together and helps to form part of the natural moisturising substance within the top layer of the skin, which prevents the skin from drying out.

Infection

“Some people with eczema have a mutation, in their filaggrin, which results in lower overall levels of this important mortar and causes their skin barrier to be weaker.

• Wet or weepy, with yellow/ brownish crusts.

“When your skin becomes too dry, irritants can enter triggering an immune reaction. Once the immune system is triggered, this results in red, inflamed itchy areas seen on the skin. “Another contributing factor is the imbalance in the skin microbiota. Staphylococcus aureus is a type of bacteria which is found frequently on the skin in healthy people and an overgrowth could be another contributing factor in AD. “Depending on the severity of AD, management includes topical therapies, anti-inflammatory drugs, phototherapy and immunosuppressant medications. “This improved understanding of skin barrier dysfunction is contributing to the development of new effective drugs (biologics). These next generations treatments will work by targeting abnormal immune pathways and will be the driving force behind prevention studies based on ‘barrier therapy’.” ECZEMA TRIGGERS Irritants and allergens Atopic eczema can be triggered or aggravated by

Atopic skin is more vulnerable to infection and infection is often associated with a worsening of eczema. Advise customers to seek medical attention if skin becomes:

• Very sore, with clusters of painful itchy blisters, particularly if there has been contact with someone who has a cold sore. EVERYDAY CARE Emollients Atopic eczema and dry skin go hand-in-hand; medical moisturisers / emollients have been used for managing eczema for many years and are still the recommended first-line treatment. Emollients are an essential part of daily care, even when skin is clear. Emollients are moisturisers that are used in two ways, applied directly to the skin as a leave-on moisturiser, and as a soap substitute instead of soap or shower gel. Used several times a day, emollients help to soothe dry, itchy skin and repair the skin’s barrier, thereby preventing entry of irritants and allergens, which can trigger eczema flares. Soap substitutes/emollient wash products Ordinary soaps, bubble baths and shower gels should be avoided as they dry out the skin by stripping away its natural oils. Instead, advise customers to


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Recommend Doublebase Emollient Gel to soften, moisturise and protect dry skin and conditions such as eczema or psoriasis. Doublebase Emollient Gel Therapeutic ingredients: Isopropyl myristate 15% w/w, liquid paraffin 15% w/w. Presentation: White opaque gel. Uses: Highly moisturising and protective hydrating gel for regular and frequent use in the management of dry skin conditions such as eczema, psoriasis or ichthyosis. Directions: Adults, the elderly, infants and children: Apply directly to dry skin as often as needed. It may also be applied before washing, showering or bathing to prevent further drying of the skin. Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. In the rare event of a reaction stop treatment. 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: Isopropyl myristate, liquid paraffin, glycerol, carbomer, sorbitan laurate, trolamine, phenoxyethanol, purified water. Pack sizes: 100g tube and 250g pump pack. Legal category: Class I medical device. Further information is available from the manufacturer: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: December 2017. ‘Doublebase’ is a trademark. 11mm Adverse events should be reported to Dermal.

DEGPR074/I/AUG18

Essential Information ™

Always read the label/leaflet.


Feature been reformulated in recent years to remove SLS.

do not usually occur before two months of age.

Clothing & Wet Wraps

In older children, from about 1-2 years onwards, atopic eczema is most often seen on the inner sides of the arms at the elbow creases, behind the knees, and on the face and neck.

Sometimes it can be difficult for children or indeed anyone who suffers with eczema to find comfortable clothing, particularly when there has been a flare up of the condition. Clothing can aggravate eczema as skin can be very hot and heat increases itch. Basic Tips: • Avoid harsh synthetic fabrics • Seams • Wool • Fabrics that do not let the skin breathe choose emollient wash products when bathing which leave the skin coated with a protective film afterwards. Emollients come as lotions, creams and ointments. Finding the right emollient is often a matter of trial and error but the best emollients are ones that the sufferer prefers to use and will continue to use every day. Remember, a higher price doesn’t necessarily indicate a better product. Some practical tips for emollient therapy • Establish a good daily skin care routine and try to stick to it. • Don’t stop moisturising when skin is clear. • Apply emollients in a smooth, downward motion, in the direction of the hair growth. • A child with atopic eczema often requires a minimum of 250g of ‘leave-on’ emollient per week, while an adult may need approximately 500g per week. • Remember avoid soap, bubble bath and shower gel. • Use soap free products for bathing and specially formulated shampoos. • Bathwater should be a lukewarm temperature; 5 minutes with an emollient bath additive is sufficient. • After bathing or showering, gently pat skin dry. It is a great time to apply emollient all over when the skin is still ‘slightly humid’. • Remember to change the tub of emollient at least every six weeks, as it can become contaminated, or use a pump dispenser.

Sodium lauryl sulfate (SLS) and Aqueous cream

• Use thin layers rather than one thick layer of clothing

One common emollient, Aqueous cream, has been on the market for decades but according to some studies the negative effects on the skin barrier are thought to be related to a particular ingredient: sodium lauryl sulfate (SLS) 1%.

Bedtime

Reports of skin reactions such as burning, stinging, itching and redness after using Aqueous cream have been highlighted over a number of years. SLS is a component of emulsifying wax and is a detergent and surfactant – which means it breaks surface tension and separates molecules – and allows products to lather (causing bubbles and suds). It helps to maintain the creamy consistency of emollients. Aqueous cream is not a leave-on moisturiser There have been several studies which have assessed the effect of aqueous cream on the skin structure. These studies concluded that Aqueous cream as a leave-on moisturiser had a negative impact on the skin barrier – leaving skin dryer, more vulnerable to irritants and flares of eczema. UK NICE guidelines for atopic eczema in under 12’s (published in 2013) acknowledges that Aqueous cream can be used as a wash product, but is related to stinging when used as a leave-on emollient and therefore is not recommended as a leave-on moisturiser. Likewise the UK regulatory advises that if there are signs of skin irritation with the use of aqueous cream, it should be discontinued in use in favour of another emollient that does not contain SLS. Other products are available without SLS Several emollients and some brands of Aqueous cream have

38 | PHARMACYNEWSIRELAND.COM

• Consider using eczema specific clothing • Consider using soft cotton or silk sheets and thin cotton blankets • Avoid woolen underlies, blankets and plastic mattress protectors • Use Anti-dust mite covers on beds, pillows etc. if an allergy is suspected

To mark Eczema Awareness Month in September, sensitive skin expert La Roche-Posay, in partnership with the Irish Skin Foundation unveiled research which suggests childhood eczema could be a silent sleep disruptor to unsuspecting parents across Ireland. Despite broken patterns of sleep often being the first indicator of the chronic skin condition, a mere 1 in ten parents would consider this as a potential cause of their child’s sleep disturbance. The research findings show that, although 1 in 5 children in Ireland are living with eczema, over half (57%) of parents admitted to have little to no preparation when it came to awareness of baby skincare. According to Consultant Dermatologist with La RochePosay, Dr Niki Ralph, often times the first signs of onset eczema in young children can be disturbed or disrupted sleep patterns, caused by the itching and uncomfortable sensations experienced as a result of the sensitive skin condition.

ECZEMA IN CHILDREN

CUSTOMER TIPS

Atopic eczema is a very common skin condition, affecting one in five children. Atopic dermatitis is the most common form of eczema affecting young children. For most children affected, the disease is mild. However, often those who have seemingly outgrown the condition will continue to have lifelong sensitive skin and may have recurrences of eczema following long symptom-free spells.

• Always keep fingernails short

An intense itch is the major symptom of atopic eczema. Scratching only provides momentary relief, and leads to more itching (the itch-scratch cycle). Scratching worsens eczema and can make the skin more vulnerable to infection. The intense itch is very uncomfortable, can disrupt sleep and negatively impact on the child’s quality of life, as well as that of his/her parents and the wider family. Some children with more pronounced eczema can also experience social embarrassment due to the visibility of their condition.

• Use a non bio washing powder and do not use fabric conditioner

In infancy, the first noticeable signs of atopic eczema may be skin dryness and roughness, but other symptoms (e.g. red itchy skin which can affect the cheeks and forehead, and/or the trunk and outer aspects of arms and legs)

• Wear cotton clothing where possible • Use soap free products for bathing • Use specially formulated shampoos • Read the ingredients on cosmetics

• Do not use chemical sprays and plug-ins around the home • Cut down on harsh cleaning products • Shower immediately after swimming in a chlorinated pool and apply a moisturiser • Use heavy protective gloves when working with paint or chemicals and wear a mask • Sore skin and sand don’t mix so be careful with children while on holidays or on a trip to the seaside • Avoid having anybody smoke in the home, avoid houses where there are smokers


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Atopic Eczema is an increasingly common skin

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(*) except bath oil (a) Analysis by thin-layer chromatography of ceramides extracted from Stelaskin reconstructed epidermis. 72-hour treatment with Avocado Perseose. (b) ELISA measurement of Involucrin in normal human epidermal keratinocytes as a proportion of the number of live cells estimated by MTT assay. 48-hour treatment with Avocado Perseose. (c) Immunolabelling of Transglutaminase on skin explants following delipidation using an ether/acetone mixture. 3-hour treatment with Avocado Perseose. (d) ELISA analysis of hyaluronic acid in the culture medium of normal human epidermal keratinocytes as a proportion of the number of live cells estimated by neutral red assay. 24-hour treatment with Avocado Perseose. (e) Immunolabelling of Integrin alpha 6 on skin explants subjected to UV.Treatment with Avocado Perseose 24 hours before and after UV irradiation. (f) Culture of human skin explants treated with Stelatopia for 24 h, and stimulated with a cocktail of Th2 cytokines for 24 h.

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Feature

Topic Team Training

Smoking Cessation in the pharmacy A community pharmacy environment that fosters teamwork ensured high levels of consumer satisfaction. This series of articles is designed for you to use as guide to assist your team in focusing on meeting ongoing CPD targets and to identify any training needs in order to keep the knowledge and skills of you and your team up to date. Actions:  Consider how we can increase smoking cessation rates within our community and make sure we have the relevant support and educational materials  Ensure we check customer’s smoking habits in those presenting with associated factors or with smoking-related illness  Update the team’s knowledge of available NRT products, indications and doses to ensure appropriate product selection for each customer  Train the team to meet all the above considerations Learning The below information, considerations and checklist provides support to enable you to run a team training session and identify opportunities for learning within the topic of Smoking Cessation. According to the latest Healthy Ireland survey, 22% of people in Ireland are smokers; down from 23% last year. About one third of men and women aged 25-34 are smokers and, importantly, overall smoking rates are falling. As frontline healthcare providers, community pharmacists and their teams are ideally placed to help this trend continue. They are centrally located with the opportunity to promote smoking cessation to a wide spectrum of the community.

 How educated is my team on the NRT products available over-the-counter?

 Lifestyle and smoking habits which may need considered in product selection

 Is there any further training required to assist the team discussing smoking cessation advice with customers?

 Side effects, dosage and contra-indications such as those with cardiovascular conditions

Key Points: Check your pharmacy team are aware and understand the following key points  Customers that should be referred to the pharmacist

 Their local pharmacy is ideally placed to support them and to act as advocates for lifestyle changes to improve their quality of life

 The HSE and Tobacco Free Ireland Action Plan offers further educational information - https:// www.hse.ie/eng/about/who/ tobaccocontrol/ tobaccofreeireland/state-of tobacco-control.pdf  Knowing the health benefits associated with smoking cessation may help motivate many smokers to initiate a plan to successfully quit – See table

 Those presenting with persistent coughing should be asked about their smoking habits

Time since quitting

Health Benefit

20 minutes

Pulse starts to return to normal

8 hours

Nicotine is reduced by 90% and carbon monoxide levels in blood reduce by 75%. Circulation improves

24 hours

Carbon monoxide and nicotine almost eliminated by from body. Lungs start to clear out smoking debris

72 hours

 Have I, or any of my team, assessed the patients’ readiness to change?

Breathing is easier. Bronchial tubes begin to relax and energy levels increase

2-12 weeks

Circulation improves

1 month

 Am I familiar with current European Medicines Agency guidelines on smoking cessation?

Physical appearance improves. Skin loses its grey pallor and becomes less wrinkled

3-9 months

Coughing and wheezing declines

1 year

Excess risk of a heart attack reduces by half

10 years

Risk of lung cancer falls to about half that of a continuing smoker

15 years

Risk of a heart attack falls to the same as someone who has never smoked

Consider:  Have I, or any of my team, asked about smoking habits? How often?

 Do we have information available on Stop Smoking services and contact details in our local area?

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News launches ‘Space for your Time’ news brief IPN The Pharmaceutical Manufacturers Institute of Ireland (PMI) recently held their Annual Charity RETAIL EXCELLENCE FOR LLOYDSPHARMACY LloydsPharmacy has scooped the prestigious InBUSINESS Recognition Award for Retail Excellence at a gala luncheon ceremony in Dublin. The awards, now in their seventh year, acknowledge outstanding accomplishments in the Irish business community. The awards, comprised of 20 categories, are judged based on the broad criteria of business growth, profile of business, range of services and customer care. LloydsPharmacy is Irelands leading pharmacy chain with 88 owned and 3 franchised pharmacies around the country. The company consistently seek new and improved retail experiences for customers with new product ranges and improved services and efficiencies, which allow employees to focus their time and attention to offering customers in store a premium shopping experience. LloydsPharmacy employs a workforce of 1,000 people who are highly trained to become trusted health experts who care. LloydsPharmacy employees collectively undergo 17,000 hours of training annually across a breadth of healthcare knowledge, including Health & Wellbeing, Heart Health, Diabetes, Pain Management, Asthma, Skincare and Children’s Health, providing customers with the best quality care and advice. LloydsPharmacy was delighted to take home the award for Retail Excellence. Patrick Watt, Director of Sales & Marketing LloydsPharmacy said, “We are delighted to have won the InBUSINESS award for Retail Excellence this year. It is an honour to be recognised for the hard work that is done in our pharmacies around the country and for providing the best retail experience that we can for our customers. I would like to thank each one of the LloydsPharmacy team for the effort and dedication they demonstrate every day. They are committed to offering LloydsPharmacy customers and patients the best possible retail experience in store each time they visit.”

Lunch in Dublin at which over 320 pharmaceutical colleagues gather in the Round Room of the Mansion House to support the fabulous work of their charity partner Hugh’s House. Started in May 2015 by Stacks Pharmacy MD Ade Stack, Hugh's House provides accommodation 365 days a year to the families of children who are long-term in-patients of Temple Street, Holles Street, the Coombe and Rotunda Hospitals. Everyone involved helps on a totally voluntary basis. The house is run by a dedicated team of caring and compassionate volunteers and supporters, without whom the charity would not be able to offer their families the support and care they need. To show our support for the fantastic work being carried out by Ade and the team at Hugh’s House, Irish Pharmacy News have launched a ‘space for your time’ initiative. Encouraging all pharmaceutical companies and their teams across Ireland to engage with the charity and donate one of the biggest gifts possible – that of your time – we are offering coverage in the magazine to all those who

volunteer their time to help with this extremely worthwhile cause. Why not organise a company volunteer day? Just 3 hours a month makes an incredible difference.

Contact Kelly Jo Eastwood, Editor, at kelly-jo.ipn.ie or on mobile (87)737 6308 for further information.

Biosimilars added to pharmacy policy Pharmacists’ authority to use their expertise to substitute one medicine for another should also apply to biological medicines, the International Pharmaceutical Federation (FIP) has made clear. The Federation has published a revised Statement of Policy on “Pharmacists’ authority in pharmaceutical product selection: Therapeutic interchange and substitution”, which has been updated to account for the emergence of biological medicines and their biosimilars onto the medical landscape. The core principles that were in the original statement remain, and include: that generic substitution is recommended as part of the pharmacist’s dispensing role; that pharmacists should be provided with bioavailability data by regulatory authorities and manufacturers; and that a medicine should only be substituted with a product containing a different active ingredient in agreement with the prescriber. The use of generic names is still encouraged, but the revised statement gives focus to the use of international non-proprietary names in particular. The revision also recommends that, to ensure safety, information about excipients should be taken into account when making decisions on substitution. “To date, no major safety issues

42 | PHARMACYNEWSIRELAND.COM

with the use of biosimilars as alternatives to the original biological medicine have been reported,” the statement says. However, the new text calls for “adequate pharmacovigilance” to ensure identification of a biological medicine should any product-specific safety (or immunogenicity) concerns arise, as well as for post-marketing safety studies by companies marketing generic medicines or biosimilars, with safety updates to be made publicly accessible. “Pharmacists are key stakeholders in product selection and evaluation. The purpose of this policy is to guarantee quality and good pharmacy practice in this area of pharmacists’ activities. FIP supports well regulated processes

in product changes where goals of safety, positive patient outcomes and economic benefits can be achieved with a good collaboration of all parties,” said FIP Vice President Eeva Teräsalmi. The full FIP Statement of Policy “Pharmacist’s authority in pharmaceutical product selection: Therapeutic interchange and substitution” can be found at www.fip.org The International Pharmaceutical Federation (FIP) is the global federation of national associations of pharmacists and pharmaceutical scientists, and is in official relations with the World Health Organisation. Through its 144 member organisations, it represents over four million practitioners and scientists around the world.


6hrs Just 3 Sprays helps relieve pain for up to 6 hours Strepsils Intensive 8.75mg/dose Oromucosal Spray is indicated for the symptomatic relief of throat infections including acute sore throat. Strepsils 15ml Spray contains Flurbiprofen which is a non-steroidal anti-inflammatory drug which has potent analgesic, and anti-inflammatory properties.

Strepsils Intensive 8.75mg per dose Oromucosal Spray contains Flurbiprofen for relief of acute Sore Throat. Over 18s only. Max duration of use three days. ALWAYS READ THE LABEL. Date of prep Nov 2018, IRL/CC/1118/0020


News news brief SUICIDAL RESEARCH Irish research has revealed that one quarter of suicide attempts are associated with dysfunction in how the brain interprets basic perceptual information, such as what we see, hear and think. The research shows that this dysfunction can predict suicidal behaviour, and offers new prospects for treatment and suicide prevention. The research was carried out by the Royal College of Surgeons in Ireland (RCSI). Symptoms such as depressed mood, feelings of worthlessness and a sense of hopelessness are well documented in suicidal behaviour. However, in an analysis of more than 80,000 people, new research has revealed that one quarter of individuals who attempted or died by suicide had problems in basic sensory experiences, such as hearing or seeing things that aren’t really there, otherwise known as ‘perceptual abnormalities.’ Such episodes are not necessarily associated with psychotic illnesses or depression and can occur in people who do not experience mental illness, according to the study. Research over the past 15 years has shown that experiences such as ‘hearing voices’ are far more common than previously thought, about 5-7% of the general population report at least occasionally having experiences such as hearing voices. For some people, these experiences emerge when the brain is under stress or when coping levels are exceeded.

Falsified Medicines Directive Deadline looming Preparations are underway across Ireland towards meeting the Falsified Medicines Directive, which comes into effect from February 9th this year. The aim of this directive is to prevent falsified medicines entering the supply chain. Accord Healthcare has recently revealed the company has worked hard to ensure they are ready to meet the deadline. Speaking from the company’s Headquarters in Cork, Mary O’Meara, Accord’s Head of Regulatory explains, “We have been working extremely hard over the past few years to ensure our compliance with the FMD directive from February 9th. We have been working closely with all our sites to ensure that all packs released for the Irish market from February 9th carry safety features (unique identifiers and anti-tamper devices). We have also completed the next step in the process and have uploaded all our master data to the IMVO and EMVO websites to ensure HCPs will be able to decommission our products. It has taken a lot of work across every department of our organisation to make changes such as upgrading production lines in order to apply these extra identifiers and anti-tamper devices, along with onboarding all our data to the

EMVO website, I am very pleased therefore to say we are FMD ready”. Health Care Professionals (HCPs) may not immediately notice a difference to packs coming to their pharmacy from February 9th as many product batches released before February 9th will work their way through the supply chain, it may take years before every product on a pharmacy shelf is FMD complaint. HCPs will start to notice two differences on all packs of medicines, a unique identifier which is a 2D barcode containing a unique number and an anti-tampering device or seal. Before dispensing a medicine, HCPs will check that the seal has not been tampered with and then decommission the pack by scanning the code on the box, the IMVO and EMVO will ensure that the medicine is safe and authentic and can immediately be dispensed to the patient.

“We are very happy to have met the February 9th deadline,” adds Ms O’Meara. “However, I want to reassure HCP that all Accord products which are released before FMD kicks in are also tested and released to the highest European standards. We have worked hard to ensure continuity of supply with both FMD and Brexit deadlines approaching in close succession. It is a busy time for HCPs and we want them to rest assured that we in Accord Healthcare are with them every step of the way. Our goal like that of all HCPs is to ensure the safety and efficacy of all medicines dispensed to patients. “If you have any queries in relation to FMD we ask that you call you Accord Healthcare representative or our offices in Cork on 021 461 9040. We are always here to help”, concluded Ms O’Meara.

Honour for Health Summit Founder David Neville, a Director at events & marketing company Investnet, has been honoured with the prestigious Fáilte Ireland Conference Ambassador Award for his outstanding contribution in bringing the Future Health Summit to Ireland. The summit, titled ‘The Global gathering for Healthcare’, has brought thousands of international delegates to Ireland over the last ten years and will take place at the RDS in Dublin on May 20 and May 21, 2019. Pictured presenting the award to David (a native of Fethard on Sea in County Wexford) at the ceremony in Christ Church Cathedral is Fáilte Ireland CEO, Paul Kelly.

Kathryn Yates, RCSI Psychiatry and study co-author, said: “If we are to understand suicide, we need to understand a lot more about perceptual abnormalities – what causes people to hear voices? How do these experiences relate to the biological and social factors involved in suicide risk? There are still a lot of unanswered questions; but this research points to new avenues to improve prediction of suicidal behaviour.”

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News How does the Pharmacy Future look? At a recent presentation in Dublin, community pharmacists Dermot Twomey, Jonathan Morrissey and Keith O’Hourihane gave their opinions on what the ‘pharmacy future looks like.’ the new service he noticed a significant improvement in patients control of their INR. Dermot continued to inspire with anecdotes of how a pharmacist can significantly improve patient outcomes by engaging with doctors and clinicians and also advised pharmacist to be brave in your role as an expert in medicines.

Keith O'Hourihane and Jonathon Morrissey

Each a community pharmacy owner, they have all taken their own initiatives to progress the role of the community pharmacy in Ireland. The overarching emphasis was placed on the need to push the pharmacy profession forward and allow pharmacists to engage with patients in a new way. I attended the talk out of curiosity with a hope that I would get some kind of “insider information” on the type of pharmacy model that might exist in twenty years time. Dermot, Jonathan and Keith each provided information on how they have managed to implement extra services for patients within their own community pharmacies.

Each spoke with so much enthusiasm for their role as a pharmacist in the community and each delivered their own message with a sense of urgency – the take home message was “START NOW!”. Dermot Twomey is the Director of two pharmacies in East Cork in Youghal and Cobh. He was the first pharmacist in Ireland to introduce a warfarin clinic service in his pharmacy and reflected on the efforts he made initially to get the service up and running. Starting the service was slow but as the service built momentum and patients began to embrace

Keith O’Hourihane is the Managing Director and Superintendent Pharmacist of the Pharmacy First Plus Group in Cork. Keith began on a positive note explaining why he is proud to be a community pharmacist and encouraged pharmacists attending to choose to be positive with regard to the pharmacy profession. Keith began to run health clinics in his pharmacy and it too was a slow process. However he has seen a measurable improvement in patient outcomes. He mentioned that as soon as patients had metrics to compare blood pressure or cholesterol readings before and after taking medication for a period of time he found they were more compliant in taking medication. He also found that patients were more likely to embrace simple lifestyle changes advised by the pharmacists at Pharmacy First Plus. Jonathan Morrisey is the Director and Superintendent Pharmacist at Marrons Pharmacy in Clane, Co. Kildare. Jonathan studied in the Royal College of Surgeons and says it was there where he felt that what was being taught in the college was not being implemented in the community pharmacy setting. He mentioned that he felt

that proper consultation services were not being provided in the community such as asthma clinics, cholesterol testing, blood sugar testing and more. His enthusiasm for the provision of these extra services was evident on the night. He spoke of how in his experience the simplest of interventions can have a significant impact on patient outcomes. He emphasised that you could perform a blood pressure test that prompts a trip to the GP which may lead to a high blood pressure diagnosis that would have otherwise gone unnoticed. The speakers certainly showed a lot of enthusiasm for the future of pharmacy. They also warned that it may sound like a lot of work and advised that you must start small, persist and make slight changes along the way. It was mentioned that the return on investment for these types of services are evident in their pharmacies. They all noted that patients had improved outcomes, the services improved footfall to their premises and the services also provided a decent financial return. The talk took place at The Red Cow Moran Hotel in association with Promed Medical Supplies. Frank Olden is a qualified Pharmacist and a Member of the Pharmaceutical Society of Ireland. Frank graduated from University College Cork in 2015 with a degree in Pharmacy and later completed his Masters in Pharmacy at The Royal College of Surgeons of Ireland in 2016. Frank Currently works as a Locum Community Pharmacist and is based in Dublin.

Respiratory Health of the Nation 2018 The challenge of providing integrated care for conditions such as COPD with a properly-resourced primary care community was highlighted as the Irish Thoracic Society launched a major new report on the burden of respiratory disease. The Society has also called for the establishment of a National Respiratory Taskforce to address the rising tide of respiratory disease. Respiratory Health of the Nation 2018 provides an overview of the impact of respiratory disease in the country as well as information on 11 common respiratory conditions and their impact on two key population groups – children and older people. Professor Ross Morgan, President of the Irish Thoracic Society, said, “What is clear from this report is the increasing strain of

lung disease on our health services due to our growing and ageing population. “Together with improved focus on prevention, awareness and earlier detection of these conditions, our patients need better access to adequately-resourced, co-ordinated and specialist services based on best evidencebased practice. That’s why the Irish Thoracic Society believes a national taskforce is needed to put respiratory disease on an equal footing with heart disease and cancer where, thanks to dedicated strategies in recent years, patients have experienced improved outcomes.”

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Eimir Hurley, Pharmacist and PhD Scholar, Health Services Research and Bernard Duggan, Pharmacist, HSE Medicines Management Programme


umeclidinium/vilanterol

HAS POSITIVE HEAD-TO-HEAD DATA VS. ANOTHER ONCE-DAILY LAMA/LABA* 1 In symptomatic patients with moderate COPD An 8-week, randomised, open-label, two-period crossover in symptomatic patients with moderate COPD (post bronchodilator FEV1 ≤70% and ≥ 50% of predicted value, mMRC≥2) and not receiving ICS at inclusion.1

*Anoro compared to tiotriopium/olodaterol showed statistical superiority on pre-specified secondary endpoint of trough FEV1 at 8 weeks in the Intent to Treat population. ITT population n=236 (180mL vs. 128mL in trough FEV1; Difference 52ml (p<0.001, 95% CI:28,77). The primary endpoint of non-inferiority on trough FEV1 at Week 8 in the PP population was met. Non-inferiority was met for the primary endpoint at Week 8 in the PP population (n=227) (175mL Anoro and 122mL tiotropium/olodaterol, 95% CI: 26, 80; p<0.001)1

COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; LABA, long-acting beta2-agonist; LAMA, longacting muscarinic antagonist; mMRC, modified Medical Research Council scale; ITT, intent to treat. COPD, FEV PP, ITT

Learn more by visiting: www.anoro.ie/headtohead Anoro Ellipta is contraindicated for patients who are hypersensitive to the active substances or to any of the excipients. Anoro is not indicated for the treatment of acute episodes of bronchospasm. Cardiovasular events, such as cardiac arrhythmias, may be seen after the administration of muscarinic receptor antagonists and sympathomimeticagents, including umeclidinium/vilanterol. Therefore, Anoro Ellipta should be used with caution in patients with severe cardiovasular disease.2

Anoro 55/22mcg is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD)2

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Anoro® Ellipta® (umeclidinium bromide/vilanterol [as trifenatate]) Prescribing information (Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Anoro® Ellipta®▼ 55/22mcg (umeclidinium bromide/ impairment. No dosage adjustment is required in renal or mild pain, constipation and dry mouth. Uncommon: Hypersenstivity vilanterol [as trifenatate]) inhalation powder. Each single to moderate hepatic impairment. Acute symptoms: Anoro reactions including rash, tremor, dysgeusia, dysphonia, atrial supraventricular tachycardia, rhythm inhalation of umeclidinium bromide (UMEC) 62.5 micrograms Ellipta is not indicated for acute episodes of bronchospasm. fibrillation, (mcg) and vilanterol (VI) 25mcg provides a delivered dose of Warn patients to seek medical advice if short-acting inhaled idioventricular, tachycardia, supraventricular extrasystoles and UMEC 55mcg and VI 22mcg. Indications: COPD: bronchodilator use increases, a re-evaluation of the patient palpitations. Rare: Anaphylaxis, angioedema, urticaria, vision Maintenance bronchodilator treatment to relieve symptoms in and of the COPD treatment regimen should be undertaken. blurred, glaucoma, intraocular pressure increased, paradoxical adult patients with COPD. Dosage and administration: Interactions with other medicinal products: Interaction bronchospasm, urinary retention, dysuria and bladder outlet Inhalation only. COPD: One inhalation once daily of Anoro studies have only been performed in adults. Avoid β-blockers. obstruction. Marketing Authorisation (MA) Holder: Glaxo Ellipta. Contraindications: Hypersensitivity to the active Caution is advised when co-administering with strong Group Ltd, 980 Great West Road, Brentford, Middlesex TW8 substances or to any of the excipients (lactose monohydrate CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, 9GS, UK. MA Nr: 55/22mcg 1x30 doses [EU/1/14/898/002]. and magnesium stearate). Precautions: Anoro Ellipta should itraconazole, ritonavir, telithromycin). Anoro Ellipta should not Legal category: POM B. Last date of revision: August not be used in patients with asthma. Treatment with Anoro be used in conjunction with other long-acting β2-adrenergic 2018. Job Ref: IE/UCV/0063/15 (5). Further information Ellipta should be discontinued in the event of paradoxical agonists or medicinal products containing long-acting available on request from GlaxoSmithKline, 12 Riverwalk, bronchospasm and alternative therapy initiated if necessary. muscarinic antagonists. Caution is advised with concomitant Citywest Business Campus, Dublin 24, Tel: 01-4955000. Cardiovascular effects may be seen after the administration of use with methylxanthine derivatives, steroids or non- Adverse events should be reported to the Health Products muscarinic receptor antagonists and sympathomimetics potassium-sparing diuretics as it may potentiate possible therefore Anoro Ellipta should be used with caution in patients hypokalaemic effect of β2-adrenergic agonists. Fertility, Regulatory Authority (HPRA) using an Adverse Reaction with severe cardiovascular disease. Anoro Ellipta should be pregnancy, and breast-feeding: No available data. Balance Report Form obtained either from the HPRA or electronically used with caution in patients with urinary retention, narrow risks against benefits. Side effects: Common: Urinary tract via the website at www.hpra.ie. Adverse reactions can also be angle glaucoma, convulsive disorders, thyrotoxicosis, infection, sinusitis, nasopharyngitis, pharyngitis, upper reported to the HPRA by calling (01) 6764971. Adverse events hypokalaemia, hyperglycaemia and severe hepatic respiratory tract infection, headache, cough, oropharyngeal should also be reported to GlaxoSmithKline on 1800 244 255. References: 1. Feldman G.J et al. Adv Ther 2017; 34:doi 10.1007/s12325-017-0626-4 2. Anoro Ellipta Summary of Product Characteristics. Available from: www.medicines.ie. Accessed: January 2018. ANORO ELLIPTA was developed in collaboration with

Anoro and Ellipta are registered trademarks of the GlaxoSmithKline group of companies ©2018 GSK group of companies. All rights reserved.

IE/UCV/0006/17a(1) Date of Preparation: September 2018


Feature

Understanding Asthma in the Pharmacy According to the Asthma Society of Ireland, 470,000 Irish people have asthma, including one in five children. One person dies every week as a result of their condition and of these deaths, 90% are preventable. importance of patient adherence, is fundamental for effectively controlling asthma. For successful management of asthma, it is important that patients be thoroughly educated about their condition, know the warning signs of asthma attacks, know the factors that may trigger an attack (see Table 1), know how to manage attacks, adhere to their asthma plan, and know how to properly use the prescribed treatment. Asthma Symptoms Asthma is a common and long term lung condition that requires ongoing management. Asthma causes sensitivity to the airways, which can become inflamed and narrow on exposure to certain triggers, leading to difficulty in breathing. The symptoms of asthma commonly start in childhood but it is possible to develop asthma at any age. The condition cannot be cured, but with a good asthma action plan it can be well controlled. Symptoms of asthma include: • shortness of breath • wheezing – making a noise like a whistle when you breathe out

Statistics shows that uncontrolled asthma is dangerous, with someone in Ireland visiting an Emergency Department every 26 minutes. Costing the state more than ¤500 million per year, asthma prevalence is very high in Ireland, we are number four in the world asthma league after Australia, New Zealand and the United Kingdom. There has been a very considerable increase in asthma prevalence in developed countries over the last two decades. While asthma tends to run in families, the reason for the increase is not genetic. It is more likely environmental, either due to a great change in the external environment over this period

(allergic substances, pollution, smoking) or a change in our bodies' response to the external environment. Pharmacists can be instrumental in providing patients with valuable resources to educate them about pharmacologic agents for treating and managing asthma; educating them about the proper use of inhalation devices, especially newly diagnosed patients who may be overwhelmed with diagnosis and treatment plans. As more treatment options and patient resources become available for controlling asthma, a collaborative effort between healthcare professionals and patients, coupled with patient education and stressing the

48 | PHARMACYNEWSIRELAND.COM

medication before exercise can often prevent symptoms. When Asthma attacks Research shows that only 7% of asthmatics know all the symptoms of an asthma attack. One person dies a week in Ireland as a result of their asthma, but 90% of these deaths are preventable. A recent Asthma Society survey of over 1,100 asthmatics shows an alarming gap in knowledge around managing asthma and the resulting asthma attacks. Chief Executive Officer of the Asthma Society of Ireland, Sarah O’Connor says, “It is troubling to think that so few asthmatics know all the symptoms of an asthma attack, placing them at huge risk of a serious attack which can be fatal. Therefore, it is vital that all asthmatics and their carers learn the symptoms of an asthma attack and the 5 Step Rule so that they are fully prepared. It really could be the difference between life and death.” All pharmacists and their teams should be aware of the 5 Step Rule so that they can effectively advise asthma sufferers within their community. 5 Step Rule

• tightness in the chest

1. Stay calm. Sit up straight - do not lie down.

• coughing

2. Take slow steady breaths.

Sometimes the airways only narrow a little, resulting in mild symptoms. But some people’s airways can become so narrow that they can’t get enough oxygen into their lungs and their bloodstream. This is very dangerous and requires immediate medical attention.

3. Take one puff of the reliever inhaler (usually blue) every minute.

Anything that irritates and inflames the airways can make asthma worse. This could be an infection or something sufferers breathe in. The air itself can make asthma worse, for example those that are breathing more quickly or if the air is cold or damp. Physical activity, particularly running in cold weather, can make asthma worse. This is sometimes called exercise-induced asthma. But advise customers not to avoid exercise. Taking reliever

Use a spacer if available. • People over 6 years can take up to 10 puffs in 10 minutes. • Children under 6 can take up to 6 puffs in 10 minutes. 4. Call 112 or 999 if symptoms do not improve after 10 minutes. 5. Repeat step 3 if an ambulance has not arrived in 10 minutes. It is also important to remember, if someone is having an asthma attack: • Do not leave them on their own. • Extra puffs of reliever inhaler (usually blue) are safe.


A 2013 report by Kathleen Buckley of Trinity College Dublin looked at 'The role of the community pharmacist in optimising patients' inhaler use in asthma management.’ She concluded that, ‘it is evident that the current system of asthma care, where each profession is operating in isolation and the burden of care is the responsibility of the GP, is not viable. To improve asthma care, each healthcare professional should be familiar with the evidence-based asthma guidelines and collaborate with each other to provide the patient with team-based guidelineconcordant asthma care. This project has demonstrated that community pharmacists can play a vital role in asthma care by successfully educating patients on inhaler technique resulting in improvements in their asthma control and quality of life.’

Symptoms of an asthma attack include wheezing, continuous coughing, chest tightness, shallow breathing, lips turning blue and difficulty finishing sentences

patient counselling and improving knowledge about the disease, risk factors, medication management and preventative measures to control asthma.

Pharmacist Asthma Management

One of the main goals in treating asthma, and other chronic respiratory diseases such as COPD, is ensuring that patients receive the required doses of medication over the course of treatment. This has proven to be quite a challenge as many patients do not use their inhaler with the correct user technique.

Drug therapy is an essential element in managing asthma. Uncontrolled asthma presents a serious problem. It is well accepted that people may experience problems of uncontrolled asthma due to inappropriate therapy and also due to poor compliance, lack of understanding about their condition and the importance of regular preventative drug therapy. Research shows that many asthmatics have a knowledge gap when it comes to managing their condition. 27% of asthmatics do not consider daily use of their reliever inhaler as an indication that they are at risk of an asthma attack and worryingly, almost half would not see a health care professional after having an attack 20% do not know that exposure to known asthma triggers is putting oneself at risk of an asthma attack and only one in five know it is safe to have 10 puffs of reliever inhaler during an asthma attack. Preventative measures taken by asthma sufferers play an important role in improving life span and quality of life. This can be done more efficiently by community pharmacists and their teams through the provision of

Inhalers are handheld devices used to deliver medication directly to the airways to treat asthma and COPD. The pressurised metered dose inhaler (pMDI) is the most commonly used inhaler worldwidE. It is a handheld, cheap, multi-dose, portable device that is available for a number of medications. The pMDI consists of a pressurised canister which contains the medication (suspended or dissolved in a propellant), a metering valve and support casing. Critical errors significantly reduce the dose of medication delivered to the patient and are associated with poor disease control, increased hospitalisations and increased mortality rates. Two of the most common critical errors patients make while using pMDIs include poor actuation coordination and inhaling too fast with a PIFR of over 90 L/min. Studies have reported that 45% of patients have poor actuation coordination while using a pMDI.

There are two classes of inhaler devices: aerosols, which are either solutions containing medications or suspensions of solid particles in a gas, generated from devices (e.g. pMDIs or breath-actuated pMDI); and DPI delivery devices containing drugs in powdered formulation that have been milled to produce particles in the respirable range. DPI delivery devices allow the particles to be separated by the energy created by the patient’s own inspiratory flow, compared with the pMDI where the device itself generates the energy. All types of inhaler devices have similar efficacy when tested under strict clinical trial conditions, however, in the real-life setting of clinical practice, a perfect inhaler does not exist; each has its advantages and limitations. For the individual patient, inhalers should not be viewed as equivalent, and device type must become an important variable to consider when planning optimal treatment. Ensuring effective inhalation and drug delivery to the target site depends on many factors, which ultimately impact on patients’ response to treatment. In practice, the choice of inhaler device should not only take device-related aspects (e.g. aerosol velocity) into consideration, but also patient factors (e.g. inhalation flow, dexterity, cognition and preferences). A study of 3,660 patients across eight countries has identified the types of inhaler technique errors that are associated with the greatest impact on asthma outcomes.

The research involved 3,660 patients taking part in iHARP (initiative Helping Asthma in Real-life Patients) a cross-sectional study.The researchers found that insufficient inspiratory effort was a common error for patients using a DPI, and was recorded in 32%-38% of patients. This error was associated with a 30% increased risk of uncontrolled asthma in those using a Turbohaler and a 56% increased risk in those using a Diskus device (adjusted odds ratios 1.30, 95% confidence interval [CI] 1.08–1.57, and 1.56, 95% CI 1.17–2.07, respectively). The rate of exacerbations was also increased for both devices when patients made this error. However, failure to breathe out to empty the lungs before inhalation was not associated with uncontrolled asthma, despite being demonstrated by around a quarter of patients. For MDIs, actuation before inhalation was associated with a 55% increased risk of uncontrolled asthma (adjusted odds ratio 1.55, 95% CI 1.11-2.16). But the most frequent error inspiratory effort not being slow and deep enough was not associated with uncontrolled asthma. And none of the identified errors were significantly associated with exacerbation rate in MDI users in adjusted analyses. Other specific errors linked to poor outcomes include: failure to remove the cap and the dosage being compromised after the device was shaken or tipped, which were significantly associated with uncontrolled asthma for Turbohaler users; and not tilting the chin upwards, which was linked to uncontrolled asthma in MDI users. For metered-dose inhalers (MDI), researchers found that important factors relating to errors included the coordination and positioning of people’s bodies, such as not having their chin in the right orientation. For dry powder inhalers (DPI), the most critical factors related to breathing errors were not breathing out before inhaling, and not breathing in hard and fast enough. There are many things that pharmacists can do to help patients use their inhalers better, including observing their inhaler technique and following up on their technique regularly. It is really important for pharmacists to acknowledge that optimal inhaler technique is fundamental for asthma treatments to work.

PHARMACYNEWSIRELAND.COM | 49


Feature Flu and other viruses can trigger serious asthma attacks in adults and children. This is one of the reasons hospital admissions for people with asthma increase during the winter months. Pharmacists should advise customers with asthma to get the flu vaccine from their pharmacy, or their GP, to substantially decrease the risk of catching the flu.

the CairTM app to log their asthma symptoms for 3 months. Halfway through the study, a CliniAir air purifier unit from Envirion was installed in the home and used for the final 6 weeks of research. The research showed that a significant number of asthma events could be linked to poor air quality within the home and that installing an air purifier led

to a dramatic drop in dangerous air pollution, particularly a type linked to more severe asthma symptoms, COPD and even lung cancer. The importance of clean outdoor air is well understood; however, indoor air quality is just as important. We spend the majority of our time indoors (up to 90% for young children and elderly people) which means that the air we

breathe impacts our health and well-being. John Sodeau, Professor of Chemistry at UCC, said of the study, “The main lesson to be learned from this report is that air filtration systems are a real help in reducing the numbers of airborne particulates present in your house. Every asthma management plan should have one.”

Air Quality Improving indoor air quality may help those with asthma manage their symptoms, data shows. A study by the Asthma Society of Ireland, sponsored by Envirion and NuWave Sensors, suggests air quality monitoring and air cleaning could be a vital part of ongoing asthma management. Kevin Kelly, interim CEO of the Asthma Society of Ireland, says, “The results of this study highlight the need for a larger, longer-term study to fully illustrate the benefits of air quality monitoring and the use of air purifiers as a way to better inform public health initiatives.” As part of the study, 9 members of the Asthma Society of Ireland installed a CairTM smart air quality sensor from NuWave Sensors in their home and used

Table 1: Common Asthma Triggers Tobacco smoke

Asthma patients should quit smoking and avoid tobacco smoke

Dust mites

Use mattress covers and pillowcases to separate sufferers from dust mites

Pets

Bathing pets frequently is recommended. Pet fur doesn’t cause asthma attacks so trimming the fur will not help. Pet dander, the animal’s dead skin cells, will trigger an attack

Outdoor air pollution

Listen for reports on the air quality forecast and when rated as unhealthy avoid going out if possible

Mould

A dehumidifier will lower humidity in the home. Humidity should be less than 50%

Smoke

Smoke from burning wood or grass contains gases and small particles that irritate the lungs

Infection

Flu, cold, sinus problems and acid reflux disease are known to cause asthma attacks

Irish survey reveals lack of awareness and understanding about menopause and hormonal therapy A new survey, conducted by VIP Magazine in cooperation with global pharmaceutical company Mylan and coincided with World Menopause Day sought to get a better understanding of women’s views of the menopause and their knowledge about the treatment options available to them.

given to them on women's health issues due to insufficient time spent with their General Practitioner (GP).

According to the survey, misconceptions around menopause, its symptoms and options for treatment are still persistent among many women, despite new research and more information being available.

With the remaining half of women preferring to discuss this topic with friends and family (19%) or consult the internet (30%) before approaching their GP, there is a need for improved communication so that women do not feel the need to turn to the internet, where often misconceptions can be found. Health professionals can continue to play an important role in supporting their patients.

It was promising to see that 51% of women typically speak to a healthcare professional for information on the menopause, however almost half of women surveyed (47%) said that during medical visits they did not feel there was enough information

Of those currently going through the menopause or who are postmenopausal, over 60% of these women said they aren’t using or didn’t use Hormone Replacement Therapy (HRT) - a treatment used to replace the female hormones that a woman's body is no

50 | PHARMACYNEWSIRELAND.COM

longer producing because of the menopause - as either their GP did not discuss it with them or because of a misperception linking the treatment to breast cancer. A further 69% of women who identified as non, or peri-menopausal said they were unsure about or wouldn’t consider using HRT as a treatment for symptoms because of negative publicity associating it with cancer. Commenting on these results, Owen McKeon Country Manager of Mylan in Ireland, who has a strong presence in women’s health, said, “It’s clear from the survey that women feel they need to be better supported, and medical professionals play a key role in providing the latest information, including the range of available treatment options. Health care professionals (HCPs) are in a position to empower women in

helping them make their healthcare decisions and if women are more informed, then they are better placed to choose the treatment they feel is best suited to them.” Dr Deirdre Lundy of Bray Women’s Health Centre and advocate for the use of HRT said: “Every woman experiences the menopause in a different way so there is a need for access to a variety of treatment options. There are many solutions out there which can help ease the symptoms of menopause and women should be encouraged to speak to their healthcare professional about what they’re experiencing. If HCPs can take the time to discuss the options, that are available, and the benefits and risks associated with them, women will be well-informed and can work together with their GP to choose their own individual treatment path.”


News

HSE publishes National Service Plan 2019 Health Budget of ¤16.05bn allocated – 5.6% increase on 2018 The HSE has published its National Service Plan 2019, following approval from Government and includes €70.3m in primary care scheme changes. The Plan confirms the level and type of health and social services to be delivered next year within the allocated budget of €16.05bn. A total of ¤198m of development funding has been provided by the Department of Health (¤178m for new 2019 developments). Offsetting the 1st charge estimated as ¤114m, and setting aside ¤2.5m dormant accounts funding, this leaves a budget of ¤15,755m for all other 2019 costs. The total cost, in 2019, of the existing level of service activity in place by the end of 2018, is estimated at ¤15,805m. This cost of ¤15,805m is ¤50m above the available ¤15,755m. It includes providing for centrally agreed pay rate, incremental credit and pension decisions (c.¤375m), full year cost of approved 2018 developments (c.¤102m) and the full year cost, in 2019, of additional service activity commenced in 2018 (c.¤116m). It excludes the cost of additional service activity from 1st January 2019 to deal with demographic, technology, unmet need and other pressures on the system. The HSE’s key service priorities for next year are to maintain activity levels at 2018 planned/ outturn, focus on cost reductions and improved efficiency, minimise risk and promote patient safety, and reprioritise activities as necessary. Of paramount importance is ensuring that the most pressing patient and client needs are met within the resources available. A number of new developments will be made in 2019 whilst maintaining services at the planned level. They include; • New children’s hospital -¤6.7m • Mental health services - ¤55m • Disability services - ¤14.5m • CervicalCheck and HPV vaccination - ¤9m • Termination of pregnancy ¤12m • Primary Care Scheme changes - ¤70.3m • Care redesign and new entrant pay - ¤29m.

Speaking at the launch Dean Sullivan, HSE Deputy Director General – Strategy, stated, “While we will endeavour to ensure we provide value for the monies we spend, we are very cognisant that meeting both current and future challenges is not sustainable. We continue to experience high hospital occupancy levels, pressure regarding waiting lists and increasing demands on other social care and demand led schemes. “We will however, continue to respond to the most pressing patient and client needs within the resources available. We will seek to maintain activity levels at 2018 planned outturn position and focus on cost reductions and improved efficiency.” Priorities for 2019 in the area of Primary Care include the development of community healthcare networks, the agreement and implementation of GP contractual changes and an improvement in access to therapies services. The HSE will provide additional packages of care for children discharged from hospital with complex medical conditions. Featuring investment of ¤70.3m in Primary Care Scheme Changes and ¤4.5m in the delivery of safe abortion services, the service also aims to

issue over 1.5m medical cards along with over 528,000 GP visit cards. They are also seeking to provide 457 home care packages and provide 45,432 community intervention team contacts. Despite the challenges the HSE is facing in delivering services and introducing new health programmes, Services for Older Persons will see the implementation of both the National Dementia Strategy and National Carer’s Strategy, and implement the integrated care programme for older persons in 2019. The HSE will provide home support through a single funding model, and provide quality and safe residential and transitional care as follows: • 18.2m home support hours to over 53,000 people, including 360,000 hours to 235 people through intensive home care packages • 10,980 people to be supported for transitional care to leave hospital • 23,042 people under NHSS in long term residential care in any month • 4,900 long stay and 1,850 short stay public residential care beds.

By improving community mental health team capacity, expanding out-of-hours responses for adults and continuing to implement Connecting for Life, the HSE will continue to support people with mental health needs. Mental Health sees a major investment of ¤55m to enhance and expand services in order to continue to safeguard vulnerable people. Targets for next year include: • 28,716 adult referrals seen by mental health services • 12,148 admissions to adult acute inpatient units • 8,896 psychiatry of later life referrals seen • 10,833 CAMHs referrals received and seen. The Acute Hospitals will continue to deliver impatient and day cases to 1.707m people, see 3,339 new and return outpatient attendances and 1.228m ED visits, whilst enhancing capacity and improving access to both scheduled and unscheduled care. A continued focus in bringing down waiting lists and meeting 2019 targets set, and implementation of the National Cancer Strategy and the National Maternity Strategy will continue.

PHARMACYNEWSIRELAND.COM | 51


Feature

Expanding the Family –

what Pharmacy teams should know It is a noticeable trend that many people are now starting families older, and this trend is set to continue. More women than ever are deciding to have children later in life, and thus many will turn to their community pharmacy for ovulation and pregnancy self-testing kits, supplements and advice. Women should be advised to adhere to the testing directions provided by the manufacturer and should read the testing procedure before starting the test. Medical conditions such as polycystic ovarian syndrome (POS) and menopause, which are associated with high levels of LH, may cause false- positive test results. The use of fertility medications, a patient recently discontinuing the use of oral contraceptives, or impaired hepatic and renal function also can cause false-positive results. The decision on which ovulation prediction kit to select will ultimately be the customer’s choice and dependent on factors such as cost and convenience so ensure your pharmacy teams are educated and equipped to offer the latest and best advice on all available. It is also important to note that those who do not have pregnancy success after more than three months of trying should be advised to speak to their local GP.

The most recent data from the Central Statistics Office shows that the number of mothers in their 40s has increased significantly. The average age of a mother who gave birth in Ireland has increased from 30.8 in 2004 to 32.5 in 2015 whilst the number of births to teenage mothers also fell to 1,199 in 2015, down from 2,406 in 2005. Pharmacists, and their teams, have the unique role as accessible healthcare providers to optimise preconception health, such as in screening tobacco and alcohol use, in counselling on preconception risk factors and current medication use. They are also well placed to offer guidance on the plethora of pregnancy and ovulation self-testing kits now on the market. Because there is such an extensive array of these products available today, selecting the appropriate test may be overwhelming and confusing to many.

Ovulation and Pregnancy Testing Home testing to detect pregnancy was unheard of until the late 1970s, when the first early pregnancy test debuted, followed by additional products. Eventually, home pregnancy tests were joined by a group of ovulation kits, designed to assist couples in achieving a successful pregnancy. A variety of at-home diagnostic tests are available for detecting ovulation and pregnancy. Pharmacists can be a valuable resource for women electing to use these tests by aiding in both their selection and proper use. Approximately one in six women in Ireland face fertility problems that interfere with achieving a successful pregnancy. Some women ovulate irregularly, and/or the male’s sperm count may have dropped. Devices used for ovulation prediction monitor the natural

52 | PHARMACYNEWSIRELAND.COM

hormonal changes that occur during a woman’s menstrual cycle. OTC products available for predicting ovulation include thermometers measuring basal body temperaure (BBT), urine tests, fertility microscopes, and saliva tests. Factors that may be considered when selecting a method of testing include ease of use, patient preference, and cost. Urine-based ovulation tests use monoclonal antibodies specific to luteinizing hormone (LH) to detect the surge of LH.These tests should be used 2 to 3 days before estimated ovulation, and once the LH surge has been detected, testing should be discontinued. Ideally, early-morning collection is recommended because the LH is most concentrated at this time. If the test cannot be performed immediately, the urine sample should be refrigerated for testing later the same day. The sample should be returned to room temperature before testing.

Home pregnancy tests are designed to detect the presence of human chorionic gonadotropin (hCG) hormone in urine samples. These tests use monoclonal or polyclonal antibodies in an enzyme immunoassay. Early pregnancy tests enable women to confirm a pregnancy and receive early prenatal care. When advising patients about home pregnancy tests, they should be reminded to adhere to the testing protocol provided by the manufacturer, unless otherwise specified, the first morning urine should be used, because levels of hCG are most concentrated at this time. If testing takes place at another time of the day, patients should be advised to restrict fluid intake for 4 to 6 hours before urine collection. Most tests can be performed in an easy, 1-step procedure. The newest tests are digital and display readings of “pregnant” or “not pregnant,” which make the interpretation of results easier and more accurate. Women should be advised that performing a test too early after


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Feature can often become overwhelming. Mothers-to-be will visit the pharmacy for advice, as this is often more convenient than visiting their GP surgery.

a missed menstrual cycle may result in a false-positive test result, and it may be best to wait to test at least one week after an expected cycle. Patients obtaining a negative test result should be advised to retest if menstruation does not begin as expected, as well as be advised to seek

medical evaluation from their GP for a serum hCG test and physical examination. Advice and Careful Merchandising Pregnant women have access to plenty of health information but it

Community pharmacists are key players in managing medication user during pregnancy as they are often the first line of contact and the last professional seen by patients after medicines have been prescribed. Equipped with knowledge of pharmacotherapy, as well as skills in health education and chronic disease management, pharmacists could help prevent drug-related issues by assessing the likelihood of fetal exposure and reviewing prescriptions to identify any dose errors, as well as potential drug interactions. There are many myths surrounding medications, supplements and lifestyle factors in pregnancy and what women can or can’t do or take. Pharmacists and their teams can help demystify these for customers.

Current recommendations are that women should take 400mcg folic acid daily from before pregnancy until the end of the first trimester, and 10mcg vitamin D daily throughout pregnancy and while breastfeeding. The role of folic acid in reducing the risk of neural tube defects and the value of vitamin D supplements in building bone formation in babies is well supported. Expectant mothers can therefore be reassured that it is not necessary to invest in expensive multivitamin supplements, and that eating a good balanced diet during pregnancy, along with folic acid and vitamin D supplements, should be all that is required to ensure the best possible health outcomes for both themselves and their unborn child. Careful merchandising will help reach with other products such as for those suffering from stress incontinence, iron supplements and haemorrhoid creams.

News Guide to AMD launched by Fighting Blindness Age-related Macular Degeneration, or AMD, is the most common cause of sigh loss in people over the age of 50 in Ireland and it’s estimated that over 7% of this population are living with the condition. With over 7,000 people newly diagnosed with age each year, a new ‘Guide to AMD’ has been launched by Fighting Blindness. The number of people affected by AMD is expected to reach 288 million globally by 20403, but it is important to underline that many of these cases can be managed through early diagnosis and monitoring. The Guide was launched by footballing legend Ronnie Whelan and amongst the guest speakers were Professor Matthew Campbell, an AMD researcher at Trinity College Dublin, as well as Pat O’Donoghue and John Leonard, who live with AMD and are both members of the MIST (Macular Impairment Support and Togetherness) support group. For Professor Keegan, UCD Clinical Professor of Ophthalmology & Retina, and Fighting Blindness board member, it is important that people diagnosed with AMD stay positive about the future.

“This Guide provides a very useful explanation to those who have been newly-diagnosed with AMD, or who have family members with the condition,” he said. “While hearing mention of AMD for the first time can be scary, it is important to stay positive and be aware that most people with AMD maintain reasonable vision. Even in advanced cases, patients retain peripheral vision and are still able to continue most of their day-today activities. It is also important to note that in certain types of AMD, we can treat degeneration with intra-ocular injections and they are very successful if given on time. There are many supports available to optimise visual function, from magnifiers to reading devices to phone apps, and people can be hopeful that there are new treatments being developed all the time that we anticipate will have a very positive impact in delaying the onset of sight loss and in reducing its severity.” Those over 50, and not only with a

54 | PHARMACYNEWSIRELAND.COM

family history of AMD, were urged to have an eye examination every two years. Copies of the Guide, which was developed with the

support of Bayer, are available by contacting Fighting Blindness by telephone at 01 6789004or by email at info@fightingblindness.ie.

Cassandra Fanara (Pharmed), Professor David Keegan, UCD Clinical Professor of Ophthamology and Retina, and Fighting Blindness Board Member, Dr Laura Brady, Fighting Blindness Research Manager, Professor Matthew Campbell, Smurfit Institute of Genetics, TCD and Itziar Canamasas, Managing Director of Bayer


Fingerprick Vitamin D Test

HOW TO TEST: 1. PREPARE SAMPLE 2. ADD TO TEST 3. WAIT 15 4. READ VIT D VALUE

Vitamin D levels plunge in winter. This affects bone resilience, but mood, immune function and pain sensitivity too. Rapi-D is the first reliable Vitamin D test suitable for pharmacy use. Itâ&#x20AC;&#x2122;s DEQAS benchmarked. And it gives 25-hydroxyvitamin D results in 15 minutes from a fingerprick blood sample. Then, following international best practice, you calculate the appropriate dose of Vitamin D3. At 12 weeks, you test again and, if necessary, adapt the dose.

AFib is scary. But so is recuperation after a heart operation. D-Heart is a compact ECG that is run by a mobile phone App. The scans can be uploaded to the 24/7 team of cardiologists for assessment. In 15 minutes, theyâ&#x20AC;&#x2122;ll give a Green, Yellow or Red flag verdict. At reasonable cost. You can screen the public or teams. Or rent D-Heart to surgical heart patients during their vulnerable post-op period. NB D-Heart requires a smartphone

Nutricentric Healthcare provides Point of Care tests to pharmacies, nutrition professionals and (some) GPs. Ask us about other popular pharmacy fingerprick screening services, such as: ImmunoCAP rapid the 30-minute respiratory IgE allergy test. Or our inexpensive single-use safety lancets.

Find out more. E-mail info@nutricentric.com or call +353 86 348 3592 NUTRICENTRIC HEALTHCARE LTD. BRAY ROAD, ENNISKERRY, CO. WICKLOW A98 C1Y6


News Pharmacists attend Aware for All Pictured are pharmacists Niamh McGrory and Johanna Walsh who attended the recent ‘Aware for All’ information seminar in Trinity’s Translational Medicine Institute at St James’s Hospital, Dublin. The event was organized by the Centre for Information and Study on Clinical Research Participation (CISCRP), a globally focused non-profit that aims to increase clinical research awareness and overall health literacy, particularly among those from disadvantaged backgrounds. The team have been actively working with research and charity groups throughout the country these past few months to organise AWARE for All. Participating organisations include: Health Research Board – Clinical Research Coordination Ireland (HRB – CRCI), the Medical Research Charities Group (MRCG), Longboat, The Wheel, Cystic Fibrosis Ireland, Sickle Cell Society Ireland, Alpha-1 Foundation Ireland, Irish Health Research Forum, Cancer Trials Ireland, Trinity College, Boots Pharmacy, IPPOSI, Merck, ICON, and the Medical Research Network in the UK

Niamh McGrory, Suport Pharmacist, Boots Pharmacy and Johanna Walsh pictured at the Aware for All event

Despite the level of health research activity in Europe, and although clinical trials may be the only option remaining for patients facing a serious illness or a disease for which there are no good treatments, a recent global study entitled “Public and Patient: Perceptions & Insights” found that

the European public shows the lowest general knowledge about the clinical research process and the lowest willingness to participate in clinical trials. Meanwhile, the volume of clinical research activity is actively growing here in Ireland. According to statistics from Health

Research Board Clinical Research Co-ordination Ireland, there has been a steady increase in the number of open trial sites across its network of research centres in Ireland, up from 143 in 2014 to 237 in 2017, with 18 hospitals and 333 investigators involved in these

clinical trials in Ireland in 2017. Figures from the Health Products Regulatory Authority show that last year 96 new clinical trials of human medicine, and 9 new clinical investigations for medical devices, were approved here.

Falls, frailty, polypharmacy event Save the date; a falls, frailty, polypharmacy, sarcopenia conference is taking place on February 1st, 2019 in the Mercer Institute for Successful Ageing, St James’s Hospital. This international conference is led by national and international experts on the topics of falls, frailty, polypharmacy & sarcopenia. The prominent speakers have been chosen to reduce gaps in knowledge and improve clinical practice.

Participants will be able to identify frailty, polypharmacy and sarcopenia when working in the clinical area. They will also be able to identify explained and unexplained falls and how to complete gait assessment in the laboratory and the clinical area. This knowledge can be used for the

improvement of patient care and healthcare delivery Expert speakers include: • Professor Tahir Masud, Professor of Geriatric Medicine, Nottingham University Hospitals NHS Trust; and President elect of the British Geriatrics Society

• Professor Rose Anne Kenny, Director, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin and Centre for Medical Gerontology, Trinity College Dublin, Ireland • Professor Alfonso Cruz Jentoft, Physician. Specialist in Geriatric Medicine and Gerontology. Director of the Geriatric Department of the Hospital Universitario Ramón y Cajal, Madrid, Spain • Dr Rob Morris, Consultant in Geriatric Medicine, Nottingham University Hospitals NHS Trust • Dr Roman Romero-Ortuno, Consultant Geriatrician, Cambridge University Hospitals NHS Foundation Trust, UK The conference takes place in the 1st floor seminar rooms. CPD points awaited.

56 | PHARMACYNEWSIRELAND.COM


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News Are all cancers treated equally? Only 9% of the population could correctly identify lung cancer as the biggest cancer killer among woman. That is just one of the startling statistics revealed through new research initiated by the Marie Keating Foundation and supported by MSD. Almost half of those questioned (47%) believed that breast cancer was the leading cause of cancer deaths in Irish women and almost a third (37%) identified cervical cancer.[vi] Revealing a significant knowledge gap amongst the general public on the current and future prevalence and impact of lung cancer in Ireland, the research shows that despite lung cancer being the single biggest cancer killer in Ireland[ii], three in five people (59%) were unable to identify it as such.[iii] This knowledge gap is particularly acute amongst young people with 52% of 18 to 24 year olds believing that breast cancer kills more women in Ireland than lung cancer. Just 1% of 18 – 24 year olds correctly identified lung cancer as the single biggest cancer killer of women in Ireland.[vii] Despite the National Cancer Registry predicting that lung cancer rates in women will increase by as much as 136% by 2040[viii], the new research revealed that just 3% of the population correctly believe that rates of lung cancer among women in Ireland will have increased by 136%.

Approximately 2,600 Irish people are diagnosed with lung cancer every year and more Irish men and woman die from this disease than any other type of cancer[iv]. In fact, the disease kills more people than colorectal cancer and breast cancer combined.[v] Just over a quarter (28%) believe that rates will increase by as much as 35% by 2040.[ix] In contrast, over 40% of those surveyed stated that they expect lung cancer rates to decrease over the next 25 years, with a further 28%believing that lung cancer rates would stay the same over that period.[x] The new research was presented at an event in the Royal Hibernian Academy (RHA), Dublin, to mark Lung Cancer Awareness Month 2018 and discuss health and social inequalities in Irish lung cancer treatment. The event, “Living with Lung cancer in Ireland - Are all Cancers treated equally?” was hosted by Marie Keating Foundation and MSD. Speaking at the event, Dr AnneMarie Baird of Lung Cancer Europe said, ‘’The research presented at this meeting, underscores the continued lack of awareness around lung cancer both in terms of incidence and mortality. The numbers are particularly striking in the 18-24 age group, as just 1% correctly identify lung cancer as the single biggest killer of women

in Ireland. We need to change the conversation around this disease and dramatically increase the profile of lung cancer in this country. In parallel we must tackle the stigma and ‘blame game’ mentality associated with it. By doing this as a community, we will ensure that people affected by lung cancer have improved outcomes through equal and timely access to innovative diagnostics, treatment and care.’’ Ger Brennan, Managing Director of MSD Human Health in Ireland, added that despite such high and increasing incidences of the disease, a distinct lack of awareness still exists. “Further, lung cancer patients in Ireland are often met with stigmatisation and lack of empathy in relation to their illness with lung cancer not receiving the same levels of attention as other cancers in Ireland,” he said. “We’re very proud to support the Marie Keating Foundation and the work being undertaken to address this imbalance. No patient should ever be stigmatised and all cancers must be treated with equal importance.” The research initiated by Marie Keating Foundation and supported by MSD, was conducted from the 9th - 16thNovember 2018 by Empathy Research with a nationally representative sample of 1,015 adults aged 18 and over.

Pharmacy Student Prize Giving The School of Pharmacy and Pharmaceutical Sciences at Trinity College (TCD) hosted its annual prize giving ceremony on Wednesday the 5th of December in the Senior Common Room, Front Square.

Jemima Turner, Sarah Fitzpatrick, Joseph O’Shea, Lucy Dwyer, Kateryna Kozachenko, Elizabeth Lyons, Leanne Madden and Darryl Crabb (not in photo)

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This year, and thanks to a generous sponsorship by Alexion Pharmaceuticals the student prize giving ceremony doubled up as a networking event with colleagues from the Pharmaceutical Industry. The Prize Giving Ceremony is a celebration of the outstanding performance of the TCD Pharmacy students in their academic achievements in the MPharm Degree course. Prizes are awarded for excellent academic performance in particular areas of Pharmacy study. All prizes are valued by the School as a statement of support for students and by the recipient for the recognition it offers for their achievement. The School acknowledges the generosity of all sponsors and congratulations to all recipients on their awards and their academic achievements. See page 60 for the all prize winners details.

news brief CENTRALISED DRUG PAYMENT SCHEME The HSE's National Medical Card Unit, PCRS has launched the new centralised Drugs Payment Scheme (DPS) service. This new service allows people, for the first time, to apply online at www. hse.ie/dps for their Drugs Payment Scheme card. As well as now being able to apply for and renew DPS cards at www.hse.ie/dps, new DPS application forms have been developed, in conjunction with the National Adult Literacy Agency. Forms are available at local community pharmacies, community Health Offices, GP surgeries, Citizens Information Centres and can be downloaded at www.hse.ie/dps Under the Drugs Payment Scheme, a person and their family pay a maximum of ¤134 in a calendar month for approved prescribed drugs, medicines and certain appliances in that month. GPs and community pharmacists have been updated about these changes and have been sent new leaflets, application forms and posters about the scheme for patients. According to Anne Marie Hoey, HSE PCRS: “Making applications for the Drug Payment Scheme available online is another positive development in the centralisation of schemes in the National Medical Card Unit. This new, streamlined service will bring great benefits for people in terms of turnaround times, convenience and security. Anything that makes applying for HSE demand led schemes more convenient for people helps us provide a better service to the public.” Further information is available on www.hse.ie/dps or LoCall 1890 252 919.


OTC & Retail Pharmacy Product Awards 2019 For more information about the awards, please contact: Sophie Maxwell on 0873379258 or email sophie@ipn.ie


News Pharmacy student Prize-Giving Trinity School of Pharmacy and Pharmaceutical Sciences hosted its annual prize giving ceremony on Wednesday the 5th of December. The Prizes and prize winners are detailed below. Paul Higgins Memorial Medal/Uniphar Prize in Pharmaceutical Chemistry Awarded to the student who attains the highest overall combined mark in modules PH3002 and PH4002. Presented by: Mr Brian Collins, Uniphar Director of Innovation and Strategy. Winner: Sarah Fitzpatrick Mr Brian Collins, Ms Sarah Fitzpatrick and Associate Professor Astrid Sasse

Johnson & Johnson Practice of Pharmacy Prize Awarded to the student who attains the highest overall combined mark in modules PH4006 and PH4007. Presented by: Ms Biola Wyrwas, Brand Activation Manager, Johnson & Johnson Ireland Winners: Lucy Dwyer, Sarah Fitzpatrick and Joseph O’Shea Ms Biola Wyrwas, Mr Joseph O’Shea, Ms Lucy Dwyer, Ms Sarah Fitzpatrick and Professor Cristín Ryan LEO Pharma Prize in Pharmaceutics Awarded to the student who attains the highest overall combined mark in modules PH4004 and PH4005. Presented by: Dr. Lorraine Nolan, Interim Senior Manager, Manufacturing, Science and Technology Finished Goods, LEO Pharma Winner- Leanne Madden Dr Lorraine Nolan, Ms Leanne Madden and Professor Anne Marie Healy

Sanofi Prize in Pharmacognosy Awarded to the student who attains the highest overall combined mark in modules PH3003 and PH4003. Presented by: Ms Lorraine Glynn, Country Head of Pharmacovigilance and Safety, Sanofi Ireland. Winner: Darryl Crabb Ms Lorraine Glynn, Mr Darryl Crabb and Associate Professor John Walsh

Carrick Therapeutics Prize in Pharmacology Awarded to the student who attains the highest overall combined mark in modules PH3009, PH3010, PH4009 and PH4011. Presented by: Dr Manfred Lehnert, Chief Medical Officer, Carrick Therapeutics. Winner: Kateryna Kozachenko Dr Manfred Lehnert, Ms Kateryna Kozachenko and Professor Lorraine O’Driscoll

The Alexion Senior Sophister Pharmacy Prize Awarded to the student who attains the highest overall mark in the B.Sc. (Pharm.) Degree. Presented by: Mr Robert Byrne, Site Quality Head, Alexion College Park, Alexion Pharmaceuticals. Winner: Sarah Fitzpatrick Mr Robert Byrne, Ms Sarah Fitzpatrick and Associate Professor John Walsh

Meagher’s Senior Fresh Pharmacy Prize Awarded to the student who attains the highest overall combined mark in the Senior Fresh year. Presented by: Mr Eugene Renehan, Supervising Pharmacist, Meagher’s Pharmacy Group and Adjunct Assistant Professor, School of Pharmacy and Pharmaceutical Sciences. Winner: Elizabeth Lyons Associate Professor Astrid Sasse, Ms Elizabeth Lyons and Mr Eugene Renehan

Solvotrin Therapeutics Junior Fresh Pharmacy Prize Awarded to the student who attains the highest overall combined mark in the Junior Fresh Year. Presented by: Mr Pat O’Flynn, CEO, Solvotrin Therapeutics. Winner: Jemima Turner Mr Pat O’Flynn, Ms Jemima Turner and Assistant Professor Máire O’Dwyer Photographs courtesy of Elizabeth O’Shaughnessy

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Clinical Profiles JANSSEN’S STELARA® (USTEKINUMAB) DEMONSTRATES SUSTAINED EFFICACY IN IMPROVING CLINICAL REMISSION RATES IN PATIENTS WITH MODERATE TO SEVERE CROHN’S DISEASE THROUGHOUT THREE YEARS The Janssen Pharmaceutical Companies of Johnson & Johnson announced new three-year data from the IM-UNITI study, which demonstrates the continued efficacy of ustekinumab in improving clinical remission rates and shows ustekinumab to be well-tolerated in patients with Crohn’s disease. The data from the IM-UNITI trial, which will continue for a further two years, were presented at the 26th United European Gastroenterology Week (UEGW) congress. These data are the first to be presented from the three-year assessment of subcutaneously (SC) administered 90 mg ustekinumab in Crohn’s disease. Overall efficacy assessments at week 152 demonstrated that 60.3% of all randomised ustekinumab-treated patients who entered long-term extension study were in clinical remission. Furthermore, 68.8% of randomised ustekinumab treated patients had demonstrated a clinical response.1 The key study findings for different dosing regimens found that 61.9% of patients who were randomised to receive 90 mg ustekinumab SC every 12 weeks (q12w) and continued to receive this dose in the study extension were in clinical remission. For those patients who were randomised to receive 90 mg ustekinumab SC in the every eight week dosing regimen group (q8w) and continued to receive this dose, 69.5% of patients were in clinical remission. The study also found that, of those patients who were naïve to TNF antagonist therapy and treated with ustekinumab, 67.6% were in maintained clinical remission at week 156.1 This demonstrates that patients who have not yet received TNF antagonist therapy (the most commonly prescribed class of biologic treatments) could benefit from ustekinumab treatment.2 Further to this, of those ustekinumab treated patients who had previously failed (i.e. were refractory to) or who were intolerant to TNF antagonist therapy, 48.4% were in clinical remission. Laurent de Saint Sernin, General Manager Commercial Operations, Janssen Sciences Ireland UC said, “Janssen is dedicated to helping improve the lives of people living with Crohn’s disease. With that

mission in mind, we are pleased that these study findings indicate that ustekinumab can help a substantial proportion of people with moderate to severe Crohn’s disease achieve clinical remission. The IM-UNITI study will continue to explore ustekinumab for a further two years, as part of our ongoing commitment to our patients, innovation and scientific leadership.” Safety events (per hundred patient years) were not higher amongst all ustekinumab treated patients entering the long-term extension study compared to placebo from week 44 through to week 156. No new safety signals were observed. Between weeks 96 and 156, three deaths were reported (one each of kidney failure, acute myocardial infarction and sepsis). Additionally, two cases of non-melanoma skin cancers (adenocarcinoma of the small intestine and CML) were seen in these treatment groups. The common (≥1/100) adverse reactions reported in controlled periods of the adult psoriasis, psoriatic arthritis and Crohn's disease clinical studies with ustekinumab as well as postmarketing experience were: arthralgia (joint pain), back pain, diarrhoea, dizziness, fatigue, headache, infection site pain, injection site erythema, myalgia (muscle pain), nasopharyngitis, nausea, oropharyngeal pain, pruritus (itching of the skin), upper respiratory tract infection and vomiting.

TWO-YEAR DATA FOR NOVARTIS BROLUCIZUMAB REAFFIRM SUPERIORITY VERSUS AFLIBERCEPT IN REDUCING RETINAL FLUID IN PATIENTS WITH NAMD Novartis announced additional brolucizumab Phase III results from year two that reaffirmed its positive year one findings. Brolucizumab met its primary endpoint of noninferiority versus aflibercept in best corrected visual acuity (BCVA) and exhibited superiority in key retinal outcomes at year one (48 weeks). Secondary endpoints at year two (96 weeks) reaffirmed superiority of brolucizumab 6 mg in reduction of retinal fluid, an important marker of disease activity in patients with neovascular age-related macular degeneration (nAMD). Approximately 20 to 25 million people are affected by nAMD, also known as wet AMD, a leading cause of blindness worldwide. The year two HAWK and HARRIER findings demonstrated that fewer patients with nAMD had intraretinal fluid (IRF) and/or sub-retinal fluid (SRF) key markers used by physicians to determine injection frequency in clinical practice

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with brolucizumab 6 mg versus aflibercept at week 96 [24% for brolucizumab 6 mg vs. 37% for aflibercept in HAWK (P=0.0001); 24% vs. 39%, respectively, in HARRIER (P<0.0001). Additionally, brolucizumab 6 mg patients continued to demonstrate reductions in central subfield thickness (CST) at week 96. An increase in CST in nAMD is an important measure of abnormal fluid accumulation and edema and may result in reduced vision. Absolute reductions in CST from baseline were 175 µm for brolucizumab 6 mg versus 149 µm for aflibercept in HAWK (P=0.0057) and 198 µm versus 155 µm, respectively, in HARRIER (P<0.0001). Also at week 96, fewer brolucizumab 6 mg patients had sub-retinal pigment epithelium (sub-RPE) fluid (11% for brolucizumab 6 mg vs. 15% for aflibercept in HAWK; 17% vs. 22%, respectively, in HARRIER)1. Additionally, of the patients on brolucizumab 6 mg who successfully completed year one on a 12-week dosing interval, 82% in HAWK and 75% in HARRIER were maintained on a 12-week dosing interval in year two. “These findings at year two reaffirm the excellent year one brolucizumab data regarding retinal fluid reduction, a key goal for physicians treating patients with nAMD,” said Dr. Pravin U. Dugel, Managing Partner, Retinal Consultants of Arizona; Clinical Professor, Roski Eye Institute, Keck School of Medicine, University of Southern California; and principal investigator of both trials. “These consistent results continue to support brolucizumab as a potential new treatment for patients with nAMD.” As previously announced, HAWK and HARRIER met their primary endpoint of non-inferiority in mean change in BCVA at week 48 with brolucizumab versus aflibercept2. Brolucizumab maintained robust visual gains in year two, with mean change in BCVA of 5.9 letters for brolucizumab 6 mg versus 5.3 letters for aflibercept in HAWK, and 6.1 letters versus 6.6 letters, respectively, in HARRIER. “Over two years, brolucizumab consistently dried retinal fluid better than aflibercept while keeping many patients on a quarterly dosing schedule. Additionally, the robust visual gains shown in year one with brolucizumab were maintained in year two,” said Shreeram Aradhye, Global Head Medical Affairs and Chief Medical Officer, Novartis Pharmaceuticals. “With sustained improvements in key anatomical outcomes that denote

disease activity, brolucizumab is an important scientific advance and underscores our commitment to reimagining medicine.” No new, previously unreported types of safety events were identified at week 96, and brolucizumab continued to be comparable to aflibercept with the overall incidence of adverse events balanced across all treatment groups in both studies1. The most frequent ocular adverse events (≥5% of patients in any treatment arm) were reduced visual acuity, conjunctival hemorrhage, vitreous floaters, eye pain, dry eye, retinal hemorrhage, cataract and vitreous detachment1. The most frequent non-ocular adverse events were typical of those reported in a nAMD population; there were no notable differences between arms. These new 96-week data, based on pre-specified secondary endpoints from the HAWK and HARRIER trials, were presented at the American Academy of Ophthalmology (AAO) 2018 Annual Meeting as a follow-up to the year one data presented in November 2017.

ORION ACQUIRES SALES AND DISTRIBUTION RIGHTS FOR CERTAIN EUROPEAN COUNTRIES FOR PARKINSON'S DISEASE DRUG STALEVO Orion Corporation and Novartis Pharma AG have agreed that Novartis will return the sales and distribution rights in certain European countries for Parkinson's disease drug Stalevo® to Orion. The sales and distribution rights in certain European countries for the proprietary product Stalevo® (active pharmaceutical ingredients: levodopa, carbidopa, entacapone), which has been patented and developed by Orion for the treatment of Parkinson's disease, transfer from Novartis to Orion as of 3 December 2018. Central nervous system (CNS) disorders are one of Orion's three core therapy areas, and, measured by net sales, Parkinson's disease drugs are Orion's largest family of pharmaceutical preparations. Stalevo has been on the market since 2003. Orion has been responsible for selling and marketing Stalevo in the Nordic and Baltic countries, Germany, Poland, the United Kingdom and Ireland. Under the concluded agreement, the sales and marketing rights for Stalevo will transfer back to Orion in another 18 EU countries and also some European countries outside of the EU. Novartis will continue to be Orion's sales and distribution partner in Switzerland.


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A choice you can feel better about *Perrigo Cold & Flu Multi-Relief Max Sachets. Perrigo Cold & Flu Multi Relief Max Powder for Oral Solution, Paracetamol 1000 mg, Guaifenesin 200 mg, Phenylephrine 12.2 mg. For the relief of symptoms of colds and flu and the pain and congestion of sinusitis, including aches and pains, headache, blocked nose and sore throat, chills, lowering of temperature, and to loosen stubborn mucus and provide relief from chesty coughs. Adults, the elderly and children aged 12 years and over: One sachet every four hours as required to a maximum of 4 sachets (4 doses) in a 24-hour period. Do not give to children under 12 years. Not to be continued for over 3 days without consulting a doctor. Contraindications: Hypersensitivity to any of the ingredients, hyperthyroidism, diabetes, cardiovascular disorders, patients who are taking or have taken monoamine oxidase inhibitors within the last two weeks, those taking tricyclic anti-depressants or patients currently receiving other sympathomimetics, phaeochromocytoma, prostatic enlargement or urinary retention, glaucoma, hepatic and renal impairment and porphyria. Precautions: Circulatory disorders, patients with hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. May be harmful to people with phenylketonuria. May act as cerebral stimulant. Do not take with alcohol. Pregnancy and lactation: Not to be taken during pregnancy or whilst breast feeding. Side effects (unknown frequency): Agranulocytosis, thrombocytopenia, abnormal hepatic function, anaphylaxis, cutaneous hypersensitivity reactions, bronchospasm. See SmPC for full list of side effects and further information. Legal classification: P. PA 1120/1/3. MAH: Wrafton Laboratories Ltd. (T/A Perrigo), Braunton, Devon, EX33 2DL, UK. RRP (ex. VAT): 10 €7.60 Date of preparation Apr 2018. http://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA1120-001-003_14022018144055.pdf Perrigo Cold & Flu Multi Relief Capsules, Paracetamol 500 mg, Guaifenesin 200 mg, Phenylephrine 6.1 mg. For the relief of symptoms of colds and flu and the pain and congestion of sinusitis, including aches and pains, headache, blocked nose, sore throat, lowering of temperature, and to loosen stubborn mucus and provide relief from chesty coughs. Adults, the elderly and children aged 16 years and over: Two capsules every 4-6 hours when necessary to a maximum of 4 doses in 24 hours. Do not give to children under 16 years. Not to be continued for over 3 days without consulting a doctor. Contraindications: Hypersensitivity to any of the ingredients, hepatic or severe renal impairment, hyperthyroidism, diabetes, heart disease, those taking tricyclic anti-depressants or beta-blockers, patients who are taking or have taken monoamine oxidase inhibitors within the last two weeks or those currently receiving other sympathomimetics, phaeochromocytoma, prostatic enlargement or urinary retention, closed angle glaucoma, and porphyria. Precautions: Circulatory disorders, asthma, may act as a cerebral stimulant. Do not take with alcohol. Pregnancy and lactation: Not to be taken during pregnancy or whilst breast feeding. Side effects (unknown frequency): Thrombocytopenia, agranulocytosis, anaphylaxis, cutaneous hypersensitivity, bronchospasm, hepatic dysfunction, acute pancreatitis. See SmPC for full list of side effects and further information. Legal classification: P. PA 1120/1/2. MAH: Wrafton Laboratories Ltd. (T/A Perrigo), Braunton, Devon, EX33 2DL, UK. RRP (ex. VAT): 16 €7.30. Date of preparation Apr 2018. http://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA1120-001-002_09032018152037.pdf Perrigo Cold & Flu Powder for Oral Solution Paracetamol 500 mg, Guaifenesin 200 mg, Phenylephrine 10 mg. For the short-term relief of symptoms of colds and flu including aches and pains, headache, blocked nose, sore throat, chills and fever and to loosen stubborn mucus (phlegm) and provide relief from chesty coughs. Adults, the elderly and children aged 12 years and over: One sachet every 4-6 hours when necessary to a maximum of 4 sachets (4 doses) in a 24-hour period. Do not give to children under 12 years. Not to be continued for over 3 days without consulting a doctor. Contraindications: Hypersensitivity to any of the ingredients, hepatic or severe renal impairment, cardiovascular disorders, hyperthyroidism, diabetes, phaeochromocytoma, glaucoma, urinary retention, patients taking tricyclic antidepressants or beta-blockers, patients currently receiving or within two weeks of stopping therapy with monoamine oxidase inhibitors, or those currently receiving other sympathomimetic drugs. Precautions: Circulatory disorders myasthenia gravis, severe gastrointestinal diseases, glucose-6-phosphatedehydrogenase deficiency, haemolytic anaemia, glutathione deficiency, asthma, those on a controlled sodium diet. Patients with hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. May be harmful to people with phenylketonuria. May act as cerebral stimulant. Do not take with alcohol. Pregnancy and lactation: Not to be taken during pregnancy or whilst breast feeding. Side effects (unknown frequency): Thrombocytopenia, agranulocytosis, anaphylaxis, cutaneous hypersensitivity reactions, bronchospasm, hepatic dysfunction, acute pancreatitis. See SmPC for full list of side effects and further information. Legal classification: P. PA 1891/3/. MAH: Wrafton Laboratories Ltd. (T/A Perrigo), Braunton, Devon, EX33 2DL, UK. RRP (ex. VAT): 10 €5.15. Date of preparation Apr 2018. https://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA1891-003-001_19022018162036.pdf Perrigo Cold & Flu Tablets, Paracetamol 250 mg, Guaifenesin 100 mg, Phenylephrine 5 mg. For the relief of symptoms of colds and flu, including aches and pains, headache, blocked nose, sore throat, chills and chesty coughs. Adults, the elderly and children aged 12 years and over: Two tablets every 4-6 hours when necessary to a maximum of 4 doses in 24 hours. Children under 12 years: Not to be used unless recommended by a doctor. Not to be continued for over 3 days without consulting a doctor. Contraindications: Hypersensitivity to any of the ingredients, hyperthyroidism, diabetes, cardiovascular disorders, hepatic and renal impairment, patients who are taking or have taken monoamine oxidase inhibitors within the last two weeks, those taking tricyclic anti-depressants or those currently receiving other sympathomimetics, phaeochromocytoma, prostatic enlargement, urinary retention, glaucoma and porphyria. Precautions: Circulatory disorders, asthma, may act as a cerebral stimulant. Do not take with alcohol. Pregnancy and lactation: Not to be taken during pregnancy or whilst breast feeding. Side effects (unknown frequency): Agranulocytosis, thrombocytopenia, abnormal hepatic function, anaphylaxis, cutaneous hypersensitivity reactions, bronchospasm, acute pancreatitis. See SmPC for full list of side effects and further information. Legal classification: P. PA 1120/1/1. MAH: Wrafton Laboratories Ltd. (T/A Perrigo), Braunton, Devon, EX33 2DL, UK. RRP (ex. VAT): 16 €5.40. Date of preparation Apr 2018. http://www.hpra.ie/img/uploaded/swedocuments/ LicenseSPC_PA1120-001-001_06022018104036.pdf.


Tanning Solution for people who suffer from Eczema Is there any tan I can use if I have Psoriasis, Eczema or Rocacea

TanOrganic is world’s first and only Eco-certified tan in the world with full vegan society certification, leaping bunny certification and one of the 6 cosmeceutical companies in the world with a100 score by ethical association.

All skin types and allergies are different, for some people you could be sensitive to SLS, perfume (which is the number one allergen in skin care), alcohol, or in other cases synthetic colourings like C+D red dyes- the guide colouring present in nearly all fake tans except TanOrganic as we use food colouring). Our feedback from our customers who have skin conditions such as Psoriasis, Eczema, Rosacea, is that they love TanOrganic because it has no SLS, it has organic ingredients, it is ultra moisturising and it is kinder to the skin. “I have had eczema on my legs and arms all my life and have acne prone skin and so I struggled with finding a tan that suits my skin type. I have tried so many brands of tan, but any I tried usually just made my skin break out or flare up. I got TanOrganic as a gift when I was 18 and tried it and it didn’t affect my eczema or cause any kind of harsh break out at all. It’s light on my skin and so it doesn’t get trapped in my pores and can be easily removed when I want to take it off. I’m now 20 and I use tanOrganic at least twice a week.” Orlaith, 20 years old, Dublin “I absolutely love TanOrganic products, I suffer from Eczema and my skin is super sensitive, I have tried all other “organic” tan brands but none of them are as good, I started out using the tanning oil which was brilliant for not sticking to my eczema patch’s and then I tried the tan mousse which was really amazing. Both my sisters in Australia now use it too, I also work in a well-being beauty clinic and we are oncology friendly so I have told a lot of our cancer patients about the tan.” Rachel Kearns, Kildare The main ingredients in TanOrganic, just to give you an idea of how utterly natural and organic the product is: Aloe Vera, Caramel, Orange Peel, Achiote Seed, Ginger, Thyme, Coconut, Corn, Beetroot, Sugar Cane, Lilac, Raspberry, Gingseng, Chamomile and Honey.

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