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January 2020 Volume 12  Issue 1 PHARMACYNEWSIRELAND.COM


In this issue: NEWS: Pharmacists welcome cuts u-turn Page 5

PROFILE: What has changed in the Study of Pharmacy? Page 10

CONFERENCE: Innovating for Life at IPHA Annual Conference Page 18 Now PCRS Reimburseable *Based on 2 x 1mg dose Nicorette QuickMist1 mg/spray, oromucosal spray, solution. Composition: One spray delivers 1 mg nicotine in 0.07 ml solution. 1 ml solution contains 13.6 mg nicotine. Excipient with known effect: Ethanol (less than 100 mg of ethanol/spray). Propylene glycol, Butylated hydroxytoluene. Pharmaceutical form: Oromucosal spray, solution. A clear to weakly opalescent, colourless to yellow solution. Indications: For the treatment of tobacco dependence in adults by relief of nicotine withdrawal symptoms, including cravings, during a quit attempt. Permanent cessation of tobacco use is the eventual objective. Nicorette QuickMist should preferably be used in conjunction with a behavioral support program. Dosage: Subjects should stop smoking completely during the course of treatment with Nicorette QuickMist. Adults and Elderly: The following chart lists the recommended usage schedule for the oromucosal spray during full treatment (Step I) and during tapering (Step II and Step III). Up to 4 sprays per hour may be used. Do not exceed 2 sprays per dosing episode and do not exceed 64 sprays (4 sprays per hour, over 16 hours) in any 24-hour period. Step I: Weeks 1-6: Use 1 or 2 sprays when cigarettes normally would have been smoked or if cravings emerge. If after a single spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Step II: Weeks 7-9: Start reducing the number of sprays per day. By the end of week 9 subjects should be using HALF the average number of sprays per day that was used in Step I. Step III: Weeks 10-12: Continue reducing the number of sprays per day so that subjects are not using more than 4 sprays per day during week 12. When subjects have reduced to 2-4 sprays per day, oromucosal spray use should be discontinued. To help stay smoke free after Step III, subjects may continue to use the oromucosal spray in situations when they are strongly tempted to smoke. One spray may be used in situations where there is an urge to smoke, with a second spray if one spray does not help within a few minutes. No more than four sprays per day should be used during this period. Regular use of the oromucosal spray beyond 6 months is generally not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Paediatric population: Do not administer this medicine to persons under 18 years of age. There is no experience of treating adolescents under the age of 18 with this medicine. Method of administration: After priming, point the spray nozzle as close to the open mouth as possible. Press firmly the top of the dispenser and release one spray into the mouth, avoiding the lips. Subjects should not inhale while spraying to avoid getting spray into the respiratory tract. For best results, do not swallow for a few seconds after spraying. Subjects should not eat or drink when administering the oromucosal spray. Behavioural therapy advice and support will normally improve the success rate. Contraindications: Hypersensitivity to nicotine or to any of the excipients. Children under the age of 18 years. Those who have never smoked. Special warnings and precautions for use: This medicine should not be used by non-smokers. The benefits of quitting smoking outweigh any risks associated with correctly administered nicotine replacement therapy (NRT). A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions: Cardiovascular disease: Dependent smokers with a recent myocardial infarction, unstable or worsening angina including Prinzmetal’s angina, severe cardiac arrhythmias, recent cerebrovascular accident and/or who suffer with uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions (such as counselling). If this fails, the oromucosal spray may be considered but as data on safety in this patient group are limited, initiation should only be under close medical supervision. Diabetes Mellitus. Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when smoking is stopped and NRT is initiated as reduction in nicotine induced catecholamine release can affect carbohydrate metabolism. Allergic reactions: Susceptibility to angioedema and urticaria. Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects. Phaeochromocytoma and uncontrolled hyperthyroidism: Use with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma as nicotine causes release of catecholamines. Gastrointestinal Disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions. Paediatric population: Danger in children: Doses of nicotine tolerated by smokers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be handled or ingested by children. Transferred dependence: Transferred dependence can occur but is both less harmful and easier to break than smoking dependence. Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. The plasma concentration of other medicinal products metabolised in part by CYP1A2 e.g. imipramine, olanzapine, clomipramine and fluvoxamine may also increase on cessation of smoking, although data to support this are lacking and the possible clinical significance of this effect for these drugs is unknown. Limited data indicate that the metabolism of flecainide and pentazocine may also be induced by smoking. Excipients: The oromucosal spray contains small amounts of ethanol (alcohol), less than 100 mg per dose (1 or 2 sprays). This medicinal product contains less than 1 mmol sodium (23 mg) per spray, i.e. essentially ‘sodium- free’. This medicine contains 12 mg propylene glycol in each spray which is equivalent to 150 mg/mL. Due to the presence of butylated hydroxytoluene, Nicorette QuickMist may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes. Care should be taken not to spray the eyes whilst administering the oromucosal spray. Undesirable effects: Effects of smoking cessation: Regardless of the means used, a variety of symptoms are known to be associated with quitting habitual tobacco use. These include emotional or cognitive effects such as dysphoria or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating, and restlessness or impatience. There may also be physical effects such as decreased heart rate; increased appetite or weight gain, dizziness or presyncopal symptoms, cough, constipation, gingival bleeding or apthous ulceration, or nasopharyngitis. In addition, and of clinical significance, nicotine cravings may result in profound urges to smoke. This medicine may cause adverse reactions similar to those associated with nicotine given by other means and these are mainly dose-dependent. Allergic reactions such as angioedema, urticaria or anaphylaxis may occur in susceptible individuals. Local adverse effects of administration are similar to those seen with other orally delivered forms. During the first few days of treatment irritation in the mouth and throat may be experienced, and hiccups are particularly common. Tolerance is normal with continued use. Daily collection of data from trial subjects demonstrated that very commonly occurring adverse events were reported with onset in the first 2-3 weeks of use of the oromucosal spray, and declined thereafter. Adverse reactions with oromucosal nicotine formulations identified from clinical trials and during post-marketing experience are presented below. The frequency category has been estimated from clinical trials for the adverse reactions identified during post-marketing experience. Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1 000 to <1/100); rare (≥1/10 000 to <1/1 000); very rare (<1/10 000); not known (cannot be estimated from the available data). Immune system disorders Common Hypersensitivity Not known Allergic reactions including angioedema and anaphylaxis Psychiatric disorders Uncommon Abnormal dream Nervous system disorders Very common Headache Common Dysgeusia, paraesthesia Eye disorders Not known Blurred vision, lacrimation increased Cardiac disorders Uncommon Palpitations, tachycardia Not known Atrial fibrillation Vascular disorders Uncommon Flushing, hypertension Respiratory, thoracic and mediastinal disorders Very common Hiccups, throat irritation Uncommon Bronchospasm, rhinorrea, dysphonia, dyspnoea, nasal congestion, oropharyngeal pain, sneezing, throat tightness Gastrointestinal disorders Very common Nausea Common Abdominal pain, dry mouth, diarrhoea, dyspepsia, flatulence, salivary hypersecretion, stomatitis, vomiting Uncommon Eructation, gingival bleeding, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral Rare Dysphagia, hypoaesthesia oral, retching Not known Dry throat, gastrointestinal discomfort, lip pain Skin and subcutaneous tissue disorders Uncommon Hyperhidrosis, pruritus, rash, urticaria Not known Erythema General disorders and administration site conditions Common Burning sensation, fatigue Uncommon Asthenia, chest discomfort and pain, malaise. MAH: Johnson & Johnson (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland. PA Number: PA 330/37/13. Date of revision of text: PA 330/37/13: May 2019. Product not subject to medical prescription. Full prescribing information available upon request. IRE/NI/19-4007

CPD: Eating Disorders and Mental Health Page 31

FEATURE: Automation in Pharmacy Page 46

TEAM TRAINING: Male Health Page 52


Headaches Period pain Joint pain

Back pain Dental pain

Panadol Extra Soluble has a dual active formula which provides up to 30% more powerful pain relief than standard paracetamol.1





Reference. 1. Laska EM et al. JAMA. 1984; 251(13):1711-1718.

Panadol Extra 500mg/65mg Soluble Effervescent Tablets. Contain paracetamol. Always read the label/leaflet. Product Information: Please consult the summary of product characteristics for full product information. Panadol Extra 500mg/65mg Soluble Effervescent Tablets, paracetamol 500mg, caffeine 65mg. Indications: Relief of mild to moderate pain including rheumatism, neuralgia, musculoskeletal disorders, headache, symptoms of colds and flu, fever, toothache and menstrual pain. Dosage: Adults and children 16 years and over: 2 tablets up to 4 times a day. Do not exceed 8 tablets in 24 hours. Children aged 12-15 years: 1 tablet up to 4 times a day. Do not exceed 4 tablets in 24 hours. Do not give to children under 12 years. Minimum dosing interval: 4 hours. Contraindications: Hypersensitivity to paracetamol, caffeine or any ingredients. Precautions: Avoid concurrent use with other paracetamol-containing products. Diagnosed liver of kidney impairment. Patients with depleted glutathione levels or chronic alcoholism or sepsis. Avoid excessive caffeine intake. Caution in those with hereditary sugar intolerance or on a low sodium diet. Should not be used in pregnancy or lactation without medical advice. Do not exceed the stated dose. Prolonged use except under medical supervision may be harmful. Side effects: See SPC for full details. All very rare: Thrombocytopenia, hypersensitivity reactions including anaphylaxis and skin rash, angioedema, Stevens-Johnson syndrome, bronchospasm, hepatic dysfunction. Frequency unknown: Nervousness, dizziness. When combined with dietary caffeine intake, higher doses of caffeine may increase potential for caffeine related adverse events such as insomnia, restlessness, anxiety, irritability, headaches, GI disturbances and palpitations. Overdose: Immediate medical advice should be sought in the event of an overdose, even if symptoms of overdose are not present. Legal Category: Supply through pharmacy only. MA Number: PA 678/39/10. MA Holder: GlaxoSmithKline Consumer Healthcare (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24. Additional information is available upon request. Text prepared: November 2019. CHGBI/CHPAN/0107/19




Page 4: Galway Pharmacists calls out prescription levy

As Irish Pharmacy News was going to press with our December bumper issue, the news broke of the Minister’s intentions towards further pharmacy cuts. Not one week later, we learned that he agreed not to proceed. He has also agreed to recommit to early talks on a new pharmacy contract and on investment in pharmacy services.

Page 6: Meaghers gives the gift of conscience Page 14: New charity partner for Hickeys Page 16: Boots open Flagship Pharmacy on Dawson Street


Turn to page 5 for the full story.

Page 18: IPHA host Annual Conference on Innovation

On page 14 of this issue we feature the opening of Boots Pharmacy Ireland’s flagship store. For the past 23 years, Boots has sought to bring the best of health and beauty to Ireland and last month, the pharmacy-led health and beauty retailer marked a new chapter as it opened its new format store on Dawson Street in Dublin city centre.

Page 44: Launch of the Irish Pharmacy Awards 2020 Page 46: Robotics the way forward for Pharmacy


Many students were experiencing financial strain as well as mental health issues associated with their study.

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

ADVERTISING DIRECTOR Debbie Graham: 00353 (87) 288 2371 debbie@ipn.ie ADVERTISING EXECUTIVE Amy Evans: amy@ipn.ie CONTRIBUTORS Lauren O’Reilly | Gary O’Brien Amy Oates DESIGN DIRECTOR Ian Stoddart Design




The brand-new store will introduce exciting new brands, innovative experiences and access to expert advice and excellence in pharmacy in the bustling city centre location. It was January last year, when pharmacy students across Ireland voiced their concerns and highlighted difficulties under the newly introduced MPharm programme and a lack of payment for placements.

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

EDITOR Kelly Jo Eastwood: 00353 (87)737 6308 kelly-jo@ipn.ie

IPU Secretary General Darragh O’Loughlin said, “While this reprieve is welcome, a significant increase in resources is urgently needed to meet the ever-increasing costs of providing the existing service, to ensure the viability of community pharmacy and to allow pharmacists to deliver on their commitment to ongoing service development and reform, which will have significant benefit for patients and the public.”

18 Irish Pharmacy IRISH News is PHARMACY circulated to all NEWS independent, multiple Pharmacists and academics in Ireland. 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 permission. IPN Communications Ltd. has taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

In February, APPEL lifted the ban on payment for placement. By way of follow-up to this story, Irish Pharmacy News spoke to Lauren O’Reilly, Vice President Public Relations of the Irish Pharmaceutical Students’ Association to gauge what it’s like to study pharmacy today. Turn to page 10 to read her thoughts. This issue also carries educational focuses on HIV, pre-pregnancy and fertility, sport and fitness and COPD with a closer look at the recent GOLD Guidelines. I hope you enjoy our first issue of 2020.


P26 P31 P36 P52 P62

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Script levy ‘false economy’ says Pharmacist Galway Pharmacist Frank McAnena, who offers medical help to the homeless along with GP colleague Dr Kieran Coleman, has criticised the State’s prescription levy on vulnerable people as a ‘false economy.’ Galway Pharmacist, Frank McAnena Dr Coleman and Mr McAnena point out that rough sleepers often have complex medical and psychiatric conditions, requiring medication, and every effort should be made by the State to support them. “Complex patients with complex needs need complex care,” Mr McAnena said.

The levy per item of medication is a serious deterrent for those most in need of help, they point out. They claim that people with complex medical needs, who have not taken medication, end up in hospital emergency departments, at a greater cost to the State. Dr Coleman and nurse Regina Boyle provide a walk-in clinic and medical outreach service for homeless people in Galway City which is run through the HSE’s National Office for Social Inclusion and two non-governmental organisations, Galway Simon and Cope Galway.

Pharmacist Mr McAnena has offered to waive the ¤2 prescription charge for patients, but both he and Dr Coleman question why the HSE is imposing the charge on homeless people in the first place. The levy per prescription item charge was introduced for medical card-holders in 2010, with a monthly maximum. It started at 50c, but is now ¤2 per item, and ¤1.50 per item for people aged over 70. It is waived for asylum seekers under the Irish Refugee Protection Programme, methadone users, and those with a long-term illness.

Dr Coleman said someone with diabetes who requires insulin and may have other conditions, would face an estimated extra ¤10 cost per week to cover the prescription levy. “It becomes a reason not to take medication,” said Dr Coleman. Mr McAnena pioneered a weekly delivery service for people who are at risk of forgetting to take medication, and extended his work into working with homeless people two years ago. The pharmacist has also urged Health Minister Simon Harris to undertake a pilot scheme for a “domiciliary pharmacy” which would improve compliance and prevent hoarding and ordering of unnecessary medications.

Greenlight for Pharmacy Prescribers A “highly-trained pharmacist prescriber” under the governance and supervision of a managing GP would be “an additional valuable resource in the community”, the Irish College of General Practitioners (ICGP) has stated. Responding to questions from the Medical Independent, a College spokesperson added, “If care is shared with GPs and is guided and directed by the GP, then a pharmacist prescriber would add to the community support team for patients. Pharmacist prescribers would require extra training and thorough and comprehensive guidelines and protocols in order to ensure patient safety and wellbeing.” The College also issued a positive opinion on a potential minor ailments scheme in pharmacy, subject to certain conditions being met.

Measuring Distance to Pharmacy Nearly 30% of people in Ireland live within 5km of an emergency department, according to a new report from the Central Statistics Office (CSO). Ireland’s national statistics office published a new report called Measuring Distance to Everyday Services in Ireland. It combined data from multiple sources to show how close or far away Irish people live from common facilities such as schools, GPs and public transport stops.

population. For 5% of people, a train station is the closest public transport option.

The report found that a bus stop was the closes public transport option for 93% of the

Dermot Corcoran, a CSO statistician said the results indicated people in the counties

One-fifth of Ireland’s population lives less than 500 metres from a pharmacy. Two-thirds of people live within 2km of a GP, while 4% live 10km or more away.


of Galway, Donegal, Mayo, Leitrim and Roscommon had higher average distances to most of these services compared to other counties. A large difference in distance can be seen between rural and urban areas. For example, a full-time operating garda station is 14.7km away from people living in rural Ireland on average, but just 3.7km away in urban areas.

Uniphar continues expansion Uniphar has agreed to pay up to ¤40m to buy two companies, as it continues to expand following a summer stock market flotation that raised ¤139m. Uniphar is buying EPS Group, which has units in Sweden and Finland, and Ireland-based M3 Medical. Both EPS Group and M3 Medical provide sales, marketing and distribution services to medical device makers focused on interventional cardiology and vascular medicine. The EPS Group purchase follows Uniphar‘s previously stated intent to enter the Nordic market, as it expands the European footprint of its commercial and clinical division. EPS provides services across Scandinavia, Iceland and the Baltics. M3 Medical exclusively services the Irish market. Uniphar, which is also the single biggest pharmacy wholesaler in Ireland, said the acquisitions were expected to add combined revenue of ¤22m a year to the group. The company has focused its expansion sights on Europe for its commercial and clinical division. Meanwhile, it is aiming to become a global leader in its product access activities, where it sources and supplies unlicensed medicines, and also manages the release of speciality medicines on behalf of pharmaceutical manufacturers. Uniphar CEO Ger Rabbette said the latest acquisitions were a “key strategic step” in the group‘s plan to offer its clients a pan-Europe service. “With this development, we add to our already considerable expertise in the area of interventional technologies in key therapeutic areas, and Uniphar advances its ambition to become a leading independent distributor of medical devices throughout Europe,” he said. Mr Rabbette added that Uniphar would invest in the newly acquired platforms in the short term. Uniphar floated on the Dublin and London stock exchanges during the summer. Its shares had jumped almost 6pc by early yesterday afternoon, to ¤1.25, above their ¤1.15 debut price.

News New Pharmacy Strategic Plan The Federation of International Pharmacists (FIP) has published its new Strategic Plan, which was approved by the FIP Council in September. The plan articulates the mission of FIP in order to further strategic partnerships, purposeful collaborations and enhanced benefits for members and the profession. It defines the scope of the federation and will guide its activities for the next five years. The Strategic Plan document sets out six strategic outcomes of the plan: • Everyone has access to the medicines they need. • Everyone has access to the health and medicines-related information they need. • Everyone benefits from innovations in medicines, health technologies and services. • Pharmacists ensure the responsible and quality use of medicines. • Work collaboratively to ensure comprehensive and integrated healthcare outcomes for patients. • FIP is a cost-effective, unified, vibrant and growing organisation that meets the needs and supports the work of its members. “FIP has led the profession globally since 1912, expanding and organising itself to include, represent and advocate for many types, sectors, sections across pharmacy, pharmacists and pharmaceutical science. Our mission remains: to support global health by enabling the advancement of pharmaceutical practice, sciences and education,” said FIP CEO Catherine Duggan. Dr Duggan added, “Like all membership organisations in order to thrive, we must adapt to the demanding challenges facing the profession worldwide. This Strategic Plan has been developed in full consultation with our member organisations and FIP officers. With this new plan, we will maximise the strengths of our position and reach, take advantage of opportunities for growth that have been identified in the global healthcare environment, including strengthening partnerships and collaborations and we will mitigate any weaknesses and threats from competition or duplication of efforts.”


Minister makes pharmacy cuts u-turn Health Minister Simon Harris has agreed not to proceed with proposed savage cuts in fees to pharmacies, in a move welcomed by the profession. He has also agreed to recommit to early talks on a new pharmacy contract and on investment in pharmacy services. Deep cuts to pharmacy fees were proposed by the Department of Health in October and, following a concerted effort by pharmacists to push back against these further fee cuts, Minister Harris met with the IPU last month and announced his decision not to introduce the cuts, but to leave fees as they are and to start contract talks early in the New Year. Speaking after the meeting,

IPU Secretary General Darragh O’Loughlin said, “After a decade of decline in payments for delivering services on behalf of the State, pharmacy businesses and their staff are under unsustainable pressure. While this reprieve is welcome, a significant increase in resources is urgently needed to meet the ever-increasing costs of providing the existing service, to ensure the viability of community pharmacy and to allow pharmacists to deliver on their commitment to ongoing service development and reform, which will have significant benefit for patients and the public.”

“New contract talks will also include discussions on an expansion of healthcare services in pharmacy. As we continue into the winter months and a rising trolley count, this will deliver real benefits for patients and will take pressure off the rest of the health system and in particular overstretched Accident and Emergency Departments and GP clinics. We look forward to working with Minister Harris and his officials in the New Year, and ensuring Irish patients are able to fully benefit from the professional expertise of their local pharmacist.”

New Scheme to revitalise Irish Pharmacy Industry Leading Irish Pharmacy group, totalhealth, have launched a new scheme to revitalise the local Irish pharmacy industry. The Pharmacy Assistance Purchase Scheme (PAPS) aims to facilitate Irish pharmacists who wish to purchase their own pharmacy. The purpose of the scheme is to remove some of the barriers faced by pharmacists who are eager to become pharmacy owners, by providing financial assistance and business support to purchasers. The scheme is not designed to build new pharmacies but to utilise existing premises, allowing sellers to sell their pharmacy to someone who wishes to continue to serve the local community. The pharmacy industry in Ireland is a fast-changing landscape with independent pharmacies most challenged and for pharmacists who wish to establish their own local operation and serve their local community, the task is becoming more difficult. totalhealth aims to support budding pharmacy owners through their PAPS initiative by assisting financially, allowing them a realistic route to purchase an existing pharmacy. The scheme will also see the pharmacies open under the totalhealth symbol group, who currently have 80 pharmacies nationwide, which has countless benefits for pharmacy owners when it comes to supply chain, brand awareness, marketing and much more. The PAPS initiative is part-funded by totalhealth member investors and will provide financial assistance to those wishing to purchase an existing pharmacy. John Arnold, Managing Director of totalhealth Pharmacy says, “We want to facilitate pharmacists with the PAPS scheme in achieving their goal of owning and operating

Rory O’Donnell, PAPs Chairperson, John Arnold, Managing Director, totalhealth Pharmacy Group and Sheena Mitchell, Pharmacist, Milltown totalhealth Pharmacy

their own pharmacy. I have seen the struggles faced by both current and potential pharmacy owners. Raising capital is a major barrier to entry, with financial institutions requiring a significant percentage of the purchase price up front. Potential owners are also aware of the difficulties of running a pharmacy; operational costs can be daunting. By buying an existing pharmacy within an established symbol group such as totalhealth, owners have all the benefits of working with an overarching, recognisable brand, as well as an alleviation of the financial constraints, giving aspiring pharmacy owners a fair start on their business journey”. PAPS Chairperson Rory O’Donnell

says “It’s almost as difficult for a pharmacist to sell their business as it is for someone to buy it. With this new scheme, we’re helping at both ends of the process, as well as offering our existing members a unique investment opportunity. Pharmacy owners wishing to retire or sell their businesses can be confident that their patients and customers will continue to receive a high standard of service and care when they do.” The board of PAPS is made up of members of totalhealth who bring a wealth of experience to further enhance the business. The board is advised by Fitzgerald Power Chartered Accountants and AMOSS Solicitors.




Meaghers Wrap up Homelessness Meaghers Pharmacy had Christmas traditions all wrapped up as they continued to support homelessness. Oonagh O’Hagan, Managing Director, Meaghers Pharmacy Group and their ‘The Giving Keys’ initiative

ePortfolio and Practice Review Notices Pharmacists selected for ePortfolio Review 2019/2020 will receive an email from the Irish Institute of Pharmacy (IIOP) on 6 January 2020 notifying you that you may submit CPD Cycles from your ePortfolio. Pharmacists selected for Practice Review in April 2020 will have received information on the process from the IIOP on 13 December 2019.

Update on the Substitution of Anti-Epileptic Medicines

Under the leadership of Pharmacist and owner Oonagh O’Hagan, the pharmacy group launched a new campaign to help raise funds for the Peter McVerry Trust to support them to transition more people within their services out of homelessness. Oonagh launched The Giving Keys, a piece of jewellery manufactured by those who have fallen into homelessness which has been stamped with a word of meaning. They encouraged everyone to embrace their word - be that Hope, Strength, Believe, Dream and to draw upon its meaning and

then “Pay it Forward “ when you encounter someone who needs that word more than you. Meaghers are donating 40% of all profits directly to Peter McVerry Trust and reinvesting the remaining 60% to purchase more pieces and expand their range, selling even more pieces and helping more people transition out of homelessness in 2020. The Giving Keys are a company based in Los Angeles who employ those who have fallen into homelessness to make beautiful pieces of jewellery from old keys.

Patient involvement in new Medicines is Key Patients should have a greater say in the evaluation of new treatments, according to the Irish Pharmaceutical Healthcare Association (IPHA), the representative organisation for the originator pharmaceutical industry. IPHA’s call came following the publication of a report by IQVIA, ‘Assessing Person-Centered Therapeutic Innovations’, which urged the inclusion of patient experience and patient preferences in Health Technology Assessment (HTA) evaluation, and pricing and reimbursement decisions. Person-centered therapeutic innovations can have a significant impact on patients’ quality of life, improve adherence and, as a consequence, deliver better outcomes. Yet, the report shows that many HTA bodies and payers do not consider personcentered therapeutic innovations meaningfully in their evaluation of new treatments.

Oliver O’Connor, IPHA Chief Executive, said: “The inclusion of the improvement of patient experience and patient preferences in HTA evaluation and pricing and reimbursement decisions is necessary. Person-centered therapeutic innovations can have a significant impact on patients’ quality of life, improve adherence and, as a consequence, improve outcomes.” The IQVIA report, commissioned by EFPIA, which represents Europe’s originator pharmaceutical industry, outlined the significant difference between how payers and end-users - patients and clinicians - perceive the value of person-centered therapeutic


innovations. The report found that many payers and HTA bodies often overlook the added value of these innovations. Many HTA bodies do not consider patient experience benefits in their own right, favouring a more singular focus on clinical outcomes. David Haerry of the European Aids Treatment Group welcomed the report. “HTA processes stand today where regulators found themselves 20 years ago - isolated from natural stakeholders and partners who have to cope with the consequences of their decision making. This report should be a wake-up call,” he said.

The HPRA has included pregabalin and gabapentincontaining medicinal products on the List of Interchangeable Medicines. As pharmacists will be aware, these medicinal products are indicated for the treatment of epilepsy. When a medicine is substituted, pharmacists must take time to ensure that patients receive appropriate counselling to ensure that patients understand the correct use of their medicines and are not confused by changing packaging, colour or shape of the tablets/capsules.

Pharmacy Assessment System Now is a good time for superintendent and supervising pharmacists to review progress and ensure that all sections of the Pharmacy Assessment System relevant to your pharmacy have been completed for 2019. Please also ensure that the action plan booklet for 2019 has been approved by all that hold a key governance position in the pharmacy. The Pharmacy Assessment System provides a practical way for the supervising pharmacist, superintendent pharmacist and pharmacy owner(s), with their pharmacy team, to critically review their pharmacy's practice, validate and record good practice and identify areas where improvements are required. By now you should have received a new set of the Pharmacy Assessment System booklets for 2020. The editable PDF version is also available on the PSI website at www.thepsi.ie



CCF:22656 Date of preparation: (10-19)

ABBREVIATED PRESCRIBING INFORMATION Product Name: Emazole Control 20 mg Gastro-Resistant Tablets Composition: Each tablet contains 20 mg esomeprazole (as magnesium dihydrate). Description: Light pink oval film coated tablet. Indication(s): Proton Pump Inhibitor (PPI): Short-term treatment of reflux symptoms (e.g. heartburn and acid regurgitation) in adults. Dosage: Swallow tablets whole with liquid, do not chew or crush. Disperse in half a glass of non-carbonated water if difficulty in swallowing. Stir until tablets disintegrate, drink liquid with pellets immediately or within 15 min, or administer through a gastric tube. Do not chew or crush pellets. Adults: The recommended dose is 20 mg esomeprazole (one tablet) per day. It might be necessary to take the tablets for 2-3 consecutive days to achieve improvement of symptoms. Duration of treatment is up to 2 weeks. Once complete relief of symptoms has occurred, treatment should be discontinued. If no symptom relief is obtained within 2 weeks of continuous treatment, the patient should be instructed to consult a doctor. Elderly (≥ 65 years old): As per adults. Paediatric population (< 18 years): Not recommended. No relevant use in this group in the indication: “short-term treatment of reflux symptoms (e.g., heartburn and acid regurgitation)”. Severe impaired renal function: Caution. Severe liver impairment: 20 mg max daily dose. Contraindications: Hypersensitivity to esomeprazole, substituted benzimidazoles or any of the excipients. Not with nelfinavir. Warnings and Precautions for Use: On demand treatment: Contact a physician if symptoms change in character. In the presence of any alarm symptom (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded, as treatment with esomeprazole may alleviate symptoms and delay diagnosis. Treatment with proton pump inhibitors (PPIs) may lead to a slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and in hospitalised patients, also possibly Clostridium difficile. Patients should consult their doctor before taking this medicinal product if they are due to have an endoscopy or urea breath test. Absorption of vitamin B12 may be reduced due to hypo- or achlorhydria. Not recommended for long-term use as the following may also occur: Hypomagnesaemia; Risk of fracture. Consider stopping Emazole Control in cases of Subacute cutaneous lupus erythematosus (SCLE) accompanied by arthralgia. Interference with laboratory tests: Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours. To avoid this interference, Emazole Control treatment should be stopped for at least 5 days before CgA measurements. If CgA and gastrin levels have not returned to reference range after initial measurement, measurements should be repeated 14 days after cessation of PPI treatment. Contains glucose and sucrose. Interactions: Effect of esomeprazole on other drugs: Co-administration with atazanavir is not recommended. If the combination of atazanavir with a PPI is judged unavoidable, close clinical monitoring is recommended in combination with an increase in the dose of atazanavir to 400 mg with 100 mg of ritonavir; esomeprazole 20 mg should not be exceeded. Esomeprazole is a CYP2C19 inhibitor. When starting or ending treatment with esomeprazole, the potential for interactions with drugs metabolised through CYP2C19 should be considered. Serum levels of cilostazol, cisapride, tacrolimus, methotrexate may be increased. An interaction is observed between clopidogrel and esomeprazole, but the clinical relevance is uncertain. As a precaution, concomitant use of esomeprazole and clopidogrel should be discouraged. Gastric acid suppression by PPIs increase or decrease absorption of drugs with pH dependent absorption (decreased absorption of ketoconazole, itraconazole); esomeprazole inhibits CYP2C19 metabolising enzyme and could increase plasma concentrations of diazepam, citalopram, imipramine, clomipramine, phenytoin (monitor plasma levels of phenytoin), etc. resulting in need of a dose reduction; monitor INR when given with warfarin or similar. Caution as absorption of digoxin can increase. Effect of other drugs on esomeprazole: CYP2C19 and CYP3A4 inhibitors (clarithromycin, voriconazole) may increase the esomeprazole exposure. Dose adjustment not regularly required, except in severe hepatic impairment and long-term use. CYP2C19 and/or CYP3A4 inducers (rifampicin and St. John’s wort) may lead to decreased esomeprazole serum levels by increasing the esomeprazole metabolism. Pregnancy and Lactation: Caution in pregnancy due to lack of clinical data. No studies in lactating women, therefore, not recommended during breast-feeding. Ability to Drive and Use Machinery: Minor influence on the ability to drive or use machines. Adverse reactions such as dizziness (uncommon) and blurred vision (rare) have been reported. If affected, patients should not drive or use machines. Undesirable Effects: Common: Headache, abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting, fundic gland polyps (benign). Uncommon: Peripheral oedema, insomnia, dizziness, paraesthesia, somnolence, vertigo, dry mouth, increased liver enzymes, dermatitis, pruritis, rash, urticaria, fracture of the hip, wrist or spine. For other side effects refer to the SPC. Marketing Authorisation Holder: IQ Pharmatek Ltd., Gurtnafleur, Old Waterford Road, Clonmel, Co. Tipperary. Marketing Authorisation Number: PA 22777/001/001. Further information and SPC are available from: Rowex Ltd, Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417. E-mail rowex@rowa-pharma.ie Legal Category: Not subject to medical prescription. Date of Preparation: September 2019 Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie) or by emailing medsafety@hpra.ie or by emailing Rowex pv@rowa-pharma.ie

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News Pharmacy Diary Dates Code of Conduct Information Events To provide information and support to pharmacists in the roll-out of the new Code of Conduct, the Pharmaceutical Society of Ireland are holding two information events in Spring 2020. • Tuesday, 4 February 2020 at 7.30pm - Raddison Blu Hotel & Spa, Little Island, Cork. This event will focus on Principle 4 - work with others. Guest speaker is Dervla Kelly PhD, MPSI, a Lecturer in Medical Education at the University of Limerick and part-time community pharmacist. • Wednesday, 5 February 2020 at 7.30pm - Newpark Hotel, Castlecomer Road, Kilkenny. This event will focus on Principle 3 - communicate effectively. Guest speaker is Aoife Mellett, Legal Affairs Manager, PSI. Register to attend: Events are free to attend but please register with the PSI in advance. These are interactive events and a chance to share your experiences and discuss your approach to ethical dilemmas with other pharmacists and members of PSI staff. Pharmacists who attended the Code of Conduct events in 2019 said they were interesting and informative and an opportunity to share experiences with colleagues during group discussions. Event feedback from attendees:

Pharmacy signs up to Innovation The Pharmaceutical Society of Ireland have signed up to the Declaration on Public Service Innovation in Ireland, which is developed as part of the all-ofGovernment reform and development framework – Our Public Service 2020. This move signifies their commitment to promoting and developing a culture of innovation in all that they do. Through their core value of embracing change, the team are focussed on innovating and adapting to achieve results and continuously improve. The PSI has also been celebrating the first ever Public Service Innovation Week led by the Department of Public Expenditure and Reform. They have been identifying and promoting opportunities for developing new and improved ways of working and delivering better services for the public. “We will take this into our 2020 programme of work and embed in our Better Ways of Working initiative and through our business transformation programme,” said a PSI spokesperson.

Joanne Kissane, President, APPEL and Niall Byrne, Registrar, PSI

Warnings over illegal medicines Over 350,000 units of prescription medicines bought online were seized by Ireland’s medicine watchdog last year. From January to August, a total of 363,820 tablets, capsules, and vials of medicines purchased over the internet have been discovered.

In 2016, 555,406 units were seized. This fell to 507,889 in 2017. In 2018, 413,289 were found by authorities.

Between 2016 and 2018, the Health Products Regulatory Authority (HPRA), with the cooperation of Revenue’s Customs Service and the gardaí has detained over 1.8 million dosage units of medicines bought online.

The medicines found include abortion pills and erectile dysfunction medication. Health Minister Simon Harris said the online supply of prescription medicines into or within Ireland is illegal.

• 100% said that they found the seminar a useful way of learning more about the Code of Conduct.

There has been a steady decline in the number of medicines seized in the last three years.

• Over 90% stated that the format of the workshop was useful for the topic under discussion and that they had adequate opportunity to share their experience as a pharmacist during discussions.

Pharmacy Students have their Say

• 9 out of 10 pharmacists said they would attend another event like this in future to contribute their views in relation to the PSI's work. Pharmacists can check the PSI website for information about past events including learning and information sessions for pharmacists and the National Medicines Management Forum.


“The HPRA is aware of many illegal websites that purport to be

pharmacies and offer to supply a range of prescription medicines direct to the public. Medicines bought from these sites may be falsified. They may contain no active ingredient, too much or too little of an active ingredient, or the wrong ingredients altogether. “There is no way to be certain how or where the medicine was made, the quality of the active ingredients or fillers used and the medicine may not have been packaged, labelled or stored correctly and could be out of date,” he warned.

Pharmacy students across Ireland recently took time away from studying for upcoming exams to raise awareness of the potential disastrous consequences of cuts to the profession. They have released a video featuring all committee members of the Irish Pharmaceutical Students' Associations to raise awareness on this important matter affecting not only Pharmacists and Pharmacy students, but all staff in community pharmacies nationwide, as well as all who avail of pharmacy services. In a statement they comment, “We

made this video to communicate just how concerned we are for the future of community pharmacy in Ireland, due to Financial Emergency Measures in the Public Interest (FEMPI) cuts to the Pharmacy sector. “Between 2009 and 2017, the State, through both FEMPI and non-FEMPI related measures, extracted a total of approximately ¤3.1 billion from the community

pharmacy sector in reduced medicine reimbursements and cuts to pharmacy fees, despite the fact that HSE Primary Care Reimbursement Services statistics for 2009 to 2016 show that the cost of medicines to the State has reduced by 33%. “We support the Irish Pharmacy Union in their efforts to collaborate with Minister for Health, Simon Harris on this matter.”




Studying Pharmacy in Ireland – what’s changed? It was January last year, when pharmacy students across Ireland voiced their concerns and highlighted difficulties under the newly introduced MPharm programme and a lack of payment for placements.

“It goes without saying that as the current pharmacy students, we have had many challenges along the way, from the introduction of the new 5-year integrated programme and not knowing what to expect in that regard.”

Pharmacy students at the February 2019 placement fee march

Many students were experiencing financial strain as well as mental health issues associated with their study.

burden upon pharmacy students has been successful so far, with placement providers now having the option to offer paid placements to pharmacy students once again, after a period without this option.

In February, APPEL, the Affiliation for Pharmacy Practice Experiential Learning, lifted the ban on payment for placement after over 500 students rallied outside the Dáil to express their anger and discontentment. By way of follow-up to this story, Irish Pharmacy News spoke to Lauren O’Reilly, Vice President Public Relations of the Irish Pharmaceutical Students’ Association to gauge what it’s like to study pharmacy today. Media Coverage As a pharmacy student, I am often asked by qualified pharmacists: ‘What is studying pharmacy in Ireland like nowadays? Has it changed a lot?’, and even more so after media coverage regarding our fight for paid placements, which attracted a lot of attention towards pharmacy students. Whilst the pharmacy degree is definitely a challenging one, studying pharmacy in Ireland at the

Catalyst for Change

moment also presents students with various positive opportunities. Some of the positives include the diverse content of the course, carrying out placement, engaging in research both in Ireland and potentially abroad, as well the opportunity to be involved in student pharmacy societies. Even alongside college work, having the opportunity to incorporate part-time work in a pharmacy into our schedules is a fantastic way to learn hands-on as we study, and many of my peers, including myself, choose to work in community pharmacy part-time throughout the year.


Personally speaking, this has contributed greatly to my learning as well as development of communication skills. It goes without saying that as the current pharmacy students, we have had many challenges along the way, from the introduction of the new 5-year integrated programme and not knowing what to expect in that regard, to the fight for paid placement. We have certainly had to become vocal about our needs as students. This is not something which one could really have foreseen upon entering into the course at first, but thankfully, our efforts to reduce the

Having organisations such as the Irish Pharmaceutical Students Association (IPSA), the Irish Pharmacy Union (IPU) and the Union of Students in Ireland (USI) on our side as students, has been a phenomenal catalyst for change with regards to our experience studying Pharmacy. I am now fortunate enough to be a part of IPSA, in my role as Vice President of Public Relations, and am excited for our future achievements in the coming year. All pharmacy students in Ireland who are members of their respective pharmacy society in college, are automatically members of IPSA. We aim to bring pharmacy students from all three schools of pharmacy together through networking events, seminars, and conferences relating to pharmacy and the development ofsoft skills required for the working world, wherever that may be.

11 The Irish Pharmaceutical Students Association presented at the Union of Students in Ireland

experience, however it really depends on the nature of the placement. In fifth year, we must complete placement of 8 months duration, which must be in a patient-facing setting (either community or hospital pharmacy). As with fourth year, we still have Wednesdays away from placement to catch up on college work also.

grow as a profession beyond where it currently is, and hopefully funding and decisions from our government allow this to happen. Pharmacists have shown such outstanding capability in delivering new services such as the flu vaccine and emergency hormonal contraception, that during our careers, one could hope that the scope of practice of the community pharmacist will expand. This would create even more opportunities in the sector, reduce the burden on GPs, and serve the public to a greater extent by using our knowledge and skillset to the best of our abilities.

World of Academia

In terms of placement within the degree, APPEL (Affiliation for Pharmacy Practice Experiential Learning) engages with placement providers, striving to offer us all a suitable placement experience. The result of their hard work in this respect has been that every student is matched with a placement provider, without having to send hundreds of C.V.’s out individually. The scope of placement providers and options available which are of interest to us fourth year students is quite diverse, and hopefully even more placement providers will enter the programme in future.

We can choose between community, hospital, industry or role-emerging practice (REP), as options for placement in our fourth year of study, which must be of at least 4-months duration. In fourth year we have ‘protected time’ away from placement every Wednesday to complete our online course work. Whilst there have been mixed reviews amongst students regarding this, it is valuable to have protected time to complete our coursework, and does reduce the burden upon students to meet deadlines significantly. Some may argue that it disrupts the placement

As I am coming to the end of my fourth year placement as I write this, early next year, fourth year pharmacy students will be commencing their fourth-year research projects, alongside a lecturer from their respective university, on any one of an array of different project titles, ranging from topics within pharmaceutics, practice of pharmacy, cancer research, gastroenterology, antibiotic resistance and many others. This is a great opportunity to dip our toes into the world of academia, and for many it may be the first time doing so. IPSA have been working hard to establish connections with EPSA (European Pharmaceutical Students Association), and it is now becoming clear to see that the pharmacy degree is one with international potential. EPSA allows its members to have access to its online learning platform, with features including a mentorship programme, and ways to learn about internships and other entry-level positions across Europe, which one may never hear about otherwise. Building these international connections through EPSA so early on in our careers as pharmacists is not only exciting, but important for the future of the profession, to have many dynamic and intercultural relations. I have just recently connected with my mentor,who lives in Turkey and is running her own pharmacy, through the EPSA mentorship programme. The learning opportunities out there for future pharmacists are fantastic. In terms of the future for pharmacy students here in Ireland, there are a lot of positives. For example, we are so fortunate to have so many pharma companies based here, with many positions suitable for pharmacists to enter into. With community pharmacy, there is the hope that it continues to

“With community pharmacy, there is the hope that it continues to grow as a profession beyond where it currently is, and hopefully funding and decisions from our government allow this to happen.”

Lauren O’Reilly, Vice President Public Relations of the Irish Pharmaceutical Students’ Association




Pharmacy role in Reducing Risk People with angina should cover their face with a scarf in the cold weather. Cold air can bring on angina symptoms therefore, people with angina should cover their face with a scarf in the cold weather, avoid exercising after a heavy meal and use their GTN spray before they exercise. These were just some of the helpful tips provided at the Irish Heart Foundation’s first National Heart Support Conference by Professor Vincent Maher, Consultant Cardiologist and former Medical Director of the Irish Heart Foundation. Professor Maher addressed the well-attended patient information conference, which took place in Croke Park at the end of last year, on a range of different heart conditions including, angina, heart attack and heart failure. Professor Maher explained that smoking, diabetes, high blood pressure, being overweight and high levels of LDL cholesterol were all the things that can increase the risk of developing heart disease

and there was a lot that people can do to reduce their risk.

so they do not all try to contract at the same time.

These included, stopping smoking, maintaining a healthy weight, keeping blood pressure under control and reducing LDL cholesterol.

He advised that most of the things that trigger palpitations begin with the letter S so, if possible, its best to avoid or minimise these : Smoking, Stimulants (caffeine), Spirits (too much alcohol),Sleeplessness, Stress and Sepsis (infection).

He explained that people with established heart disease should aim to have their LDL cholesterol below 1.4. In relation to pumping problems or heart failure, which Professor Maher argued should be called heart inefficiency, he said it was important for people with the condition to balance their fluid intake, avoid too much salt and excess alcohol and monitor their weight on a regular basis as increased weight may mean excess fluid retention. On electrical problems in the heart, he explained that the electricity in the heart co-ordinates blood moving from the top chambers to the bottom chambers

Removing these triggers solves most of the problems with palpitations, he said. Professor Maher was one of a number of expert speakers who addressed the Irish Heart Foundation’s first National Heart Conference. Others included Dr Virginia Silvari, Senior Pharmacist with Cork University Hospital, who discussed medicines for those living with a heart condition and Sinead Mulhern, Principal Clinical Psychologist in cardiac rehabilitation at the Mater Hospital in Dublin, who spoke about mental health and provided a number of practical tips for people living with a heart condition.

Castlebridge Life Pharmacy moves to a bigger home Thirteen years after it first opened in the town, Castlebridge Life Pharmacy has added 2019 as a key landmark in its history after it completed its move to a new larger premises. Weeks of hard work went into refurbishing the new location to get it ready for the Christmas period with only one month separating the two photos. The pharmacy first opened two years after owner and managing

pharmacist Colm Byrne moved to Castlebridge with his family in 2004. Despite a growing population, there was no pharmacy in the town, leading Colm to take the initiative and establish his own business.

Colm’s friendly and helpful nature helped to build the reputation of the pharmacy in the community, with residents coming to rely on the team as a source of professional care and advice. It has since become a thriving pillar of the Castlebridge community, leading to significant growth and the need for a bigger store.The new location is only a few steps from its original home, meaning there will be no disruption to the routine of its regular patients and customers.

Benefits of Breast Milk Early use of breast milk could play a vital role in preventing heart disease in prematurely born infants, according to a paper led by researchers at RCSI (Royal College of Surgeons in Ireland) and the Rotunda Hospital. The review article was written in collaboration with researchers from Harvard Medical School, University of Oxford and University of Toronto. One of the long-term health complications that young adults born prematurely may experience is unique heart characteristics. One study cited in the article looked at 30 preterm-born adults who were assigned to receive exclusive human milk and 16 preterm-born adults who were assigned to receive an exclusive formula-based diet during their hospital stay at birth. They then underwent detailed cardiovascular assessment between 23 and 28 years of age, including an MRI of their hearts. As expected, all of the hearts of those born prematurely had smaller chambers than the hearts in people who were not born prematurely. However, the study showed that the smaller heart chambers were less profound for the exclusively human milk-fed group in comparison to those who were exclusively formula fed, suggesting a potentially protective effect of human milk for heart structure. The researchers then identified potential reasons for why breast milk results in a lower risk of heart disease. Identifying the key components within breast milk that result in improved heart health could pave the way for a more targeted approach to improve long-term cardiovascular wellbeing for those born prematurely. “It is becoming increasingly clear that premature birth results in long-term adverse cardiovascular effects with important clinical consequences," said Professor Afif EL-Khuffash, Honorary Clinical Professor of Paediatrics at RCSI and Consultant Neonatologist at The Rotunda Hospital, Dublin.



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IE19031 IR-REL-49-2019 Date of item August 2019



Pharmacy key to health and immunity New research has found that almost 70% of people who visited their GP last winter were prescribed an antibiotic for flu-like symptoms. It’s a timely reminder that not only should community pharmacy be the first-line provider for all minor ailments such as cold and flu, but also that public health in Ireland and internationally is being increasingly threatened by the overuse of antibiotics. The Irish Pharmacy Union (IPU) recently urged all stakeholders to be proactive in fighting antibiotic resistance. The research also found that almost one in four (24%) people do not take any proactive steps to help them maintain a healthy immune system during the winter months, which can leave them vulnerable to developing colds and other flu-like symptoms. The Scope Gut Education Index aims to educate consumers on the importance of looking after your gut health in order to maintain overall health and immunity, not least during the winter season.

To further support this work, Scope has also partnered with nutritional chef and food columnist Susan Jane White to create a series of immune-boosting dishes using Bio-Kult, the multi-strain live bacteria supplement, to help prevent and combat cold and flulike symptoms this winter. The dishes are not only immune boosting but also family-friendly, cost-effective, and easy to make. They include a one-tray red pepper soup, a hearty vegetarian curry, and some nourishing cough drops to fight off any tingly coughs and sore throats. Sarah Ussher, Product Manager at Scope says, “These stats not only show a worrying trend of dependence on antibiotics for cold and flu-like symptoms but also a large knowledge gap on how to keep your immune system healthy during the winter months. We are delighted to partner with Susan

Jane White on this recipe series as she is a powerhouse of knowledge on how immunity can be built and improved through good nutrition and proactive gut health care.”

Drug Shortages The Health Products Regulatory Authority has been notified of a shortage of the following products: • Alprazolam 0.25mg Tablet – PA0711/140/001

Kathy Maher, community pharmacist and former IPU President, said at the end of last year, “The levels of antibioticresistant infections have been increasing in Ireland for many years. It is clear that they are now a real and present threat to public health.

• Arava 20mg Tablet – EU/1/99/118/007

“We are now reaching a tipping point and, if dramatic action is not taken, we effectively risk returning to the ‘pre-antibiotic era’. This will not only cripple our ability to fight routine infections but will also undermine the treatment of more complicated infections, especially in patients with chronic diseases, and could make many surgeries impossible.”

• Menopur 600IU Powder and Solvent for Solution for Injection – PA1009/015/002

• Cozaar 50mg Film Coated Tablet – PA1286/004/002 • Letrozole Teva 2.5mg Film Coated Tablet – PA0749/085/001

• Syntocinon 10IU/ml Concentrate for Solution for Infusion or Intramuscular Injection – PA2206/003/002 • Xanax 0.25mg Tablet – PA0822/141/002 • Xanax 0.5mg Tablet – PA0822/141/003 The following shortage has been resolved and supply has resumed to the Irish market:

Hickeys partner with Alzheimer Society Hickeys Pharmacy Group have recently announced The Alzheimer Society of Ireland as their new official charity partner. Pictured (L-R): Supervising Pharmacist Lisa Malone, Store Manager Gretta O’Hare, Hickey’s Pharmacy Managing Director Paddy Hickey & Head of Fundraising at The Alzheimer Society of Ireland Mairead Dillion at the announcement in Hickey’s Pharmacy Monkstown today

• Bupivacaine 2.5mg/ml Solution for Injection – PA2315/058/001 • Bupivacaine 5mg/ml Solution for Injection – PA2315/058/002 • By-Mycin 100mg Capsule – PA1457/010/002 • Co-Amoxiclav 1000mg/200mg Powder for Solution for Injection and Infusion – PA0749/011/002 • Co-Amoxiclav 1000mg/200mg Powder for Solution for Injection and Infusion – PA1457/001/001 • Esomeprazole Krka 20mg Gastro-Resistant Capsule – PA1347/017/001 • Galfer 305mg Capsule – PA0126/314/001 • Innohep 14,000IU in 0.7ml Solution for Injection – PA0046/060/011

The Alzheimer Society of Ireland is the leading dementia specific service provider in Ireland. They work across the country in the heart of local communities

providing dementia specific services, support and advocating for the rights and needs of all people living with dementia and their carers.


On Thursday 21st November, the pharmacy group sold Memory Ribbons in all Hickey’s Pharmacy stores. All proceeds were donated to the Alzheimer Society of Ireland.

• Mercilon 150mcg/20mcg Tablet – PA1286/052/001 • Teveten 600mg Film Coated Tablet – PA2010/017/002

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Boots open Flagship Store For the past 23 years, Boots has sought to bring the best of health and beauty to Ireland and last month, the pharmacy-led health and beauty retailer marked a new chapter as it opened its new format store on Dawson Street in Dublin city centre.

¤3 million to support community mental health Minister for Health Simon Harris TD and Minister of State with special responsibility for Older People and Mental Health Jim Daly TD have announced a fund of ¤3 million to help support community mental health initiatives across the country. This fund will support local sports and community organisations that promote mental health and alleviate loneliness. Minister Daly said, “This ¤3 million fund will help local organisations to improve the mental well-being of people within our communities.

Staff of Boots Ireland cutting the ribbon. The brand-new Beauty and Wellness offering will introduce exciting new brands, innovative experiences and access to expert advice in the bustling city centre location

Boots Dawson Street will offer customers exciting new brands, innovative experiences and access to expert advice. Pictured at the opening are Erica Bracken and Rachel Purcell

bags, improving the environmental footprint. This is a continuation of Boots journey to reduce plastic use across the business. The store will also feature a Rehydration Station for refilling water bottles on the go. The new Dawson Street branch will be managed by Lauren Gorman and will have 18 staff, creating 10 new jobs within the 221m2 store.

Nimah Kuzbari, Boots, Tom Willis Boots, Nathalie Lennon and Pat Laffey, Boots

The brand-new store will introduce exciting new brands, innovative experiences and access to expert advice and excellence in pharmacy in the bustling city centre location.

to help people to quit smoking, which includes private and confidential support and advice, and rewards customers who meet their goals along the way.

Beauty fans will love picking up their favourite brands including Florence by Mills, Revolution, The Inkey List, BH cosmetics, Pixi, Lime crime and Milani, to name but a few.

Health promotion initiatives offered in the Pharmacy at Boots Dawson Street also include: Alcohol Awareness, Asthma Let’s Breathe Easy, Blood Pressure Measurement, Diabetes Risk Assessment and Healthy Heart Support. A private consultation room will also allow for one to one support and advice as required.

In Pharmacy, services available in Boots Dawson Street include: winter flu and pneumococcal vaccinations, travel vaccinations, emergency contraception, compression hosiery, shingles vaccinations and Stop for Good – a 12-week, three-step programme

The store will feature brown paper bags which include a high recycled content and require less processing than white paper


Commenting on the store opening, Bernadette Lavery, Managing Director of Boots Ireland said, “Our new Dawson Street store starts a journey of reinventing Boots for the future in Ireland. Mapped on our Store of the Future concept, we’re thrilled to share with our customers a selection of some of the most exciting new beauty brands on the market, offering them access to pharmacy services to help them live better and ultimately, feel good. We look forward to welcoming our customers through the doors of our beautiful new store.” Miriam Kerins Hussey, Pharmacist and Co-Founder of The Awakening and Soul Space, The Experience, co-hosted a launch event to celebrate the new store opening, during which she shared her tips on how to live a healthier and more holistic life through integrated wellness. Guests also got to enjoy a guided meditation session.

“Local community groups such as sporting organisations, youth clubs and others have an existing network of members along with an existing built infrastructure that allows them to connect with large numbers of people with the minimum of effort. “The leaders of these clubs are generally held in high regard and very much trusted by their members. “This fund is designed to assist these voluntary groups to enhance the wonderful work they are already doing by providing funding to put in place preventative and early intervention well-being practices within their organisation.” Minister for Health Simon Harris TD added, "This year, we will invest over ¤1 billion in mental health services. We will open a new state of the art Central Mental Hospital. We will recruit more staff. “These national policies must support the role our local communities have in the area of mental health. They reach places our health service can't. They have the trust, respect and admiration of their community.” The fund is being dispersed through the Local Community Development Committees (LCDCs) and the Children and Young People's Services Committees (CYPSCs) to deliver innovative actions in line with local and national policies and objectives for the benefit of people in their communities.


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IPHA Conference

‘Innovating for Life’ – IPHA Annual Conference 2019 The Irish Pharmaceutical Healthcare Authority (IPHA) held their annual conference towards the end of last year (November) with a slightly different twist.

IPHA President Aidan Lynch

Daragh Conolly, President, Ciara Browne, Communications & Events Executive and Siobhán Kane, Press and Communications Manager, all from the Irish Pharmacy Union

For over 25 years, IPHA have been running an annual conference. The conference made a bold statement about their work and what they do to the external environment. It celebrated the science and innovation that guides this work. It marked the impact they make in society and the economy. And it explored themes that will define the future of medicines, especially how they can be adopted faster by the health services.

other comparable European countries, an analysis by IPHA found, with the new figures released at the conference.

IPHA’s goal, as they near talks on a new agreement with the State on the pricing and supply of medicines, is to partner with policymakers on a deal that works for all, especially for patients. The theme was ‘Innovate For Life’ and the event was IPHA’s 26th annual conference and dinner, gathering some 350 industry, policy, research and patient leaders to share their insights on improving standards of care through medicines innovation. There were 24 contributors across keynotes, panels and a learning lab. Interestingly, almost half the contributors were women. In the evening, they debuted ‘Innovate for Life’, a mini-documentary, which told an impact and value story for the biopharmaceutical industry in Ireland. Medicine waits Patients in Ireland are waiting three times as long to get the same medicines as patients in

Prices for innovative medicines in Ireland are calculated at the average of the price in 14 EU countries. IPHA analysed the reimbursement dates in these countries for 15 medicines which have completed their pharmacoeconomic assessment in Ireland but have yet to be reimbursed by the HSE. The analysis found that, on average, each of these medicines has so far been reimbursed in ten out of the 14 reference countries. Patients in these countries were able to access these life-changing medicines within an average of 289 days from the date of EMA licensing. In Ireland, however, patients have so far been waiting an average of 843 days to get access to the same medicines: almost three times as long - a difference of 18 months on average. Five of the 15 medicines are either fully or partially made in Ireland. Nine of the medicines are for cancer, two are for multiple sclerosis, two are for cardiovascular disease and two are for gastrointestinal diseases. Ahead of a new agreement on the pricing and supply of medicines, IPHA called for an explicit ‘Medicines Policy’ aimed at helping


to fix the access problem and future-fit the biopharmaceutical industry. Aidan Lynch, IPHA’s President, said the agreement, replacing the existing one whose four-year term expires in July, must be a ‘win-win-win’ for patients, industry and the State. ‘When it comes to introducing new medicines into the health services,’ he told the conference ‘Ireland is ‘slow and late’. The new agreement between industry and the state is an opportunity for the industry and the state to partner on a solution. We must accelerate access to new medicines for patients and secure pricing and funding certainty so medicines are both affordable and available. We must integrate the adoption of new medicines with a longer-term vision for the future of the industry.’ ‘We want to apply the same lessons of strong industry-state partnership on Brexit planning to the search for joint solutions to medicines access and funding challenges,’ added Oliver O’Connor, IPHA’s Chief Executive. Trust in vaccines Almost seven in ten people trust vaccines and believe the medical evidence for their effectiveness, according to a new survey by Ipsos MRBI for IPHA, which was also presented at the conference. The research shows 67% of people

IPHA President Aidan Lynch with Gwynne Morley, General Manager, IQVIA

are vaccine ‘believers’ while just three per cent are ‘non-believers’. An alarming 30% remain unsure about them. The figure for ‘believers’ was higher among women at 70%. For men, the figure is 65%. Uncertainty about vaccines was highest among the over-55s at 34%. Respondents said a lack of information is the biggest barrier to being vaccinated, followed by concerns over side-effects. Almost half of respondents have never heard of the term ‘herd immunity’ which arises when a high percentage of the population is protected through vaccination. But once explained, almost nine in ten accept that herd immunity is important, according to the survey. IPSOS MRBI carried out the survey in the first half of last month, with 975 interviews conducted by telephone with adults aged over 18. The World Health Organisation identifies vaccine hesitancy among the top 10 threats to global health in 2019. This hesitancy is caused by a number of elements including misinformation, complacency and varying societal factors. Vaccines have potentially become a victim of their own success with people becoming desensitised to the potentially devastating effects of vaccine preventable diseases. For example, it is estimated that 110,000 people died from measles


Pierre Meulien, Executive Director of the Innovative Medicines Initiative

Yvonne Goff, HSE; Maeve McGrath, Roche Ireland; Richard Bergstrom, Guardtime Health; Frank O'Donnell, Microsoft Ireland and Anne Jones, GMI

in 2017. Most of those who died were under the age of five. This equates to 301 preventable deaths every day or nearly 13 each hour. Aside from this, measles is a highly infectious and serious disease that can cause chest infections, fits, ear infections, swelling on the brain and brain damage. Oliver O’Connor described the research as ‘an important signpost’ on the path to increasing the uptake of vaccinations as a barrier to disease. ‘Vaccines work,’ he said. ‘They save lives and protect the wider community. Our industry, which develops vaccines, is keen to boost public awareness of the importance of vaccinations. That’s a goal we share with the Government and the health authorities. Together, we can help to stop the spread of vaccinepreventable diseases.’

During 2019, IPHA launched a social media campaign, #VaccinesWork, aimed at raising public awareness about the importance of vaccination. The WHO estimates that vaccines saves up to three million lives each year. With the exception of clean, safe drinking water, vaccination is one of the most successful and cost-effective public health interventions ever. However, its success is increasingly under threat as vaccination rates continue to fall below the required 95% uptake rate to ensure ‘herd protection’. A direct result of that is an increase in the number of global outbreaks of serious diseases such as measles. The best way to protect populations against these diseases is to vaccinate directly.



IPHA Conference 2





1. Lisa Carmody, Senior Account Manager, Verge the Live Agency with and Katrin Ostwald, Strategy and Business Development, WifOR Institute 2. Ciaran McKinley, Sanofi, Declan Healy, Franchise Head, Immunology, Hepatology & Dermatology, Novartis and Ciaran McGreal, Sales & Business Development Manager, Novartis



3. Stephen Hammond, Business Support Manager, Robert Saunders, Global Commercial Director and Gary Orr, Head of Creative & Digital, all from Perigord Life Sciences 4: Aoife McAuliffe, Head of Medical Affairs & Market Access, Servier and Bronagh Hayden, Associate Medical Director, Biogen 5: Dr Brid Seoighe, Head of Medical Affairs, Janssen, Philip Mallon, Market Access Manager, Astra Zeneca and Carmel Mulray, Head of Communications & Public Affairs, Bayer 5: Michael O’Connor, Area Business Manager, Biogen and Tom Coogan, General Manager, Grunenthal 7: Colin O’Donnell, Senior Account Director, Hanover Communications and Dr Eimear O’Leary, Business Development Lead, IPHA 8: Eoin Newell, Business Development Manager, GP Buddy, Dr Paul Ryan, PharmaBuddy and Feargal O’Shea, Key Account Manager, IQVIA



9. John Sheehy, Chair of IPHA CHC Division with Aidan Lynch, IPHA President


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The HIV Epidemic Timebomb The epidemic that is HIV continues to tick as shocking new statistics reveal not only increases in newly diagnosed cases in Ireland, but also late diagnoses on an European level. According to the HIV/Aids surveillance in Europe 2008-2017 data, newly diagnosed cases of HIV in Ireland are still increasing, despite the introduction of new initiatives to combat the problem. With World AIDS Day being held on December 1 past, the figures show 476 new diagnoses of HIV in 2019, compared to 447 in the same time period for the year before. Ireland is currently at almost double the European average, with higher numbers than during the Aids epidemic in the 1980s and 1990s. The numbers of new diagnoses continue to rise, despite the initial stages of the PrEP (pre-exposure prophylaxis) HIV prevention programme being implemented by the government after a review by the Health Information and Quality Authority (HIQA) found the drug is highly effective at preventing HIV in people at substantial risk. A PrEP scheme card ensures prescriptions of the drug for those who are eligible, and a full screening every three months. Noel Donnellon from group ACT UP Dublin said there is a long way to go. “HIV rates are still high, the figures are always tweaked slightly, but we’re still at a higher rate than last year,” he said. “However the PrEP programme has just started now, it hasn’t gone to full roll out yet, but some people clinically eligible in the program can take part, and we’re seeing good take up, so the hope is that will eventually effect figures.

“Awareness of PrEP is growing definitely, it’s being articulated among most groups, and there’s been a lot of press around it, so more people are aware. It’s early days, I know for a lot of clinics there’s been great take-up.” David Delaney, European Director - Policy & Market Access & President of Medicines for Ireland with Mylan says, “Mylan is committed to the fight against HIV which is why we are delighted to see the launch of the Irish government's new preventative HIV pre-exposure prophylaxis (otherwise known as PrEP) programme. “Approximately 40% of people living with HIV around the world depend on a Mylan product every day and our teams drive important conversations among healthcare, community and policy experts to encourage innovative solutions for improving the lives of those living with HIV. “In Ireland, we want to tackle the rise of HIV infections, we want to make sure everyone knows about these preventative medicines and that they are now available from the Health Service Executive (HSE) in the form of a comprehensive care package that includes testing and monitoring. #mylanireland #access #hivprevention.” Meanwhile, according to data for 2018 released by the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe, women accounted for one-third of the 141,000 new HIV diagnoses in the Region, indicating that this population

needs more attention in Europe's prevention and testing efforts. Many women in the WHO European Region, particularly those in their 40s, are diagnosed at a late stage of HIV infection when their immune system is already starting to fail. They are three to four times more likely to be diagnosed late than younger women. The HIV epidemic in the Region is driven by a persistent problem with late diagnosis, and this affects 54% of known cases among women. Such proportions of late diagnoses are partly a result of relatively low HIV testing coverage and uptake in the Region, and are an indication that sexual risks, including HIV and other sexually transmitted infections, are not being adequately addressed with older adults. Two-thirds (60%) of the HIV diagnoses among women in 2018 were in the age group 30–49 years old. Heterosexual sex was the most commonly reported HIV transmission mode (92%) among women in the Region. Countries in central Europe reported almost six times fewer diagnoses among women compared to men in 2018, and three times fewer diagnoses among women than men were reported in the European Union and European Economic Area (EU/ EEA). The only exception is the eastern part of the Region, where there is a more even distribution between women and men, and where 86% of the almost 50 000 cases among women were reported in 2018.

Early diagnosis of HIV allows people to start HIV treatment sooner, which in turn increases their chances of living a long and healthy life. In addition, it reduces the risk of transmitting HIV to others, since effective treatment results in an undetectable viral load, meaning that the virus can no longer be transmitted to others. Enhanced strategies and systems, making HIV testing more widely available and user-friendly, are required to ensure early diagnoses. The WHO consolidated guidelines on HIV self-testing and partner notification and ECDC’s evidencebased guidance on integrated testing for HIV and viral hepatitis recommend innovative approaches that include self-testing and community-based testing by lay providers as part of overall HIV testing services. Enhanced strategies to diagnose women earlier include: • increasing awareness among women and health-care providers; • offering counselling and testing services adapted to the needs of women; • notifying partners of men who are diagnosed with HIV; • providing HIV testing based on specific health conditions, such as other sexually transmitted infections, viral hepatitis, tuberculosis or certain cancers; • providing testing and treatment services in the community, closer to populations in need

CarePlus Christmas Drive CarePlus Pharmacy Group took part in a special fundraising drive with the Irish Cancer Society for Christmas 2019, which saw their Pharmacists and teams pledge to come together and support the Irish Cancer Society’s inspirational Volunteer Driver Service. More than 5,800 patients have used this scheme since it was set up in 2008, with volunteer drivers bringing them to and from 82,000 chemotherapy appointments in hospitals around the country. The Irish Cancer Society looks after recruitment, training and reference checking, while the volunteers also undergo Garda vetting. CarePlus Pharmacies also collected customer donations to raise much needed funds to support Irish Cancer Society initiatives through in-store activities. The highlight of the fundraising campaign was a Christmas Jumper Drive in all CarePlus stores on Friday 7th December, where staff were decked out in festive gear and hosted activities such as bake sales and Santa visits. Pictured are Dr Sinead Beirne, GP and regular TV contributor with Mary McAndrew, a client of the Volunteer Driver Service and Siobhan Ashe, Pharmacist at Mangan’s CarePlus Pharmacy, Celbridge County Kildare.


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Informing Pharmacy on Public Health Community pharmacists have always played a significant role in promoting, maintaining and improving the public’s health. Based at the heart of communities, they gain a unique understanding of the health needs of the communities they serve through daily interactions with patients and customers. Reports often point to the potential for pharmacists to improve the public’s health and recognition of their contribution. Hence it is even more important pharmacists and their teams are educated and knowledgeable as to the health of their nation. This Report looks at the recently published Health Trends within Ireland which will help to inform pharmacists with a view to further contribution to maintaining and improving the health of Ireland’s population. Life expectancy in Ireland has increased by almost two and a half years since 2007, with male life expectancy consistently higher than the EU average throughout the last decade, and female life expectancy surpassing the EU average in 2017. Much of this increase in life expectancy is due to significant reductions in major causes of death such as circulatory system diseases and cancer. The overall mortality rate has reduced by 10.5% since 2009. Provisional data for 2018 however shows a slight increase (2.3%) in the mortality rate from 2017.

These trends emerged in the 12th edition of Health in Ireland, Health in Ireland: Key Trends 2019, published by the Department of Health. The report touches on several areas, including demographics, population health, hospital and primary care, employment and expenditure and highlights the significant achievements that Ireland has made for key health outcomes in the past decade. However, it also highlights the challenges that persist in terms of the accessibility of timely and efficient healthcare across the population. The report shows that lifestyle factors such as smoking, drinking, levels of physical activity and obesity continue to be issues which have the potential to jeopardise many of the health gains achieved in recent years. However, inequalities in health are closely linked with wider social determinants including living and working conditions, issues of service access, and cultural and physical environments. Taken together with an ageing population, adverse trends, if not addressed now, will lead to an unhealthy and costly future.

The number of medical card holders peaked in 2012 and has slowly decreased since. 32.4% of the population had a medical card in December 2018, compared to 40.4% in 2012 and 32.6% in 2009. When broken down by age group, the percentage of people with a medical card has decreased among the younger age groups following a steady decrease over the previous periods. That decrease among the youngest age groups could be partly attributed to the introduction of free GP visit cards for children under 6 from 2015. The percentage of the population participating in the Drugs Payment Scheme has decreased by 24% since 2009, while numbers for the Long-Term Illness scheme have more than doubled. In welcoming the report, the Minister for Health Simon Harris said, "Health in Ireland: Key Trends gives us the opportunity to assess the performance of the Irish health system and reflect on the health status of our people. It highlights where things are going well, and where we need to improve. “It also shows the importance of good quality data to health professionals and policy makers

alike in providing a high-quality health service for our population as we implement Sláintecare.” The Minister added, “These reports help shape the way we plan our health service into the future. A striking feature is the growth in the number of people aged over 65. Each year this cohort increases by almost 20,000 people. This trend is set to continue and will have implications for future planning and health service delivery. “The largest proportional increases in the population in Ireland will be in the category of those aged 85 years and older. The number of people aged 65 and over will grow from one-fifth to over one-third of the working population over the next two decades which will have implications on how we fund our health services. This is a good thing – people are living longer, but we need to ensure they live well. “I am also happy to see some initial results describing the various demographic characteristics of the six new regional health areas which are a major step towards reconfiguring our health service in line with Sláintecare.” Key Trends 2019 presents evidence from across the health sector of the progress made and

Figure 1

Summary of Population Health, Ireland and EU28 Average, 2016 2.5 2


Best outcome

Standard Deviations


0.5 0 -0.5 -1

Majority of EU countries (between 25th and 75th percentiles) EU28 Average Ireland

-1.5 -2 -2.5 Cancers

Acute myocardial infarction


Diseases of the respiratory system


Infant Mortality Rate

Self-Perceived Health Status

Life Expectancy at Birth

Treatable Deaths

Source: Eurostat Notes: (i) Standard deviation is a measure of how much a value varies from the mean average. (ii) Values have been adjusted so that the upper half of the graph is more desirable. For example, Ireland’s stroke mortality rate is lower than the EU average, but as this is the more desirable outcome Ireland is positioned higher up on the graph. (iii) For details on the measurement of these indicators, see the following graphs: Table 2.4 and Figure 2.9.


25 Figure 2

Prescription items dispensed under the General Medical Services (GMS) scheme: % change from previous year in number of items dispensed and average cost per item paid to pharmacies, 2009 to 2018 10 8 6

Percentage change


Change in previous year in Number of items dispensed


Change in previous year in Average cost per item

0 -2 -4 -6 -8 -10 2009










Source: General Medical Services (Payments) Board / Primary Care Reimbursement Service, HSE. Notes: (i) Data on cost per item includes dispensing fee, ingredient cost and VAT. (ii) Number of prescription items excludes Stock Order Items.

Department of Healthâ&#x20AC;&#x2122;s work in the challenges that still exist in Chapter 4 creating legislation, policy and providing and high-quality Primary efficient Care and Community Services 54 strategies to address these critical healthcare in Ireland. issues. This work is ongoing in This publication provides the the form of SlĂĄintecare, which is background and context for the working to systematically address

Top Twelve Learnings 1. We are continuing to live longer Over the past decade we have added, on average, 3 months per year to our life expectancy. 2. The life expectancy gap between men and women has narrowed from 5.3 years to 3.6 years At 80.4 years, life expectancy for women in Ireland is 3.6 years longer than for men in 2017; however, this gap has narrowed from 5.3 in 1997 and is now at its lowest since the 1950s. 3. We are living longer than our European counterparts Male life expectancy in Ireland has been above the EU average over the past decade. The life expectancy at birth for men in Ireland has been consistently greater than that of the EU average by over a year. Female life expectancy in Ireland has been similar to the EU average over the period 2008-2017 and is now just above it.

4. Increase in life expectancy is due to significant reductions in major causes of death such as circulatory system diseases and cancer This decrease is particularly strong for mortality rates from suicide (-38%), pneumonia (-37%) and stroke (-36%). The overall mortality rate has reduced by 10.5% since 2009, but 2018 provisional data shows a slight increase in this rate of 2.3% from 2017. 5. We think we are healthier than our European neighbours In 2016, 83% of Irish men and women rated their health as good or very good. This is the highest in the EU and compares with an average of 73% and 67% for males and females respectively across the EU. 6. We are seeing a reduction in deaths from suicide There has been a 38% reduction in the mortality rate from suicide since 2009. After a rise in the male suicide rate from 2008 to 2013, the three-year moving average has decreased, and the latest figures have fallen below the EU average for both sexes.

these significant challenges to the health care system in the coming years. Improving provisions for mental health, reducing pressure on

health resources, limiting spending increases in the health system, supporting the uptake of generic medicines, and reducing hospital waiting lists are key targets for the coming years.

7. Men are more inclined to be overweight or obese while women are more likely to be physically inactive

10. Half of those attending Emergency Departments can expect to be seen and discharged within 6 hours

Nearly 70% of men are likely to be overweight or obese compared to around 57% of women while just over 62% of women are physically inactive compared to about 46% of men.

50% of attendees spent less than 6 hours in the Emergency Department and 75% of attendees experience waiting time of less than 9 hours with little monthly variation in both of these measures.

8. Current smokers or ex-smokers are more likely to live with a chronic condition

11. A greater proportion of total (public and private) health expenditure is now paid for by government funds

Smokers or ex-smokers are more likely to suffer from chronic health conditions such as high blood pressure, high cholesterol, arthritis or anxiety. 9. Our public hospitals continue to treat more patients, and patients admitted to our hospitals are older Acute hospital beds, discharges, Emergency Dept attendances and outpatient appointments have increased. In 2018, 54% of inpatients and 40% of day cases were aged 65 and over. This compared to 48% and 35% respectively in 2009.

The proportion of total health expenditure paid for either out-of-pocket or through private health insurance has been reducing in recent years; the government funded 73% of total health expenditure in Ireland in 2017. 12. Our new regional health areas have different population characteristics The new regional health areasâ&#x20AC;&#x2122; populations differ in size, age structure, deprivation status, eligibility entitlements and mortality rates.


On Your Marks

Pharmacy Gets Physical R

esearch shows that, although adults are not getting any fatter, they are refusing to become more active. It is important for community pharmacists and their teams to help spread the message that fitness is not a fad, whilst also advising customers on use of supplements and therapies for sports injuries.

Obesity is a critical issue for Ireland. A Health Ireland report carried out by the Department of Health showed that just over a third of Irish adults, some 37% were of normal weight, in 2019. Half of those surveyed were achieving the recommended level of physical activity. Approximately 66% of men in Ireland are overweight or obese, according to the report, a figure which is down slightly from 70% reported two years ago. The statistics were compiled from a survey undertaken by the Department of Health which show the situation is worse for older men, who are more likely to be overweight or obese. According to Minister of State with Responsibility for Health Promotion, Catherine Byrne the

levels of overweight and obesity in the general population “remains a great cause for concern.” Sporting Benefits Increasing physical activity not only reduces the risk of obesity, diabetes, hypertension, stroke, heart disease, musculoskeletal conditions, cancer, depression and non-vascular dementia, it also improves emotional and mental wellbeing and is one of the most effective ways to improve both individual and community health and wellbeing in general. Fitness is a potential growth area for pharmacy as it dovetails with services pharmacists are already providing, such as weight management and smoking cessation, and fits with the healthy lifestyle messages that pharmacy should promote.


Pharmacists can easily introduce the subject of exercise when conducting consultations on smoking, weight management. It also can be discussed when patients are suffering from stress, back pain or sleeping difficulties. Encouraging people to become more active should be part of a pharmacist’s advice in any weight loss programme. The HSE National Guidelines on Physical Activity for Ireland were produced as one of the recommendations from the National Task Force on Obesity, to increase physical activity and reduce the levels of overweight and obesity among Irish people. These guidelines highlight the recommendations for physical activity for children, young people, adults, older people and people with disabilities, for example:

 Adults (18-64yrs) need at least 30 minutes a day of moderate activity on 5 days a week or 150 minutes a week.  Older people need at least 30 minutes a day of moderate intensity activity on five days a week, or 150 minutes a week.  Adults with disabilities should be as active as their ability allows. They should aim to meet the adult guidelines of at least 30 minutes of moderate intensity activity on 5 days a week.  Children and young people (2-18 yrs) should be active at a moderate to vigorous level for at least 60 minutes every day. Supplements Sports supplements and related products have a role to play in boosting performance and

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recovery and helping avoid injury. According to market research company Euromonitor, sports nutrition continued to record a strong performance in 2019, driven by the ongoing trend for protein-enriched products such as sports protein powder. The latter continued to record the highest current value growth and volume growth as an increasing number of Irish consumers became more confident in its use, supported by the health and fitness trend and the desire to support muscle gain through increasing their protein intake. This provides an opportunity for pharmacies to expand their sports categories. Furthermore, vitamin and mineral supplements, enzymes and probiotics that aid rehabilitation, prevent injury or give energy levels a boost could fit well with community pharmacists’ existing product ranges – especially as growing numbers of older people exercise to recover from or prevent strokes, heart attacks, osteoarthritis and other ailments. There now exits a huge and diverse range of supplements. Those participating in high-impact exercise or joint-intensive activities may benefit from glucosamine. Zinc can bolster the immune system, while vitamin C might aid recovery by mopping up free radicals generated by exercise and promoting production of new cartilage, which helps injuries heal. Furthermore, there is now a growing body of evidence that suggests that vitamin C may alleviate exercise-induced respiratory symptoms. Some people start exercising

only after a health scare, so it is prudent to check whether there are any interactions. For example, people with a history of kidney disease should not follow a highprotein diet, and that includes using supplements.

This results in pain, sensitivity and throbbing as the nerves are further sensitised. As further blood flow increases to the site, the area looks a lot redder, feels a lot warmer, becomes more sensitive and there is a decrease in mobility.

Common sports injuries

Tennis elbow (epicondylitis) is a painful condition that affects the outside of the elbow. It is caused by strenuous overuse of the muscles and tendons of the forearm and around the elbow joint.

Some of the most common sports injuries include: • Sprains, • Strains, • Cuts and bruises, • Bone fractures and breaks,

The symptoms of tennis elbow include:

• Tendonitis (inflammation of a tendon),

• tenderness around the elbow, and

• Blisters, and

• pain when moving the elbow.

• Head injuries

Tennis elbow is caused by repetitive movement of the muscles in the lower arm. It can be treated with anti-inflammatory medication, an elbow splint to support the arm or a cortisone injection. Sufferers should be advised to avoid activities that cause pain and, in a sporting setting, obtain advice to correct faulty technique.

Whilst the figures regarding sports injury presentation to A&E are of note, community pharmacies will collectively see many more minor sports injuries. A sprain or a twisted joint can happen in most limbs but most commonly in the ankle. One or more ligaments of the ankle experience excessive stress and become abnormally stretched when the foot is moved past its normal range of motion. The sudden excess stress puts a strain on the ligaments. Once the strain goes beyond the yield point, the ligament becomes damaged, or sprained. Blood vessels leak fluid into the joint, starting from the site of the injury. Increased blood flow and inflammatory exudates including white blood cells, macrophages and leukocytes migrate to the area, causing both inflammation and swelling.


the shoulder, elbow, wrist, finger, thigh, knee or the back of the heel (Achilles tendonitis). Blisters are a common minor injury caused by friction on soft skin. Endurance athletes, such as long-distance runners, sometimes develop blisters on their feet. Rowers are at risk of developing blisters on the palms of their hands. Although painful, most blisters will heal on their own unless they become infected, but they can be easily prevented in the first place by covering tender spots with a friction-resistant dressing or plaster. If they do occur, then specialist blister plasters, which claim to aid rapid healing by absorbing the fluid, protecting skin from bacteria and helping relieve the pain of friction and pressure, can be used. Remind customers who have diabetes to be particularly vigilant when checking for blisters, as their foot injuries take longer to heal due to poorer blood circulation.

Tendonitis is inflammation (swelling) of a tendon. Symptoms of tendonitis include:

Athlete's foot (tinea pedis) is a fungal infection that usually begins between the toes.

• swelling, redness and pain at the injured area,

Symptoms include itching or burning and flaking skin, particularly between the toes, although the whole foot can be affected. The condition can be treated with products containing fungicidal or fungistatic ingredients. Making sure the feet are completely dry after washing; regularly changing footwear and wearing cotton socks can help ensure feet are less fungus-friendly.

• restricted movement of the affected area, and sometimes • a change in appearance of the affected area, such as a lump or a visible change in position of a limb. Tendonitis is a fairly common injury that can result from a strain or tear in a tendon. Tendonitis can occur in the tendons around

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CPD: Eating Disorders

Continuing Professional Development



This module is suitable for use by community pharmacists as part of their Continuing Professional Development. After reading this module, in the magazine or online, complete the post-test on our website at www.pharmacynewsireland.com and include in your personal CPD ePorfolio.

Author - Amy Oates qualified from the Robert Gordon University Aberdeen with a Master in Phamacy in 2011. She then undertook a pre-registration year with Gordons Chemists in Edinburgh. After registration she moved back home and worked for Johnstons Pharmacy in Longford Town, Lanesborough and Ballygar, Co. Galway. She has also completed a Cardiology in Clinical Pharmacy Practice module with Trinity College Dublin.

Mental Health focus on ‘Eating Disorders’ 60 Second Summary A mental disorder or mental illness is an illness that affects someones thinking, emotional state and behaviour. It disrupts their ability to work, engage in personal relationships and carry out their daily activities. There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are serious mental illnesses and can often be fatal. They are associated with severe disturbances in people’s eating behaviours and related thoughts and emotions. There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are serious mental illnesses and can often be fatal. They are associated with severe disturbances in people’s eating behaviours and related thoughts and emotions. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. Treatment for eating disorders usually involved a multidisciplinary team, including doctors, mental health professionals and dietitians. Ongoing therapy and nutrition education are highly important to continued recovery. Other treatment options include cognitive behavioural therapy, Interpersonal psychotherapy and in some cases antidepressants. Mental Health First Aid is the help offered to a person developing a mental health problem or experiencing a mental health crisis. The aims are to: • Preserve life where a person may be at risk of harm • Provide help to prevent the mental health problem from becoming more serious • Promote recovery of good mental health • Provide comfort to a person with a mental health problem Pharmacists can play a vital role in identifying an eating disorder and with actions of mental health first aid, direct the patient to where they can receive the professional help they need.

The World Health Organisation defines mental health as a “state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” Mental health is an essential part of a person’s overall wellbeing – being comfortable, healthy and happy. According to Mental Health Ireland: positive mental health is normally characterised by: • Vitality • Positive relationships • Ability to deal constructively with negative feelings and emotions • Connection with other people and community • Ability to cope • Self-esteem • Contentment A mental disorder or mental illness is an illness that affects a persons thinking, emotional state and behaviour. It disrupts the persons ability to work, engage in personal relationships and carry out their daily activities. Mental illnesses often start in adolescence or early adulthood. When starting at this stage in life they can affect the young persons transition into adult roles, forming key social relationships and the formation of health habits such as the use of alcohol or other drugs. It is vital that mental illness is detected early and to ensure the person is properly treatment and supported. Eating Disorders There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are serious mental illnesses and can often be fatal. They are associated with severe disturbances in people’s eating behaviours and related thoughts and emotions. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. Eating Disorders are not simply just about food, weight and appearance. They are potentially life-threatening illnesses. An eating

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? Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author.

disorder is not only serious, but is a very complex mental illness. Typically, features of eating disorders include severe disturbances in a person’s thought processes and their relationship with food, their body and their weight. According to the Department of Health and Children, up to 200,000 people in Ireland may be affected by eating disorders with 400 new cases emerging each year, representing 80 deaths annually. In 2016, 12% of all admissions for under-18s to Irish psychiatric units and hospitals had a primary diagnosis of eating disorders. Disorders are more common in women than in men, with the median age of onset for all eating disorders is 18 years. For anorexia nervosa, the peak incidence of onset is 1418 years and for bulimia nervosa it is 14-22 years. Binge eating disorder most commonly presents in the late teens or early 20s. Patients with eating disorders also commonly present with depression, anxiety and suicidal ideation.



CPD: Eating Disorders

Distinguishing between ‘normal dieting’ and Eating Disorder Symptoms:

Signs and Symptoms

Psychological warning signs:

• Denial of being “on a diet” despite obvious restriction and weight loss

Eating disorders are often accompanied by a wide range of warning signs, symptoms and complications. Examples may include:

• Pre-occupation with food, body shape and weight

• Denial of hunger or craving

Physical warning signs:

• Change in food ‘rules’, e.g. vegetarianism, not eating after 6pm

• Frequent changes in weight/weight loss

• Distorted body image (e.g. complaining of being fat when a healthy weight)

• Attempts to hide weight loss, e.g. wearing baggy clothes

• Failure to gain expected weight in a child or adolescent who is still growing and developing

• Bathroom trips after eating Ritualised behaviours

• Wanting to lose weight when normal or underweight

• Social isolation, low mood

• Dry, discoloured skin or fine hair growing on their face and body

• Increased exercise. Risk Factors Some risk factors to developing an eating disorder include: • Family history of eating disorders • Depression • Substance abuse • Low self-esteem • Being bullied about weight • Having an obsessive compulsive personality or being a perfectionist


• Poor circulation, fluid retention • Difficulty sleeping, or concentrating • Digestive problems such as cramps, wind, constipation, diarrhoea • Loss of, or irregular periods • Unexplained infertility • Feeling weak, dizzy or tired • Erosion of tooth enamel, tooth decay • Muscle weakness • Cardiac arrhythmias

• Extreme body dissatisfaction

• Heightened anxiety around mealtimes • Depressions, anxiety or irritability Warning signs of eating disorders are often difficult to detect as the person will often hide either and exercising behaviours, will deny having a problem and find it difficult to ask for help. Anorexia and Bulimia are the most common eating disorders. The signs and symptoms can be similar for both, however the medical complications of anorexia are a result of weight and loss and malnutrition, where with bulimia the complications are associated with the mode and frequency of purging. Anorexia Nervosa (AN) Anorexia features food restriction as a method to lose weight. Persistent food restriction results in a person becoming significantly underweight. Losing weight becomes an addiction, with a person becoming obsessed with restricting, exercising and even misusing laxatives and “slimming” medication. Another


feature present, which must be present for diagnosis is the person experiences an intense fear of gaining weight and a lack of recognition of the seriousness of the current underweight bodyweight. These features can be difficult to elicit, and the person can be in complete denial of the seriousness of the weight loss and the consequences. Patients can initially present with AN with non-specific symptoms such as abdominal pain, bloating, constipation, hair nail or skin changes. The first point of contact is usually with a GP and is often made by a concerned family member. Concerns can be relating to weight loss, skipping meals and adopting a restrictive diet. Bulimia Nervosa (BN) Bulimia Nervosa is usually characterised by episodes of binge eating followed by selfinduced vomiting to avoid weight gain. In contrast to someone with anorexia, patients with bulimia are more likely to be older and will consult their GP or pharmacist without a family member being involved. The typical features of bulimia nervosa include repeated episodes of binge eating, a feeling of lack of control during the eating episode, inappropriate behaviours to prevent weight gain, such as self-induced vomiting, misuse of laxatives or excessive exercise. The effects of Bulimia can be very similar to anorexia but can have different physical effects. Repeated vomiting can lead to a number of complications. Oesophagitis frequently occurs and causes symptoms of heartburn and chest pains. If the vomiting is severe, persistent tears can develop in the wall of the oesophagus leading to bleeding which may be life threatening. Severe vomiting can also result in electrolyte imbalances such as low potassium levels. Electrolyte imbalances can lead to cardiac problems such as abnormal heart rhythms. Calluses may occur on the back of the hands from rubbing on the teeth to induce vomiting. Inflammation of the pancreas leading to abdominal pain may occur, the salivary glands can become enlarged and painful and acid from the stomach may wear away the enamel of the teeth leading to tooth decay and gum disease. Bulimia is more common than anorexia, and still affects more women than men. It can start out in the same way as anorexia, but episodes of binge eating prevent the severe weight loss associated with anorexia. This is one of the reasons that only a minority of people with bulimia get some form of treatment. Binge Eating Disorder People with binge eating disorder engage in episodes of binge eating (Eating a lot of food in a short period of time with a sense of loss of control) but do not engage in any sustained weight control behaviours. These episodes of binge eating occur at least once per week over months or more. The persons body weight may vary from normal to overweight to obese. People suffering from binge eating disorder often feel disgusted, distressed, ashamed or guilt about their actions.

Some physical effects of binge eating disorder include:

• Joint and muscular pain

behaviours, as well as the person preoccupation with body shape and weight. Another treatment that is of benefit is interpersonal psychotherapy. The aim of this treatment is to help the person identify and change interpersonal problems that are contributing to their eating disorder.

• Breathlessness

Binge eating disorder

• Poor skin condition Binge eating disorders is predominantly more common in women, it often occurs later in life compared to anorexia and bulimia and affect approximately 2-5% of the adult population each year.

Again, cognitive behavioural therapy is the best treatment, aiming to change eating habit and weight control behaviours. Interpersonal psychotherapy and antidepressants can also be of benefit, but the evidence for their effectiveness is not as strong as for CBT.


Crises associated with eating disorders


There are three main crises that maybe be associated with eating disorders:

• Significant weight gain • Digestive problems

Treatment for anorexia usually involved a multidisciplinary team, including doctors, mental health professionals and dietitians. Ongoing therapy and nutrition education are highly important to continued recovery. The first goal of treatment is getting the patient back to a healthy weight. GPs can provide medical care and supervise calorie needs and weight gain. A Psychologist or other mental health professional can help work with the patient to develop behavioural strategies to help them return to a healthy weight. Dietitians offer guidance getting back to regular patterns of eating, including providing specific meal plans and calorie requirements that are required to meet weight goals. The patient’s family will also likely to be heavily involved in helping maintain normal eating habits. Cognitive Behavioural Therapy (CBT) is a form of therapy that focuses on the important role of thinking in how we feel and what we do. The main goal of CBT is to normalise eating patterns and behaviours to support weight gain. The second goal is to help change distorted beliefs and thoughts that maintain restrictive eating.

1) The person is experiencing a medical emergency due to malnutrition and other complications. Theses include potentially fatal complications such as organ failure, electrolyte imbalance and bleeding in the digestive tract. 2) The person has suicidal thoughts or behaviours. Eating disorders increase the risk of suicide and suicide attempts. 3) The person is engaging is non-suicidal self-injury. In people with eating disorders they can experience overwhelming feelings that may be relieved in binging, purging or over exercising or by engaging in non-suicidal self-injury. Emergency help should be sought if a person has any of the following symptoms that can indicated a medical emergency: • Disorientation • Fainting • Throwing up several times a day • Painful muscle spasms


• Chest pain or difficulty breathing

Cognitive behavioural therapy is the best treatment option. There are CBP programmes that target bulimia specifically. The aim is to change eating habits and weight control

• Blood in bowel movement, urine or vomit • Cold or clammy skin indicating a low body temperature



CPD: Eating Disorders

OTC Team Training


Self-Appraisal WHAT I intend to learn and why When I completed the PSI Pharmacy Assessment System, two of the ‘areas for improvement’ identified from the ‘Management and Supervision’ section and the ‘Sale and Supply of Non-Prescription Medicines’ Section related to providing evidence that all staff are trained and competent in their role. I realised that I have no formal method of standardising or demonstrating staff training and I want to address this.


Personal Plan HOW I intend to learn it I plan to research training options available in Ireland. I plan to ask my staff to bring in their course completion certificates.

• Irregular heartbeat or very low heart beat (less than 50 beats per minute) • Appears extremely thin with a BMI of less that 16 Mental Health First Aid Mental Health First Aid is the help offered to a person developing a mental health problem or experiencing a mental health crisis. The aims are to: • Preserve life where a person may be at risk of harm • Provide help to prevent the mental health problem from becoming more serious • Promote recovery of good mental health • Provide comfort to a person with a mental health problem The Role of the Pharmacist As pharmacists, we may come across individuals experiencing mental health difficulties every day and have a huge role to play in recognising and supporting people with eating disorders and other mental health difficulties. If we are concerned about someone with an eating disorder the following steps can be taken: 1) Approach the person, assess and assist with any crisis - Before approaching the person, make sure you have an understanding of eating disorders. Ensure you have done some research from reliable sources such as from an eating disorder support organisation or another health care professional. It can be better to approach the person alone as too many people can be overwhelming. If there are no concerns that the person is in a crisis you can begin by asking them how they are feeling and how long they have been feeling that way. 2) Listen non-judgmentally - Listen to the persons worries and concerns, they may be suffering from depression or anxiety. It is important that you remain calm and listen to all of what the person is saying even when you might not agree with their thoughts about themselves and food.


3) Give support and information - The aim is to provide support to person in a way that makes them feel safe and comfortable to seek treatment or find someone else then can talk to openly about their eating disorder. Reassure the person that people with eating disorders can get better and give them information about eating disorders and the help that is available. 4) Encourage the person to get appropriate professional help - Offer to help the person to get the help that they need, explain that their behaviours may indicate a problem than needs professional attention. 5) Encourage other supports - Encourage the person to talk to their family and friends who can support them, and direct towards organisations that provide information and support for people with eating disorders. Helpful Resources Bodywhys: The national eating disorder association of Ireland. There is a variety of supports available for people with eating disorders including online support groups and face to face support groups. Helpline 1890 200 444 Beat: beating eating disorders This is a UK website which is run by the Eating Disorders Association of the UK. There is information available for consumers, families and professionals.

I plan to speak to staff at performance appraisal to explore their learning needs.


Action What I actually did I reviewed IPU OTC off-site training and distance learning. I read OTC related articles in pharmacy magazines such as IPN. I spoke to my staff about their qualifications and training needs. I contacted www.4FrontPharmacy.ie for a demo of their online Pharmacy Training Programme.


Document What I have learned specifically Three key realisations • Training staff to manage OTC sales of medicines is a core part of the Medicines Supply Chain. • The true cost of off-site training, taking into account the training fee, travel expenses, overnight and food expenses, pharmacy cover, day’s wages for person attending the training. • The value of online team training extending beyond the expertise, to include leveraging and implementing whole team learning with marketing and sales activities, for the sake of patient care.


Evaluate ONE example of how I put my learning into practice • By using an online programme designed by pharmacists for pharmacy teams, at the tip of a button, I can demonstrate my team’s up-to-date training and meet PSI training guidelines. • I can now concentrate on leveraging the expanded team skill base to extend my pharmacist service offering. • My time is now used for higher value activities that ONLY a pharmacist can do, and I am confident that OTC sales conducted by my staff, will be referred appropriately.

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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.

Pharmacy Care in Pre-Pregnancy


t 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.

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 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. 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. Home pregnancy tests are

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

Fertility Lubricants Some women may need artificial lubrication due to decreased cervical mucus production that may be caused by conditions such as diabetes and inflammatory bowel disease or by medications such as antihistamines, stimulants, anticholinergics, and antidepressants. Couples may also use lubricants for comfort and to increase sexual satisfaction. Some lubricants can actually hinder sperm from moving, or even kill them, making it harder to conceive. There are five main types of lubricants: petroleum based, natural oil -based, water based with glycerin, glycerinfree water based, and silicone. While each of these lubricants has respective advantages and disadvantages, they all may impair sperm motility. Lubricants specifically designed for conception help with sperm viability and mobility, as well as match the body’s internal PH levels, which like many things, change during ovulation. There are a number of fertilityfriendly lubricants on the market including Pre-Seed and Conceive Plus, which are marketed as fertility-friendly lubricants made of an isotonic hydroxyl-ethylcellulose base that mimics natural fluids and which will not damage sperm.

Advice and Careful Merchandising

Free Contraception

Pregnant women have access to plenty of health information but it can often become overwhelming. Mothers-to-be will visit the pharmacy for advice, as this is often more convenient than visiting their GP surgery.

The Department of Health was advised last October, that instead of giving everyone free access to contraception, that a State-funded scheme should be focused on providing free contraception to young women first.

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.

Diabetes in the Community More than 1,000 patients with diabetes or at risk of the disease are to be enrolled in a structured care programme providing treatment at their local GP surgery rather than in hospital. The initiative from the Irish College of General Practitioners (ICGP) is supported by the VHI, in the insurer’s first venture into chronic disease management in the community. The programme launched by Minister for Health Simon Harris on Monday is seen as a forerunner for the switch to care in the community, and away from hospitals, as proposed in Slaintecare.


The government established the working group in April 2019 to consider policies and legislation around improving access to contraception after the Oireachtas Committee on the Eighth Amendment recommended free contraception. The report found that local access, cost, embarrassment, inconvenience and lack of knowledge were among the barriers to accessing contraception. How the State makes contraception available is not solely about reducing the number of crisis pregnancies, the report also emphasised, but about “providing women with the opportunity to safely and effectively manage their reproductive health and wellbeing”. Despite calls from activists and opposition TDs for contraception to be made available for free, the Working Group “cautioned” against assuming that this would reduce the number of crisis pregnancies or promote more effective contraceptive methods. The report recommends that the National Condom Distribution Service should be expanded, and “measures to improve accessibility by enabling oral contraceptives to be available on a 12-month prescription basis with pharmacist consultation at six-month renewal”. Responding to the report, Minister for Health Simon Harris said, “This report provides us with a clear overview of the challenges involved in providing free contraception but also a clear pathway to doing so. I strongly believe cost should not be a barrier to accessing contraception.” The Irish Family Planning Association (IFPA) Chief Executive, Niall Behan said that the organisation welcomed the serious examination of access to contraception and said the IFPA supports “a universal, Statefunded contraception scheme”. The report also found that the challenges with expanding access to contraception are “a microcosm” of the wider challenges facing the health service – including government funding, eligibility, integrated care, primary care staffing and workforce capacity.


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40 mg/10 mg

NOW AVAILABLE Suvezen is indicated for substitution therapy in adult patients who are adequately controlled with rosuvastatin and ezetimibe given concurrently at the same dose level as in the fixed combination, but as separate products, as adjunct to diet for treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or homozygous familial hypercholesterolaemia1 Prescribing Information: Suvezen (rosuvastatin/ ezetimibe) film-coated tablets Please refer to the Summary of Product Characteristics (SPC) for full prescribing details. Presentations: Suvezen 10mg/10mg, 20mg/10mg and 40mg/10mg: Each film-coated tablet contains 10mg; 20mg or 40mg of rosuvastatin (as rosuvastatin calcium) respectively, and 10mg ezetimibe. Indication: Suvezen is indicated for substitution therapy in adult patients who are adequately controlled with rosuvastatin and ezetimibe given concurrently at the same dose level as in the fixed combination, but as separate products, as adjunct to diet for treatment of primary hypercholesterolaemia (heterozygous familial and nonfamilial) or homozygous familial hypercholesterolaemia. Dosage and Administration: The patient should be on and continue, an appropriate lipid-lowering diet, during treatment with Suvezen. Suvezen is not suitable for initial therapy. Treatment initiation or dose adjustment, if necessary, should only be done with the monocomponents and after setting the appropriate doses the switch to the fixed dose combination of the appropriate strength is possible. Patient should use the strength corresponding to their previous treatment. The recommended dose is one Suvezen tablet daily. To be administered at any time of the day, with or without food. The tablet should be swallowed whole with a drink of water. If co-administered with bile acid sequestrant (BAS), administration of Suvezen should occur either ≥2 hours before or ≥4 hours after administration of a BAS. Special populations: Paediatric (<18 years): Safety and efficacy has not been established. Elderly (>70 years): Starting dose of 5 mg rosuvastatin is recommended. The combination is not suitable for initial therapy. Hepatic impairment: Mild: No dosage adjustment is required. Moderate/Severe: Treatment with Suvezen is not recommended. Renal impairment: Mild: No dose adjustment is necessary. Moderate (creatinine clearance <60 ml/min): The recommended start dose is rosuvastatin 5mg. Race: The recommended start dose is rosuvastatin 5 mg for patients of Asian ancestry due to increased systemic exposure. The fixed dose combination is not suitable for initial therapy. Monocomponent preparations should be used to start the treatment or to modify the dose. Suvezen 40 mg/10 mg tablets are contraindicated in these patients. Genetic polymorphisms: In patients who are known to have specific types of genetic polymorphisms that can lead to increased rosuvastatin exposure, a lower daily dose of Suvezen is recommended. Dosage in patients with pre-disposing factors to myopathy: The recommended start dose is rosuvastatin 5mg in patients with predisposing factors to myopathy. Suvezen 40 mg/10 mg tablets are contraindicated in some of these patients. Concomitant therapy: The risk of myopathy (including rhabdomyolysis) is increased when Suvezen is administered concomitantly with certain medicinal products that may increase the plasma concentration of rosuvastatin (e.g. ciclosporin and certain protease inhibitors including combinations of ritonavir with atazanavir, lopinavir, and/or tipranavir). Whenever possible, alternative medications should be considered, and, if necessary, consider temporarily discontinuing Suvezen therapy. In situations where coadministration of these medicinal products with Suvezen is unavoidable, the benefit and the risk of concurrent treatment and rosuvastatin dosing adjustments should be carefully considered. Contraindications: Hypersensitivity to the active substances or excipients. Pregnancy, breast-feeding and in women of childbearing potential not using appropriate contraceptive measures. Active liver disease or any serum transaminase elevations which are unexplained, persistent or exceeding 3x the upper limit of normal (ULN). Severe renal impairment (creatinine clearance <30 ml/min); myopathy or receiving concomitant ciclosporin. 40mg/10mg dose contraindicated in patients with predisposing factors for myopathy/rhabdomyolysis; such factors include: Moderate renal impairment (creatinine clearance <60 ml/min), hypothyroidism, personal or family history of hereditary muscular disorders, previous history of muscular toxicity with another HMG-CoA reductase inhibitor or fibrate, alcohol abuse, situations where an increase in plasma levels of rosuvastatin may occur, Asian patients, concomitant use of fibrates. Precautions and Warnings: Skeletal muscle effects: have been reported in rosuvastatin-treated patients with all doses and in particular with doses >20 mg. As with other HMG-CoA reductase inhibitors, reporting rate for rhabdomyolysis is associated with use at doses >40mg. Post-marketing experience with ezetimibe, cases of myopathy and rhabdomyolysis have been reported. If myopathy is suspected based on muscle symptoms or is confirmed by a creatine phosphokinase (CPK) level, Suvezen and any of these other agents that the patient is taking concomitantly should be immediately discontinued. All patients starting therapy with Suvezen should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness or weakness, particularly if associated with malaise or fever. Creatine kinase (CK) measurement: CK should not be measured following strenuous exercise or in the presence of a plausible alternative cause of CK increase. If CK levels are significantly elevated at baseline (>5xULN) a confirmatory test should be carried out within 5-7 days. If the repeat test confirms a baseline CK >5xULN, treatment should not be started. Patients with pre-disposing factors for myopathy/rhabdomyolysis: Caution should be exercised in these patients. Risk: benefit of treatment should be considered and clinical monitoring is recommended. CK levels should be measured in these patients. Therapy should be discontinued if CK levels are markedly elevated (>5xULN) or if muscular symptoms are severe and cause daily discomfort. If symptoms resolve and CK levels return to normal, then consideration should be given to re-introducing treatment at the lowest dose. Immune-mediated necrotising myopathy (IMNM): Clinically characterised by proximal muscle weakness and elevated serum CK, has been reported very rarely during or after treatment with statins, including rosuvastatin, despite discontinuation of statin treatment. In clinical trials an increase in the incidence of myositis and myopathy has been seen in patients receiving other HMG-CoA reductase inhibitors together with fibric acid derivatives. Suvezen should not be used in any patient with an acute, serious condition suggestive of myopathy or predisposing to the development of renal failure secondary to rhabdomyolysis (e.g. sepsis, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders; or uncontrolled seizures). Liver effects: In controlled coadministration trials in patients receiving ezetimibe with statin, consecutive transaminase elevations ≥3×ULN have been observed. It is recommended that liver function tests be carried out prior to, and 3 months following, the initiation of treatment. Rosuvastatin should be discontinued or the dose reduced if the level of serum transaminases is ≥3xULN. The reporting rate for serious events is higher at the 40mg dose. In patients with secondary hypercholesterolaemia caused by hypothyroidism or nephrotic syndrome, the underlying disease should be treated prior to initiating therapy with rosuvastatin. Liver disease and alcohol: As with other HMG-CoA reductase * Suvezen is available in 3 doses in Ireland. Suvezen 10mg/10mg, 20mg/10mg and 40mg/10mg: Each film-coated tablet contains 10mg; 20mg or 40mg of rosuvastatin (as rosuvastatin calcium) respectively, and 10mg ezetimibe. Reference: 1. Suvezen Summary of Product Characteristics LDL-C: Low-density lipoprotein Cholesterol

inhibitors, rosuvastatin should be used with caution in patients who consume excessive quantities of alcohol and/or have a history of liver disease. Renal effects: Proteinuria has been observed in patients treated with higher doses of rosuvastatin and was transient or intermittent in most cases. Proteinuria has not been shown to be predictive of acute or progressive renal disease. An assessment of renal function should be considered during routine follow-up of patients treated with a dose of 40 mg. Diabetes mellitus: Some evidence suggests that statins raise blood glucose and in some patients, at high risk of future diabetes, may produce a level of hyperglycaemia where formal diabetes care is appropriate. This risk, however, is outweighed by the reduction in vascular risk with statins and therefore should not be a reason for stopping statin treatment. Patients at risk (fasting glucose 5.6 to 6.9 mmol/l, BMI >30 kg/m2, raised triglycerides, hypertension) should be monitored both clinically and biochemically according to national guidelines. Interstitial lung disease: Exceptional cases have been reported with some statins, especially with long term therapy. Presenting features can include dyspnoea, non-productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected, statin therapy should be discontinued. Protease inhibitors: Increased systemic exposure to rosuvastatin has been observed in subjects receiving rosuvastatin concomitantly with various protease inhibitors in combination with ritonavir. Consideration should be given both to the benefit of lipid lowering by use of Suvezen in HIV patients receiving protease inhibitors and the potential for increased rosuvastatin plasma concentrations when initiating and up titrating rosuvastatin doses in patients treated with protease inhibitors. The concomitant use with certain protease inhibitors is not recommended unless the dose of rosuvastatin is adjusted. Fibrates: The safety and efficacy of ezetimibe administered with fibrates have not been established. If cholelithiasis is suspected in a patient receiving Suvezen and fenofibrate, gallbladder investigations are indicated and therapy should be discontinued. Anticoagulants: If Suvezen is added to warfarin, another coumarin anticoagulant, or fluindione, the International Normalised Ratio (INR) should be appropriately monitored. Fusidic acid: Suvezen must not be co-administered with systemic formulations of fusidic acid or within 7 days of stopping fusidic acid treatment. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving fusidic acid and statins in combination. The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness. Statin therapy may be reintroduced seven days after the last dose of fusidic acid. In exceptional circumstances, where prolonged systemic fusidic acid is needed, e.g., for the treatment of severe infections, the need for co-administration of Suvezen and fusidic acid should only be considered on a case by case basis and under close medical supervision. Suvezen contains lactose monohydrate and sodium: Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine. This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-free’. Pregnancy, Breastfeeding and Fertility: No clinical data are available on the use of ezetimibe during pregnancy. Potential risk from inhibition of HMG-CoA reductase outweighs the advantage of treatment during pregnancy. If a patient becomes pregnant during use of Suvezen, treatment should be discontinued immediately. Animal studies have shown excretion of medicinal product through breast milk. However, there are no data in humans. No clinical trial data on the effects of fertility in humans. Interactions: Contraindicated combinations: Ciclosporin. Not-recommended combinations: Fibrates and other lipid-lowering products, protease inhibitors, transporter protein inhibitors and fusidic acid. Other possible interactions: Cytochrome P450 enzymes, antacids, colestyramine, anticoagulants, Vitamin K antagonists, erythromycin, Oral contraceptive/hormone replacement therapy. When coadministering rosuvastatin with other medicinal products known to increase exposure to rosuvastatin, doses should be adjusted (see SPC for full details). The maximum daily dose should be adjusted so that the expected rosuvastatin exposure would not likely exceed that of a 40 mg daily dose of rosuvastatin taken without interacting medicinal products. Adverse Reactions: Adverse drug reactions previously reported with one of the individual components (ezetimibe or rosuvastatin) may be potential undesirable effects with Suvezen. Common (≥1/100 to <1/10): diabetes mellitus, headache, dizziness, constipation, nausea, abdominal pain, diarrhoea, flatulence, myalgia, ALT and/or AST increased, asthenia and fatigue. Uncommon (≥1/1,000 to <1/100): decreased appetite, paraesthesia, hot flush, hypertension, cough, dyspepsia, gastroesophageal reflux disease, nausea, dry mouth, gastritis, pruritus, rash, urticaria, arthralgia, muscle spasms, neck pain, back pain, muscular weakness, pain in extremity, ALT and/or AST increased, blood CPK increased, gamma-glutamyltransferase increased, liver function test abnormal, chest pain, pain, asthenia, oedema peripheral. Rare (≥1/10,000 to <1/1,000): thrombocytopenia, hypersensitivity reactions including angioedema, pancreatitis, increased hepatic transaminases, myopathy (including myositis), rhabdomyolysis, lupuslike syndrome and muscle rupture. Very rare (<1/10,000): polyneuropathy, memory loss, jaundice, hepatitis, arthralgia, haematuria, gynaecomastia. Not known: thrombocytopenia, hypersensitivity (including rash, urticaria, anaphylaxis and angioedema), depression, peripheral neuropathy, sleep disturbances (including insomnia and nightmares), dizziness, paraesthesia, cough, dyspnoea, diarrhoea, pancreatitis, constipation, hepatitis, cholelithiasis, cholecystitis, Stevens Johnson syndrome, erythema multiforme, immune-mediated necrotising myopathy, tendon disorders (sometimes complicated by rupture), myalgia, myopathy/rhabdomyolysis, oedema, asthenia. Legal Category: POM. Marketing Authorisation Numbers: 10mg/10mg: PA0540/193/001; 20mg/10mg: PA0540/193/002; 40mg/10mg: PA0540/193/003. Marketing Authorisation Holder: Sanofi-Aventis Ireland Ltd. T/A SANOFI, Citywest Business Campus, Dublin 24, Ireland. Further information is available from: Sanofi, 18 Riverwalk, Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi.com Tel.: (01) 4035600. Date of Preparation: December 2019. Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie; email: medsafety@hpra.ie Adverse events should also be reported to Sanofi Ireland Ltd. Tel: 01 403 5600. Alternatively, send via email to IEPharmacovigilance@sanofi.com

SAIE.ZEN.19.09.0201e – December 2019



How prescription charges for medical cardholders affect patients Analysis: healthcare professionals are worried that these charges are negatively impacting patient safety. Written by Gary L O’Brien, Research Pharmacist and Irish Research Council Ph.D. Scholar in the School of Pharmacy at UCC.

In Budget 2020, the Government reduced the cost of the highly unpopular ¤2 prescription charge for around 1.6 million medical cardholders in Ireland. It's certainly not the first time this levy has been altered. In an attempt to counteract rising Government expenditure and to reduce medicine wastage, the Department of Health initially introduced a ¤0.50 charge per prescription item for medical cardholders, capped at ¤10 monthly, in October 2010. Since then, this fee has undergone numerous increases and decreases and March 2017 saw the introduction of different prescription charges for separate age groups. Increasing the prescription medicine charge by ¤1 or decreasing it by ¤0.50 doesn't seem like a lot, but such changes have already had a major impact. Recent analysis demonstrated that patients were mostly accepting of the ¤0.50 levy, with some reservations concerning an increased price and how the Government would use the generated revenue. The increase in levy from ¤0.50 to ¤1.50 was associated with an immediate reduction in medication taking behaviour (adherence) for most medications, including a 10%

drop in adherence to antidepressant medication. The issue of this prescription charge and adherence to medicines is amplified in the medical card population in Ireland, because those who are socio-economically disadvantaged, as well as those who are aged over 70 years of age are overrepresented in this population. Changing this prescription fee without a firm evidence base could reduce the numbers of those who will actually use these services, especially among those who are less well off. My research looks at this controversial issue from the point of view of healthcare professionals at the coalface of this policy every day, from community pharmacists to GPs. In general, both community pharmacists and GPs believe the concept of a medical card prescription charge is a good idea. However, pharmacists do not want to be an organ of revenue collection for this levy on behalf of the Revenue Commissioner. It incurs financial loss, as pharmacists are ethically obliged to supply the medicine without payment in such circumstances. Collecting the prescription charge

increases administration workload and reduces staff productivity, which leads to more financial loss and steals time from patient care duties. It also appears that the current technology systems that pharmacists must use for reimbursement are not fit for purpose. For example, one family might pay the maximum medical card prescription charge cap of ¤20 for medicines in one calendar month. But because of the IT system, it may not be recognised that the individuals in the family all fall under the maximum medical card prescription charge cap together. Instead, a ¤20 cap for each individual instead of the ¤20 cap for the whole family unit is deducted from the pharmacist, leaving them at a huge financial loss. An unexpected finding was that GPs want a similar nominal charge attached to medical card patient visits in their surgeries to prevent unnecessary overuse of this free, oversaturated service. This finding comes as no surprise as recent media reports state that doctors warn general practice in Ireland is on the brink of collapse. It was also unclear what actual evidence is guiding these prescription charge changes as shown in the infographic above. It appears that changing these fees as promised by politicians around general election time or on budget day without any solid evidence of what impact such increases or decreases can have has already yielded consequential reductions in patient adherence to essential medicines. This leads to poorer health outcomes and increased usage of health services. With our emergency department situations being described as a "national emergency" (Mary Harney, 2006), "acceptable cruelty" (Fintan O'Toole, 2018) and "bloody awful" (Leo Varadkar, 2015), it’s doubtful

that our health services are equipped for increased usage. Both pharmacy and GP representative bodies who have first-hand experience with the medical card prescription charge need to be heavily involved in this policy as it's a healthcare policy, not a revenue-generating exercise. In fact, pharmacists and GPs now recommend medical patients who have an eligible long-term illness, as classified by the Health Service Executive, to switch from the medical card scheme to the non-means tested long-term illness scheme to avoid paying the medical card prescription charge. This nullifies the whole concept of having a charge associated with the medical card scheme. It sparks discussion on the complexity of the whole medicine reimbursement system in Ireland where reform is urgently required. This analysis comes at an important time as the Irish healthcare system undergoes major political, economic and health policy reform under the ten-year Sláintecare policy. If healthcare policymakers truly want to achieve their goal of universal healthcare under this new policy, they need to start re-evaluating contemporary health policies like the medical card prescription charge to ensure future sustainability of our healthcare system as a whole. This piece is based on a qualitative study "Out of Pocket or Out of Control: A Qualitative Analysis of Healthcare Professional Stakeholder Involvement in Pharmaceutical Policy Change in Ireland" which is due for publication in 2020.

Brexit Updates At its October meeting the PSI Council approved amendments to the PSI's qualification recognition and registration rules. The rules will facilitate an efficient and practical approach for applications from UK qualified pharmacists that may be needed in the event of a no-deal Brexit. The rules will be made available following approval by the Minister for Health. To assist future applicants, we have developed frequently asked questions about registration with the PSI post-Brexit. Please note, if you are a pharmacist with a UK qualification that has already been recognised and registered in Ireland by the PSI, there will be no change to your registration status.




Flu Vaccine still available in Pharmacy It is not too late to get the flu vaccine. That was one of the key messages to come from the HSE in the New Year, as it was revealed that Ireland is still within the ‘danger zone’ of the flu outbreak. 7 - 21 days: The cough should be better by now but if it lasts more than three weeks, advise referral to their local doctor. Dr O’Connor adds, “Over-thecounter cough remedies may ease cough and help to bring up phlegm so that coughing is easier. Paracetamol or ibuprofen will relieve pain. Many people also find that hot honey and lemon drinks are helpful. Antibiotics do not actually ease a cough – they kill bacteria.” High-risk patients include: • persons aged 65 years and older;

It is believed that the current flu season arrived 3-4 weeks early this year, and has led to the death of 22 people to date, 17 of those aged 65 years and older. The Irish Pharmacy Union (IPU) has advised anyone yet to receive the flu vaccine to make an appointment in their local pharmacy and get the vaccine now. This is particularly important for those in high-risk groups. The HSE published figures showing that the ILI (influenza-like illness) rate for the week ending 8 December was 37.5 cases per 100,000 population, which is above the baseline threshold of 18.1 cases per 100,00, used to assess influenza activity. Community Pharmacist and IPU Executive Committee Member Ann Marie Horan says, “The best way to protect against the flu is the flu vaccine. While we encourage people to get vaccinated early, it’s definitely not too late. In the Northern Hemisphere, the flu season typically lasts from October to April.” Ms Horan says, “Pharmacies around the country have had a great response from the public to this year’s flu vaccine campaign. Anecdotally, we are hearing that numbers getting vaccinated are up on 2018, and we believe increased awareness of vaccination through advertising campaigns such as the IPU’s radio flu vaccine campaign have definitely helped to raise awareness.

“However, for those who have yet to get the vaccine, particularly those in high-risk groups, we are telling people it’s not too late to get vaccinated. We are also reminding people that if you were vaccinated last year, you will still need to get vaccinated again this year. Each flu season is different and therefore, unlike many vaccines which can provide lifelong protection, a flu vaccine is required annually. If you received a vaccine last year, there is no guarantee that you are protected from the strains of the virus that will hit Ireland during this year’s flu season.” Meanwhile it has also been reported that people have been banned from visiting patients at the Mercy University Hospital in Cork. Visitor restrictions are also in place at Cork University Hospital, The Mater Hospital and University Hospital Waterford. Dr Kevin Kelleher, the HSE’s Assistant National Director for Public Health said the flu season is expected to remain in place for another four or five weeks. He added, “The difficulty is, with the flu season peaking over the Christmas/New Year period, that’s a difficult time for the health system anyway because of lots of different reasons. But the system has been dealing with it, people are making every effort to deal with it.” Dr Kelleher warned the death toll could hit 100 by the time the flu season ends.


Sorting Cough The HSE has also issued a reminder that most coughs are viral which means they get better just as fast without antibiotics. Dr Nuala O’Connor, a Cork based GP and ICGP Lead for Antimicrobial Resistance says, “GPs see a lot of coughs at this time of year. Coughing is part of your body’s way of protecting your lungs. It is better to cough up phlegm than to have it stay lower in your lungs. Coughing spreads the germs that caused your cough in the first place so it is important not to spread the illness to others.” Know the time frame for cough 1 - 3 days: Most coughs are caused by colds or flu. They usually come with other symptoms such as a runny nose, fever, sore throat, earache or general aches and pains. If the cough is a result of a cold or flu, sufferers do not need to see the doctor. The simplest and cheapest way to ease a tickly or chesty cough is with any of the common over-the-counter remedies. 4 - 7 days: By this stage, many tickly and chesty coughs will start to improve, but sometimes coughs can last longer. Advise that patients continue to take over-the-counter remedies if they need them.

• persons 10-64 with a chronic illness requiring regular follow up, e.g. chronic respiratory disease (including chronic obstructive pulmonary disease, cystic fibrosis, moderate or severe asthma and bronchopulmonary dysplasia), chronic heart disease (including acute coronary syndrome), chronic renal disease, diabetes mellitus, haemoglobinopathies, chronic liver disease, chronic neurological disease (including multiple sclerosis, hereditary and degenerative disorders of the central nervous system); • those who are immunosuppressed due to disease or treatment including those with missing or non-functioning spleens; • all cancer patients; • patients with any condition that can compromise respiratory function, e.g. spinal cord injury, seizure disorder or other neuromuscular disorder; • persons with Down syndrome; • those with morbid obesity, i.e. body mass index over 40; • all pregnant women (vaccine can be given at any stage of pregnancy); • healthcare workers; • household contacts of at-risk persons; • out-of-home care givers to at-risk persons • residents of nursing homes and other long-stay institutions; • carers; and • people with regular contact with pigs, poultry or waterfowl.



Paperless Medication Management The MAMA Mobile Application is setting the standard within the healthcare sector in Ireland and the UK for medication administration management by making the move to a paperless environment a reality. Pharmacists, Nursing Homes and Doctors can now all work in tandem to deliver the highest levels of care for patients while maintaining the most rigourous compliance standards. MAR Charts and Cardex created during medication rounds are now all stored and signed electronically providing highly dynamic reporting, simplifying audit requirements and reducing costs significantly. Call us on 049-899-5000 to find out more about this revolutionary solution.

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May 23rd 2020, Clayton Hotel, Burlington Road, Dublin

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Automation; An Advancing Role in Community Pharmacy The traditional task of community pharmacists lies in providing their patients with the required medication; but yet the mechanics of this are renowned for being tedious and repetitive. This is, of course in addition to the realms of human error. However in the world of automation, pharmacists are finding solutions. Robots rarely make errors, they don’t get bored or distracted. Furthermore, they give pharmacists and technicians the glorious gift of time, valuable time with their patients and customers for more profitable clinical services. Peter Weedle, Allcare Pharmacy Townview

“We were familiar with the benefits of automation, as we had many years’ experience with an BD Arx Speedcase in our main dispensary.

Over the last few years, automation is becoming more widely embraced in Ireland. Irish Pharmacy News spoke to two local pharmacists about its use within their stores and businesses. Peter Weedle Allcare Pharmacy is based in Mallow, Co. Cork and serves an urban and rural population and a number of nursing homes. The pharmacy was established over 40 years ago and has been using dispensing robots for the past 12 years. “As our nursing home business and MDS for the community

were continuing to increase, it became clear that we needed to organise and streamline our filling of Medinoxx trays if we were to continue to grow,” Peter says. “We were familiar with the benefits of automation, as we had many years’ experience with an BD Arx Speedcase in our main dispensary. However, we wanted to automate as much of the MDS tray production as possible. Increased Efficiency “We considered the various systems on the market and for patient preference we wanted


However, we wanted to automate as much of the MDS tray production as possible.” Peter Weedle, Pharmacist, Allcare Pharmacy Mallow, Co. Cork to stay with our existing MDS – Medinoxx. We chose a SynMed® XF robot because they had a strong track-record of serving pharmacy with many installations in Canada, USA and the UK.

“We went to see the system in a Medicare pharmacy in Northern Ireland and were very impressed with their set-up. We particularly liked the safety features in the system which showed that a lot of thought and care had gone into the development of the Synmed robot. The safety features were excellent, the recording of expiry dates and batch numbers for each medicine in each Medi-cup and the Synmed Assist which takes the operator step by step. through the filling of each tray were particularly impressive. “It is hard to know how we would cope without it now.” Extending Reach Whelehans Pharmacy, a strong and robust customer led, independent, community pharmacy in Mullingar, has been serving the needs of the local population at its current location in the centre of town for over 100 years and recently celebrated their 120-year anniversary. Pharmacist and Owner Eamonn Brady told us, “As the business has grown, especially since an extensive refit of our original Pearse St Mullingar Pharmacy in 2014 and opening a second pharmacy in Clonmore Mullingar in 2017, Whelehans has been at the forefront of many health led initiatives in town, providing a range of additional services at the current location, including a beautician clinic, chiropodist,

47 holistic therapy service, pet advice clinic, counselling service and more. “Rather than grow through the philosophy of pile it high and have a primarily ‘sales focused’ pharmacy business, the core of our philosophy at Whelehans Pharmacy has been to place our pharmacy firmly at the centre of the community and to extend our reach through engagement ‘outside the front door’ so to speak.

automation offering. Looking at the possibilities open to him, he pursued the route of a Synmed® robot. This versatile automation helps pharmacists accurately prepare patients’ medication by filling 30 multi-dose blister packs/hour with hundreds of different tablet types.

advance of not forcing one type of blister pack on any of the nursing homes we supply. In our case, we use 4 different type of blister pack system and the Synmed® robot can fill them all.

pharmacies more efficient and increased efficiency is giving them the opportunity to offer more services and provide greater medication safety. Pharmacies are under increasing pressure from issues like budget cuts, the aging population and medicine shortages. These all pose challenges to pharmacy management teams, including increased responsibilities, reduced time to spend with customers and limited storage space. Therefore, it’s crucial that pharmacists consider the benefits of incorporating new technology to increase efficiency.

EXPERIENCE THE SYNMED ® DIFFERENCE N C “By doing this, Whelehans has become known in Mullingar and the wider Westmeath and Midlands area as a centre of excellence for health and beauty and with a highly trained and motivated team that not only have expertise, but the desire to treat everyone who enters the pharmacy as a ‘person’ with specific needs that we hope to resolve or help rather than just seeing them as a ‘customer’ who we try to ‘squeeze’ money out of.” Specialising in dispensing to Nursing Homes, in order to maximise efficiencies Eamonn took the plunge to develop his

“The Synmed® robot means efficiencies in dispensing time and accuracy. Most of our nursing homes are dispensed in blister packs and the preparing and dispensing or blister packs is the biggest time constraint in my pharmacy.

“The Synmed® robot can dispense on average 30 blister packs per hour. It also maximises the use of space within the pharmacy so it makes workflow a lot more efficient. Most importantly, it reduces errors in dispensing and checking so make dispensing a safer process. Low Error Rates “The Synmed® robot has the advantage of dispensing any type of blister pack; this has the

“From doing extensive research on the different types of robots on the market, I found Synmed® offer the biggest advantage of not restricting the way we dispense for our nursing home clients

“It has the advantage of a low error rate and it actually spots errors for pharmacy staff. It also has a system of making the checking of the medicines more efficient, quicker and safer so it maximises the use of the pharmacist’s time.” Eamonn carried out his research, speaking to a number of pharmacists in the UK who are using the Synmed® robot with excellent feedback on how it benefited their business in all cases.

“I worked out that the Synmed® robot will pay itself pack in 3 years through staff efficiencies,” he adds. Automation is making community


Eamonn is quick to urge his colleagues to adopt the technology. “If you are restricted for space or thinking of taking on more staff to meet increased dispensing demands, then you should consider robotic dispensing,” he says. “When you pick a space in the pharmacy to place the robot, to maximise workflow efficiencies, ensure your top 400 dispensing lines are within easy reach of the robot.

The SynMed®ULTRA and the SynMed XF® are our state-of-the-art automated dispensing systems designed to help pharmacies of any size increase capacity and boost productivity without compromising on quality. • Designed for all levels of Blister Pack production • Holds 400 to 500 medication containers

® ® • Recalibrates containers fort e - o The SynMed Ultra f and the SynMed XFare our state-of-the-art new on site in 5of any r m automated a dispensing systems designedgenerics toc help pharmacies i minutes t c size increase o capacity and boost productivity m without compromising on quality. • Compatible with most U.K. Packs • Designed for all levels of Blister PackBlister production

• Holds 400 to 500 medication containers Partner with Synergy Medical • Recalibrates containers fort new generics on site in 5 minutes m i n u e s for leading innovation, • Compatible with most U.K. Blister personalised Packs support and a

customer-focused approach.i Partner with Synergy Medical for leading innovation, l personalised s o n a support and a customer-focused approach.



Robotics Eamonn Brady, Whelehan’s Pharmacy, Mullingar

“It is important to brief staff in advance that the automation will increase efficiencies, allow the business grow more efficiently and secure growth and jobs in the future. Sometimes there can be a fear of change and fear the robot is going to ‘replace staff’. “It is also best to have two staff in the pharmacy trained as ‘experts’ in using the robot; this way they can be the “go to people” for the other staff with questions on using the robot. I would advise you choose two staff who are open to change and have a good ability to mentor and explain to other

staff. With Synmed®, they send their trainer Mandy to train two staff for a week before the system goes live.

Peter advises that automation of the dispensing process will continue to develop, and now is the time to get on board.

Business Growth

“The combination of our Medinoxx MDS system with a Synmed robot allows us to prepare individualised medicine administration medicine cups for the patient and as therapy continues to develop and become more complicated it will increase the demand for the service that we offer,” he says.

“Every pharmacist owner I spoke to who embraced robotic dispensing found that it enabled business growth and freed up many of the mundane jobs so staff could do what they do best, concentrate on the customer to give a better service and actually served to secure jobs and in many case, actually take on new people.”

“The overall distribution of medicines is going to become more centralised due to automation with pharmacists

“If you are restricted for space or thinking of taking on more staff to meet increased dispensing demands, then you should consider robotic dispensing” Eamonn Brady, Pharmacist, Whelehan’s Pharmacy spending less of their time on the packing process and more on the pharmaceutical care of their patients.” Pharmacy robots allow technicians and pharmacists to spend less time manually finding prescriptions and more time with patients. Freeing up space, reducing dispensing errors and reducing patient waiting times are just some of the ways that automated dispensing systems are changing pharmacies in Ireland.

Anti-Vaccination Misinformation Minister for Health, Simon Harris TD, has met with the social media companies, Facebook, Twitter, and Google, to discuss the measures they are taking to combat anti-vaccination misinformation on social media platforms. Vaccine hesitancy has been identified by the World Health Organization as one of the ten leading threats to global health in 2019. The Minister outlined his concerns saying, "The progress we have made in reducing, and in some cases eradicating, vaccinepreventable diseases will be in vain if we allow our immunisation programmes to be undermined by

misinformation and disinformation about the benefits and safety of vaccines, particularly on social media. "Social media is an incredibly powerful tool that can also be harnessed to direct people to sources of factual information about vaccination, so they can make informed decisions. It is in this context that I met with the social media companies today.


The Minister commended the social media companies for being proactive and putting in place measures to tackle this issue and he welcomed their commitment to work with the Department of Health to make further progress.” However, he added, “The companies themselves acknowledged they have a responsibility to their users in the area of public health. While some

of them have taken measures to combat vaccine misinformation, they acknowledged there was much more work to be done and agreed to liaise with the department regarding the work of the Vaccine Alliance and with the HSE to progress further initiatives. “We must do everything we can to ensure people get accurate and reputable information on public health.”

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Topic Team Training – Diabetes 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. in Ireland that need to consider making changes to their daily behaviours in terms of eating healthily and being more active. There are several different families of Oral Hypoglycaemic Agents (OHA’s) and the names of some of these are complicated, but each describes a drug or group of drugs that act to lower blood glucose in a way unique to that family. The main families of OHA are the biguanides, sulphonylureas (SUs), A-glucosidase inhibitors, insulin sensitisers (thiazolidinediones), prandial glucose regulators, GLP1’s, DPP4 inhibitors and SGLT2 inhibitors.

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 Diabetes. There are two types of diabetes, Type 1 diabetes and Type 2 diabetes. In the absence of a register of people who have diabetes no-one can be entirely sure how many people in Ireland live with diabetes. The total number of people living with diabetes in Ireland is estimated to be 225,840. The International Diabetes Federation Diabetes Atlas (2013) estimate that there are 207,490 people with diabetes in Ireland in the 20 – 79 age group (prevalence of 6.5% in the population) which is in line with previous estimates that by 2020 there would be 233,000 people with the condition, and

by 2030 there would be 278,850 people with the condition. Type 1 Diabetes The prevalence of Type 1 Diabetes, an auto-immune condition, is on the rise and is typically diagnosed in childhood. People with type 1 diabetes account for approximately 20,000 of the total diabetes population in Ireland i.e. 10-15% of the population of people living with diabetes. It is estimated there are 2,750 people under 16 years of age living with Type 1 diabetes (based on the Irish Paediatric Diabetes Audit 2012) results and other young adults under 20 years attending transition clinics). Type 2 Diabetes According to the Healthy Ireland survey, 854,165 adults over 40 in the Republic of Ireland are at increased risk of developing

Consider:  Is the pharmacy team fully educated on both Type 1 and Type 2 diabetes?  How is diabetes support information displayed in the pharmacy?  Do we make the most of the potential for linked sales  Am I up to date with the latest guidance on diabetes and its treatment?  Are we clear on when to refer someone to the GP?


(or have) Type 2 diabetes. More alarmingly, there are a further 304,382 in the 30 – 39 year age group that are overweight and not taking the weekly 150 minutes recommended physical activity, leaving them at an increased risk of chronic ill-health. This means that there are 1,158,547 adults

Key Points: Check your pharmacy team are aware and understand the following key points:  The types of diabetes and its causes and symptoms  What types of diabetes can be considered for management in the pharmacy  Which customers should be referred to the pharmacist  The appropriate use of self diagnostic kits  The importance of diet and lifestyle advice  Questions to ask the customer  The different families of Oral Hypoglycaemic Agents (OHA’s)

The different families of OHAs all work in slightly different ways to one other. The one thing they have in common is that they all compensate in some way for the body’s inability to make and use enough insulin. The main way of treating Type 2 diabetes is eating a healthy diet with weight reduction (in those who are overweight) and being as physically active as possible. When this alone is unable to control blood sugar (glucose) levels, medications to help insulin work more effectively or to make the pancreas produce more insulin is required.

Actions:  Include POS with associated conditions relating to this category  Ensure efficient sign posting and shop floor management with associated ailments linked for maximum cross aisle merchandising  Ensure there is a discreet area in which staff can assist with advice and product selection  Dedicated window displays will improve the shoppers experience and highlight the pharmacy  Ensure the team are able to communicate lifestyle advice  Train the team to meet all the above considerations

Ostomy & Urology Care

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Optimising COPD Care in Pharmacy P

harmacists play an integral role in managing patients with chronic obstructive pulmonary disease (COPD).

Open communication between pharmacists and patients is crucial and studies have shown that patients who feel they are informed and part of the decision-making process are more likely to adhere to a treatment regimen and actively manage their disease. At the end of last year (December), calls were made for the introduction of a New Medicine Service in community pharmacies in Ireland, similar to the proven service already available to patients with chronic illness in other countries. Speaking to mark World COPD Day the IPU said that such a service could significantly improve the outcomes for patients newly diagnosed with COPD and a range of other conditions. Kathy Maher, community pharmacist says, “COPD is an umbrella term that describes a series of progressive lung diseases. They are associated with it being difficult to empty air out of the lungs due to the airways being narrower than normal, leading to airflow obstruction and difficulty breathing. It is estimated that as many as 500,000 people in Ireland may suffer from COPD and it is known to be Ireland’s fourth

biggest cause of death after lung cancer, heart disease and stroke.” Ms Maher continued, “A condition as common as COPD should, where possible, be treated outside of the hospital setting. That is why it would often be an ideal case for a pharmacy led New Medicine Service. This would allow the pharmacist to monitor a patient, ensure they were taking medications as directed and identify any challenges with a new treatment. “Economic analysis of a similar service which has operated in the UK since 2011 found that it offers the NHS increased health gain at reduced overall cost, and provides short-term savings of £75.4 million and long-term savings of £517.6 million.” This article takes a closer look at the prevalence of COPD in Ireland and the role of community pharmacists in advising on correct inhaler techniques. GOLD Standards Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) provide pharmacists and other healthcare professionals with


an understanding of chronic obstructive pulmonary disease and its treatment options in order to collaboratively manage this progressive disease. They recently released their Guidelines in this field for 2019. GOLD’s Global Strategy for Diagnosis, Management and Prevention of COPD report is reviewed and revised annually by leading physicians in the field of COPD around the globe. It is used worldwide by healthcare professionals as a “strategy document” and tool in the management and prevention of COPD, a disease that impacts more than 65 million people globally. Chronic obstructive pulmonary diseasE is a type of obstructive lung disease characterised by long-term breathing problems and poor airflow. The main symptoms include shortness of breath and cough with sputum production. COPD is a progressive disease, meaning it typically worsens over time. In Ireland, according to the HSE, COPD is one of the most common respiratory diseases. It usually

affects people over the age of 35. Around 110,000 people in Ireland have been diagnosed with COPD, but it is thought that there are about 2 00,000 people living with the disease who have not been diagnosed. The symptoms of COPD can be improved by using both evidence-based pharmacologic and non-pharmacologic treatments. Pharmacists are in an accessible position within communities to counsel patients and answer questions regarding treatment options for COPD. COPD is both a preventable and a treatable disease. Symptoms of COPD include dyspnea, chronic cough, and chronic sputum production. Dyspnea can worsen during exercise or with respiratory infections. Pharmacists can better understand the degree of disease severity by asking patients if they experience any breathlessness during normal day-to-day functions such as walking up a flight of stairs or dressing and undressing themselves. Chronic cough can be present intermittently or daily and may be unproductive.

Chronic sputum production can be any pattern in COPD patients.

outdoor exercises or remain indoors during pollution.

Clinical diagnosis for COPD should be considered in patients who present with these symptoms and have a history of exposure to risk factors. Tobacco smoke, smoke from home cooking and heating fuels, occupational dusts, and chemicals are examples of environmental risk factors.

Pharmacological Management

Other factors that can potentially increase an individual’s risk of developing COPD include any factor that may affect lung growth during gestation and childhood such as low birthweight and respiratory infections. Non-Pharmacological Management Smoking Cessation: Pharmacists should encourage COPD patients to stop smoking immediately and recommend medications to help facilitate the discontinuation of smoking. Nicotine replacement therapy includes nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, or lozenge. Both nicotine replacement therapy and pharmacologic treatment provide long-term abstinence rates. Vaccinations: COPD patients should be educated about flu and pneumonia prevention. Influenza and pneumococcal vaccines help to decrease the risk of COPD exacerbations and are recommended for all patients with COPD. Infections may trigger 50% to 70% of COPD exacerbations. Indoor and Outdoor Air Pollution: Patients should be cognizant of the air quality depending on their disease severity and avoid rigorous

Bronchodilators help to relax and open the airways making it easier to breath. Bronchodilators are either short acting or long acting. Combination inhalers contain both a reliever and a corticosteroid preventer. The action of the reliever is to keep the airways open, providing relief. The action of the corticosteroid preventer is to reduce inflammation in the lungs. Oral Corticosteroids are high dose anti-inflammatories and can be used during a flare up for a short period of time. Occasionally some patients require a low maintenance dose. Antibiotics are used to treat infections caused by bacteria.

Patients may be given different inhaler types, receive minimal training, if any, and sometimes incorrect training on how to use the device. The themes associated with incorrect inhaler use are fairly consistent: Failure to exhale prior to use, poor co-ordination of inspiration with actuation (timing) and incorrect rates of inspiratory flow. It is imperative that pharmacists advise patients on how to properly use their inhalers. Important counseling points for patients with COPD include the following:  Demonstrate proper techniques with inhaler use. Studies have shown that more than half of patients with COPD use ineffective inhalation techniques when using their inhaler;

Theophyllines are used in some patients who may require further bronchodilation (opening of the airways).

 A metered-dose inhaler (MDI) usually requires the patient to breathe in slowly and deeply. Most MDIs require priming and shaking before use;

Expectorants can be used for patients who have excessive production of mucus, however not all patients benefit from this medication.

 A dry-powder inhaler (DPI) requires a quick and deep inhalation to pull the powdered medicine into the lungs. DPIs should not be shaken;

The Role of the Pharmacist

 Review with the patient how to clean the inhaler mouthpiece;

Despite considerable research into the ability of people to use their inhalers and the development of several new types of inhaler devices, there has been no sustained improvement in how people use their devices. Incorrect inhaler technique is common, regardless of the type of device prescribed.

 Remind patients to give themselves enough time to order their next refill so they are not without their medications;  Some inhalers expire within a certain time frame, so advise patients to discard any remaining medications past the expiration date;

 Explain the differences between the various types of inhalers. Bronchodilators relax and open the airways in the lungs. Always use the bronchodilator first before using a steroid inhaler. Steroid inhalers decrease swelling in the airways of the lungs. Rinse out the mouth with water and then spit it out after using the steroid inhaler. Providing information and supporting patients to achieve correct inhaler technique improves symptoms, quality of life and respiratory functional status, minimises short-acting betaagonist use and reduces emergency hospital admissions. Training of patients by pharmacists and health professionals is an effective means of improving this situation but should be repeated at intervals. Even after training is provided and patients can demonstrate optimum inhaler technique, some patients will continue to have difficulties using inhalers properly and ongoing support should be provided. Inhaler technique has also been found to deteriorate over time (possibly after as little as two to three months), so instruction needs to be repeated at intervals. In an Australian study, 75% of patients using an inhaler for an average of two to three years reported they were using their inhaler correctly but, on objective checking, only 10% demonstrated correct technique. Most patients will have received instruction only at the time of their first prescription. Checking use is not about catching people out but optimising what is delivered.

News McElwee Pharmacy Appreciation A fantastic day was held recently for Peter McElwee and all at McElwee totalhealth Pharmacies, as they held a Customer Appreciation Event and celebrated joining forces with the totalhealth Pharmacy Group. Peter has three pharmacies, McElwee totalhealth Pharmacy Portlaoise, McElwee totalhealth Pharmacy Connolly Street, Mountmellick and McElwee totalhealth Pharmacy O'Connell Square, Mountmellick, Co. Laois! Peter McElwee is pictured with members of his Pharmacy Team at McElwee totalhealth Pharmacy



HAS POSITIVE HEAD-TO-HEAD DATA VS. ANOTHER ONCE-DAILY LAMA/LABA* 1 In symptomatic patients with moderate COPD *Anoro Ellipta 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 Ellipta and 122mL tiotropium/olodaterol, 95% CI: 26, 80; p<0.001)1

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 COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; LABA, long-acting β2-agonist; LAMA, long-acting 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 Ellipta is not indicated for the treatment of acute episodes of bronchospasm. Cardiovascular 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. Due to antimuscarinic activity (i.e. LAMA class activity), umeclidinium/vilanterol should be used with caution in patients with urinary retention or with narrow-angle glaucoma.2

Anoro Ellipta 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/vilanterol rare hereditary problems of galactose intolerance, the Lapp total dysphonia, atrial fibrillation, supraventricular tachycardia, [as trifenatate]) inhalation powder. Each single inhalation lactase deficiency or glucose-galactose malabsorption should rhythm idioventricular, tachycardia, supraventricular of umeclidinium bromide (UMEC) 62.5 micrograms (mcg) not use Anoro Ellipta. Acute symptoms: Anoro Ellipta is not extrasystoles and palpitations. Rare: Anaphylaxis, angioedema, and vilanterol (VI) 25mcg provides a delivered dose of UMEC indicated for acute episodes of bronchospasm. Warn patients urticaria, vision blurred, glaucoma, intraocular pressure 55mcg and VI 22mcg. Each delivered dose contains approx. to seek medical advice if short-acting inhaled bronchodilator 25mg lactose. Indications: COPD: Maintenance bronchodilator use increases, a re-evaluation of the patient and of the COPD increased, paradoxical bronchospasm, urinary retention, dysuria treatment to relieve symptoms in adult patients with COPD. treatment regimen should be undertaken. Interactions and bladder outlet obstruction. Marketing Authorisation Dose and administration: Inhalation only. COPD: with other medicinal products: Interaction studies have (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, One inhalation once daily at the same time of the day. only been performed in adults. Avoid β-blockers. Caution is Citywest Business Campus, Dublin 24, Ireland. MA Nr: Contraindications: Hypersensitivity to the active substances or advised when co-administering with strong CYP3A4 inhibitors 55/22mcg 1x30 doses [EU/1/14/898/002]. Legal category: to any of the excipients (lactose monohydrate and magnesium (e.g. ketoconazole, clarithromycin, itraconazole, ritonavir, POM B. Last date of revision: February 2019. Job Ref: stearate). Precautions: Anoro Ellipta should not be used in telithromycin). Anoro Ellipta should not be used in conjunction IE/UCV/0063/15 (8). Further information available on request patients with asthma. Treatment with Anoro Ellipta should be with other long-acting β2-adrenergic agonists or medicinal discontinued in the event of paradoxical bronchospasm and products containing long-acting muscarinic antagonists. from GlaxoSmithKline, 12 Riverwalk, Citywest Business alternative therapy initiated if necessary. Cardiovascular effects Caution is advised with concomitant use with methylxanthine Campus, Dublin 24, Tel: 01-4955000. may be seen after the administration of muscarinic receptor derivatives, steroids or non-potassium-sparing diuretics as it Adverse events should be reported to the Health Products antagonists and sympathomimetics therefore Anoro Ellipta may potentiate possible hypokalaemic effect of β2-adrenergic Regulatory Authority (HPRA) using an Adverse Reaction should be used with caution in patients with severe cardiovascular agonists. Fertility, pregnancy, and breast-feeding: Report Form obtained either from the HPRA or electronically disease. Anoro Ellipta should be used with caution in patients No available data. Balance risks against benefits. Side effects: via the website at www.hpra.ie. Adverse reactions can with urinary retention, narrow angle glaucoma, convulsive Common: Urinary tract infection, sinusitis, nasopharyngitis, also be reported to the HPRA by calling (01) 6764971. disorders, thyrotoxicosis, hypokalaemia, hyperglycaemia and pharyngitis, upper respiratory tract infection, headache, cough, Adverse events should also be reported to GlaxoSmithKline severe hepatic impairment. No dose adjustment is required in oropharyngeal pain, constipation and dry mouth. Uncommon: on 1800 244 255. renal or mild to moderate hepatic impairment. Patients with Hypersenstivity reactions including rash, tremor, dysgeusia, 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 2019. 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(2) Date of Preparation: January 2019



Knowledge Gaps in PrEP Awareness According to new research conducted by Core Research on behalf of Teva Pharmaceuticals Ireland published, 1 in 5 people are unaware of any HIV prevention methods. Specifically, 87% of people had never heard of PrEP yet 36% of people admitted that they would consider taking it. The research was conducted with Irish adults over 18 years of age, with a national average sample size of 969 people. It examined several areas relating to HIV and PrEP, including the general public's understanding of HIV and anti-HIV drug PrEP, the role of HIV and STI clinics, and the awareness and use of HIV prevention methods. The survey found that 70% of people believed PrEP should be available free of charge. While the research findings show high levels of awareness of HIV generally, opinion revealed that HIV is still considered a taboo subject in Ireland. However, 97% of those who think HIV is a taboo subject in Ireland also think there needs to be more information about it.

Key findings from the research include:  65% of Irish adults still believe that HIV is a sensitive subject.  93% of people think there needs to be more information on HIV in Ireland.  79% of people say that the first thing they would do if they found out they had HIV would be to visit a HIV clinic.  70% of people feel that the risk of HIV is not taken into consideration before engaging in sexual activity.  7 in 10 people believe PrEP should be available free of charge. Commenting, Teva's Generics Director Paul Neill said, "The survey results point to a large

knowledge gap of awareness of PrEP, especially within younger age cohorts who are considerably less aware of any HIV prevention methods. It's important that the correct information is put out to those at risk of HIV and the general public. “PrEP has been shown to significantly reduce the risk of HIV infection in conjunction with safe sex practices, particularly for those deemed at high risk, such as gay and bisexual men, and transgender women. “Equally, it is important that those using PrEP are going for check-ups with their healthcare provider once every three months to ensure that the medication is working as effectively as possible for them[iii].

“The government's introduction of a PrEP programme represents an important statement on the value of preventative healthcare versus curative treatment. At a time of stretched health budgets, when our health services have so many competing priorities, medicines such as PrEP can make a huge contribution to keeping people healthy and ultimately help to reduce healthcare costs. “Further work is now needed to increase education and awareness of PrEP to ensure that patients have a better understanding of the healthcare regime that must support PrEP, such as regular sexual health testing. Teva will also work to expand awareness and knowledge of PrEP.” [iii] HIV Ireland https://www.hivireland. ie/hiv/prevention/prep-2/

Diabetes medicines The HPRA has recently been made aware that trace amounts of an impurity, N-nitrosodimethylamine (NDMA), have been found in a small number of metformin diabetes medicines outside of Ireland and the EU. At this time, the HPRA is not aware of any metformin products in Ireland that are affected. The HPRA is working closely with the European Medicines Agency (EMA) and other regulatory authorities in the review of this issue. The levels of NDMA seen in the affected metformin medicines outside of the EU are very low and appear to be within or even below the range that people would normally be exposed to from other sources, including food and water. Healthcare professionals should continue to prescribe metformin medicines as normal and remind patients of the importance of keeping their diabetes under control.

New Role for Padraic Padraic O’Brien, Accord Ireland's, Head of Commercial, has been elected as Vice-Chair of Medicines for Ireland (MFI). MFI was formed in 2017 with the merging of the Healthcare Enterprise Alliance and the Irish Generic Manufacturers Association and represents generic and biosimilar companies. MFI members include Accord Healthcare, Bluefish, Consilient Healthcare, Clonmel Healthcare, Fannin Healthcare, Fresenius Kabi, Mylan, Pinewood Healthcare, Rowa Pharmaceuticals and Teva Pharmaceuticals.

Padraic O’Brien, Accord Ireland's, Head of Commercial,


Lifelong Learning in Pharmacy The 13th International Life Long Learning in Pharmacy Conference is coming to Dublin, Ireland, from the 3rd to the 6th of July 2020. The Royal College of Surgeons in Ireland (RCSI) is delighted to host this extraordinary pharmacy education event at its historic St Stephens Green campus. Develop your knowledge and skills in the field of pharmacy education through a variety of educational programs, hear from world renowned leaders presenting internationally significant research and development and network with colleagues from around the globe. With over 100 contributed papers, workshops and posters, and a remarkable list of keynote speakers including Zubin Austin (Canada), Mary E Collins (Ireland) and Rose Marie Parr (Scotland), this is a must-attend pharmacy event. Online registration portal and abstract submission will open soon. You can find everything you need know on the LLLP 2020 website, https://lllpharm2020.com/




Accofil ▼

600 mg x 10 Film Coated Tablets

30 MU/0.5 ml Solution for Injection / Infusion in Pre-Filled Syringe x 5



Voriconazole Accord Voriconazole

50 mg x 28 Film Coated Tablets 200 mg x 28 Film Coated Tablets


Valganciclovir Valganciclovir

450 mg x 60 Film Coated Tablets


48 MU/0.5 ml Solution for Injection / Infusion in Pre-Filled Syringe x 5

Pelgraz ▼ Pegfilgrastim

6 mg Solution for Injection in Pre-Filled Syringe x1


Granpidam Sildenafil

20 mg x 90 Film Coated Tablets



Mycophenolate Mofetil Accord

Mycophenolate Mofetil 250 mg x 100 Capsules 500 mg x 50 Film Coated Tablets


Tenofovir disoproxil Tenofovir disoproxil

245 mg x 30 Film Coated Tablets


Entecavir (Actavis) Entecavir

0.5 mg x 30 Film Coated Tablets


50 mg x 28 Film Coated Tablets

Capecitabine Accord Capecitabine

150 mg x 60 Film Coated Tablets 300 mg x 60 Film Coated Tablets 500 mg x 120 Film Coated Tablets

Imatinib Accord Imatinib

100 mg x 60 Film Coated Tablets 400 mg x 30 Film Coated Tablets

Temozolomide Accord Temozolomide

5 mg x 5 Hard Capsules 20 mg x 5 Hard Capsules 100 mg x 5 Hard Capsules 140 mg x 5 Hard Capsules 180 mg x 5 Hard Capsules 250 mg x 5 Hard Capsules

Further information is available on request from Accord Healthcare Ireland Ltd, Euro House | Euro Business Park | Little Island | Cork | T45 K857 | Ireland. Tel: 021-461 9040 or from the SmPC available on www.accord-healthcare.ie Products subject to prescription. Supply through pharmacies only. Marketing Authorisation Holder for Actavis products Actavis Group PTC ehf, Reykavikurvegi, 76-78, 220 Hafnarfjordur, Iceland and for Accord products Accord Healthcare Limited, Sage House, 319 Pinner Road, North Harrow, Middlesex HAI 4HF, United Kingdom.

Date of Preparation: September 2018 UK&IE/HiT/0002/10-17a



National Service Plan for Health The HSE National Service Plan 2020 was published last month, setting out the type and volume of health and social care services to be provided by from the funding of over €17 billion made available by Government in Budget 2020.

 Enhanced Community Services – Provision of an additional 1,000 extra community frontline staff to strengthen primary care via community health networks.

Minister Harris said, "The National Service Plan being launched sets out the services and activities that the HSE will provide in 2020, from the significant funding provided. A major focus of the service plan is to continue bringing the important Sláintecare health reform programme to life in communities across the country by delivering investments in key strategic supports.

 Mental Health - Developments including phased opening of the National Forensic Mental Health Services at Portrane.

“I want to thank the HSE, the new board and the new CEO for working with the Government on delivering this Service Plan.”

 NHSS – maintaining the waiting period for funding at an average of four weeks throughout 2020

Minister of State for Health Promotion and the National Drugs Strategy, Catherine Byrne TD, welcoming the publication of the Service Plan, said:

Minister of State for Health Promotion and the National Drugs Strategy, Catherine Byrne TD

The total HSE budget for 2020 includes some significant additional investments which will be applied to enhance or expand existing services, including responding to demographic and other pressures and to commence new approved service developments. These measures include investment in core services such as;  Community Services - Additional home care hours and the establishment of a pilot for statutory home support scheme including an additional 230,000 hours beyond the 2019 target level.  Disability Services - Supports for school leavers with disabilities to access supports and services to meet their needs, for disability needs assessment, for autism services and for additional

respite capacity. In addition, there will be additional personal assistance hours and additional emergency residential places.  Palliative care - Additional palliative care beds (55 beds in Kildare, Mayo, Waterford and Wicklow).  Primary Care Reimbursement Scheme (PCRS) - Measures to widen eligibility, including the extension of free GP care to children under the age of eight, and lower co-payment thresholds.  National Acute Strategies Continued implementation of the Maternity, Cancer and National Trauma Strategy.  Care redesign - Initiatives on the shift from hospital to the community.

 Voluntary Hospices - Support for the sector in line with sustainability plans to be agreed with the HSE  Winter Capacity – Additional measures such as additional home care packages and transitional care  Homelessness and addiction services - Additional supports, including the establishment of a residential treatment service for homeless women and children in the mid-west region.  Assisted Human Reproduction Services. Minister for Health, Simon Harris TD, and Ministers of State Finian McGrath TD, Jim Daly TD and Catherine Byrne TD welcomed the publication.

“Improving the health and wellbeing of those who experience social exclusion and drug addictions a key priority for 2020. The significant expansion of addiction services for pregnant and post-natal women and their children, particularly those who are homeless , delivers on key actions in the National Drugs Strategy. I am committed to working in partnership with the HSE and the community and voluntary sector to address the severe health inequalities experienced by people with problem drug use, people who are homeless, refugees, asylum seekers and members of Traveller and Roma communities.”

AYA makes new celebrity fans Vitamins and supplements brand AYA has found new fans among Irish celebrities with coverage across multiple popular Instagram accounts helping to raise the profile of the brand.

Irish television presenters Kathryn Thomas and Lucy Kennedy were among those to post AYA products to their social media profiles. Dancing With the Stars personality James Patrice also posted about the brand, saying that he hoped it would help to keep him “fighting fit” during the winter season. News and lifestyle websites Shemazing and Mummy Pages also covered AYA, while influencers Lottie Ryan, Trine Jensen Burke, Lynda Quigley and the Irish Beauty Fairy gave the brand a shout out. In total, these accounts are followed by over 420,000 people. The AYA brand was launched earlier this year by Uniphar as a high quality, research-backed addition to the Irish pharmacy market.



How to R apid-D 1. Add b uffLipid er Cholesterol and 2. Add s ampLipid Profile in 2 minutes Cholesterol and le 3 . Wainit21minutes Profile 5 4. Read result

Detect & Monitor Easy dose calculation guide


www. .com E-mail peter@nutricentric.com, text (086) 348 3592 or call (outside pharmacy hours) www. .com Full lipid profile on one Rapi-D fingerprick test & Rapi-Read CUBE

test strip in mins Full lipid profile on2one test strip in 2 mins Cholesterol and Lipid Cholesterol and Lipid Cholesterol and Lipid Total cholesterol, www. .com Cholesterol and Lipid Profile in 2 minutes in 2 minutes Profile in 2 minutes www. .com HDL-C. Triglycerides and TotalProfile cholesterol, Full lipid profile on one Profile in 2 minutes from them) LDL HDL-C.(calculated Triglycerides and test 2 mins Full strip lipid in profile on one in 22 mins mins (calculated from them) LDLtest strip in Total cholesterol, Monitor changes in blood lipids HDL, Total cholesterol, HDL-C. Triglycerides and Total cholesterol, TG and Triglycerides (calculated) LDL (calculated from them) LDL Monitor changes in blood lipids HDL-C. and (calculated from them) LDL QuCare Multi Non-fasting or fasting Monitor changes in blood lipids QuCare Multi Monitor changes in blood lipids Just a fingerprick

QuCare Multi Nutricentric Healthcare provides Point of Care diagnostics and develops protocols for their optimal use. Easy to learn QuCare Multi Nutricentric Healthcare provides Point of Care Nutricentric Healthcare provides Point of Care diagnostics and protocolswho for their optimal use. We develops serve practitioners assess, educate guide diagnostics and develops protocols for¤38 their optimal use. Box of and 10 strips incl Buffer Solution: (excl VAT*). Meter ¤70. Single-parameter Total Cholesteral patients towards lifestyles that can restore their health. Nutricentric Healthcare provides Point of Care (per 10): ¤15. We serve practitioners whoprotocols assess, educate guideuse. diagnostics and develops for theirand optimal We serve practitioners who assess, educate and guide patients lifestyles that can restore theirtohealth. Give yourtowards patients the knowledge they need stave off statins, patients towards lifestylesHealthcare that can restore their health. reduce the practitioners need for them, to improve their compliance. We serve whoorassess, educate and guide Nutricentric Enniskerry, Co Wicklow Nutricentric A98 Healthcare C1Y6 Enniskerry, Co Wicklow A98 C1Y6 Info@nutricentric.com



Nutricentric Healthcare patients towards lifestyles that can restore their health. Enniskerry, Co Wicklow A98 C1Y6 Nutricentric Healthcare


Enniskerry, Co Wicklow Info@nutricentric.com A98 C1Y6 Info@nutricentric.com



Affordable Italian Luxury



Are You Thinking of Selling Your Pharmacy?

Cosmetic Alliance Introduces Mesauda Cosmetics to the Irish Market When asked to describe their newest cosmetics line, Cosmetic Alliance boldly give it the moniker, “Kiko Milano’s big sister and MAC’s best friend.” This young and dynamic cosmetics line brings to the market the maturity and quality of a department store brand, but at a competitive price. With a specialized laboratory right in Italy, Mesauda’s main prerogative is to provide high-quality, trendy products that are unmatched in their formulation and functionality. With key products like the super longlasting Extreme Matte liquid lipstick, flawless Perfect Skin Foundation (hailed as a Chanel dupe) and ultra-shimmery Glow Stick; it’s easy for any makeup aficionado to see the thought and quality process that goes into Mesauda. Furthermore, each product is beautifully packaged and displayed on a classy and attractive 1 or 1.2M stand, drawing the customer to it almost instantly.


JPA Brenson Lawlor has over 30 years’ experience advising pharmacy owners and will help you to maximise your return.





Contact Us Today for a Free Consultation





Telephone Jason Bradshaw or Padraic Ferguson on 01-6689760

jason@brensonlawlor.ie padraic@brensonlawlor.ie www.brensonlawlor.ie



SOLGAR® 7 Next generation joint supplement after glucosamine


Micellised turmeric extract that has shown 185x bioavailability over 24 hours

MAGNESIUM CITRATE Magnesium in the highly absorbable ‘citrate’ form

Retained by white blood cells (immune cells) for up to 24 hours

OMNIUM® Comprehensive multivitamin with essential vitamins and minerals for daily vitality

FEMALE MULTIPLE Advanced multivitamin with 27 key nutrients for optimal health

For more details on opening an account or to place an order, please call 0044 1442 821 419 or email enquiries4@solgar.com Food supplements should not be used instead of a varied balanced diet and a healthy lifestyle. Solgar® is a registered trademark. Ester-C® is a registered trademark of The Ester-C Company, US patents 6,878,744 and 6,197, 813, and International patents.

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