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July 2020 Volume 12  Issue 7 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS: Pharmacists welcome new Health Minister Page 5

NEWS: Patient trust in Pharmacy remains high Page 9

REPORT: Back2School – A Pharmacy Education Page 16

CPD: Stroke – A Bleeding Dilemma Page 32

EDUCATIONAL: Hepatitis C Management Page 40

FEATURE: Common Skin Conditions Page 44


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Contents

Foreword

Page 4: Cara Pharmacy celebrate 20 years in business

Ireland’s new Health Minister, Wicklow TD Stephen Donnelly, who replaces Simon Harris has said that the Sláintecare plan remains the main route to reform of the healthcare system and that the move towards universal healthcare had to be accelerated in response to the Covid-19 crisis.

Page 5: New statistics on medicine dumping Page 6: totalhealth Pharmacy Group launch domestic abuse support

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Page 9: Patient trust in Pharmacy remains high Page 11: Cyber Security – is your pharmacy up to date? Page 12: Research shows vital role of integrating pharmacists

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MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com EDITOR Kelly Jo Eastwood: 00353 (87)737 6308 kelly-jo@ipn.ie ADVERTISING EXECUTIVE Amy Evans: amy@ipn.ie CONTRIBUTORS Dr John Corrigan Laura Dowling MPSI DESIGN DIRECTOR Ian Stoddart Design

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@Irish_PharmNews

IrishPharmacyNews

His appointment has been welcomed by representative bodies who will be looking to engage with him on the numerous issues facing the health service outside of the current global pandemic. Community pharmacists will be seeking reassurances as to his predecessor’s promises on negotiating a new pharmacy contract, amongst other issues. “The Programme for Government commits to talks to expand the role of pharmacies. We are ready to start these talks today and pharmacists are waiting and wanting to do more for their patients. Unlike other health professions, pharmacies are still suffering from severe cuts in their incomes under the nowrepealed FEMPI legislation, which is having a direct impact on the sustainability of existing services. This needs to be addressed urgently. “We hope these promised talks will be progressed quickly so that Irish patients and communities can quickly benefit from enhanced and additional services,” said Darragh O’Loughlin, Secretary General of the IPU.

Page 16: Back to School Market – A full education PUBLISHER: IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

Certainly Covid-19 and the challenges it has brought, and continues to bring, is a daunting prospect for any new government. Coronavirus had been a complicating factor for a healthcare system already facing major challenges Stephen Donnelly told Newstalk’s Pat Kenny Show.

In other news, it has also been revealed that integrating pharmacists into general practice (GP) teams facilitates collaboration to optimise treatment plans for patients with long-term medical needs and alleviate pressures on GP practices. “Our findings clearly demonstrate the possible benefit of introducing general practice pharmacists to the Irish healthcare system. While further study is needed to establish the cost-effectiveness of such an initiative nationwide, implementing it would work towards alleviating the pressure our GPs are under and improving the quality of care for Irish patients,” said senior author Dr Frank Moriarty, a pharmacist and lecturer at the School of Pharmacy and Biomolecular Sciences. Turn to page 12 for the full story

14 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.

This issue also features an extensive look at the Back to School market. Returning to schools being fully open after the Covid-19 lockdown is going to be hard, and harder still to try and predict what it will look like. However their health needs will largely remain consistent and pharmacies should be positioning their stores and educating their teams now in preparation. Turn to page 17 for the full report. Stay safe and enjoy the issue.

Regulars CPD: STROKE: A BLEEDING DILEMMA TEAM TRAINING: PAIN IN CHILDREN EDUCATIONAL: HEPATITIS C FEATURE: WOMEN'S INTIMATE HEALTH PRODUCT PROFILES:

P32 P39 P40 P42 P46

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Cara Celebrate a Milestone Cara Pharmacy recently celebrated a major milestone, as they marked 20 years in business. On July 1st 2000, Cara Pharmacy Bundoran opened its doors and since then, they have welcomed a further 12 pharmacy stores. Managing Director Canice Nicholls said, “We had some big plans for this huge milestone but due to the current guidelines, we have put these plans on hold - but next year for our 21st, we’ll be sure to celebrate!

Canice Nicholas, Aine Cleary, Aoife Mahon, Maureen McGee and Sinead McLaughlin

“A huge THANK YOU to our fab Cara team members. Thank you for all your hard work and service to Cara over the years. We know the last couple of months have been tough but you have met the challenges head on and provided our communities with the care and compassion they have needed in these times.”

Pharmacy ready for ‘Talks’ Fianna Fáil leader Mícheál Martin has been elected Ireland's Taoiseach after rival parties voted to endorse a coalition government. Memberships of three parties agreed to work together putting centre right party Fianna Fáil, centre party Fine Gael and the Green party in coalition with each other. The new Taoiseach has said the fight against Covid-19 will be his government's first priority. Wicklow TD Stephen Donnelly will replace Simon Harris as Minister for Health after Taoiseach Micheál Martin unveiled details of the new coalition Cabinet during a sitting of the Dáil in Dublin’s Convention Centre. The 59-year-old Cork native was elected at a special meeting of the Irish parliament in Dublin. He has been the leader of the Fianna Fáil party since 2011. As Health Minister in 2004, he became the first national government minister in any part of the world to introduce a workplace smoking ban, which also banned the public from lighting up in pubs. Mr Donnelly said that the Sláintecare plan remains the main route to reform of the healthcare system and that the move towards universal healthcare had to be accelerated in response to the Covid-19 crisis. The Irish Pharmacy Union (IPU) has congratulated the newly appointed Minister for Health Stephen Donnelly on his appointment. However, while

welcoming him into the role, the IPU has warned that COVID-19 is just one of many significant challenges he faces. Darragh O’Loughlin, Secretary General of the IPU said. “Minister Donnelly comes into the portfolio with a strong reputation and background knowledge having been his party’s health spokesperson. On behalf of pharmacists across Ireland I congratulate him on his appointment – we look forward to working with him to improve our healthcare system. “Minister Donnelly takes the helm at a very challenging time for health services. With increasing demand due to the ongoing COVID-19 pandemic, as well as the day-to-day health crises, the healthcare system is under unprecedented pressure. However, there are also undoubted opportunities for reform and improvement in how healthcare is delivered, in particular through the implementation of Sláintecare. “This will require resourcing community-based healthcare, including pharmacists, to provide greater levels of patient support,

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monitoring and treatment. The Programme for Government commits to talks to expand the role of pharmacies. We are ready to start these talks today and pharmacists are waiting and wanting to do more for their patients. Unlike other health professions, pharmacies are still suffering from severe cuts in their incomes under the now-repealed FEMPI legislation, which is having a direct impact on the sustainability of existing services. This needs to be addressed urgently. “We hope these promised talks will be progressed quickly so that Irish patients and communities can quickly benefit from enhanced and additional services. “We would also like to thank Minister Simon Harris for his engagements with us during his tenure as Minister for Health. During the pandemic Minister Harris introduced changes which were good for Irish patients, including the electronic transfer of prescriptions from prescribers to the pharmacy and increasing the maximum period of validity of a prescription from 6 months to 9 months. We wish him well in his new portfolio.”

Pharmacists in Vaccinations Pharmacists around the world can now make use of a resource from the International Pharmaceutical Federation (FIP) to help them expand their role in vaccination. The resource, “Give it a shot: Expanding immunisation coverage through pharmacists”, available from today, offers practical guidance on implementing a vaccination service and sets out the roles and technical requirements for pharmacy-based vaccinesrelated services. FIP is making this document freely available to pharmacists and their teams around the world. It makes the case for pharmacy-based vaccinations and presents a compilation of evidence and best practice from around the world. “FIP strongly believes that pharmacists should be involved in vaccination strategies in a multitude of roles everywhere around the world and has given high priority to this area for a decade. In recent years, the number of countries that have introduced vaccination by pharmacists or at community pharmacies has increased. However, barriers and opposition to this expansion of pharmacists’ scope of practice remain in many countries and with this resource, we want to inspire these countries to move forward and individuals to act,” said FIP President Mr Dominique Jordan. He added, “Vaccination is one of the most successful, safe and cost-effective health interventions of all time. Improving vaccination coverage is a global imperative and pharmacists must join these efforts.” In other news, the new dates for the 80th World Congress of Pharmacy and Pharmaceutical Sciences and the 22nd National Pharmaceutical Congress will be 12 – 16 September 2021, and 14-16 September 2021, respectively. Given the current situation with the COVID-19, FIP and its cohost, the General Pharmaceutical Council of Spain, have taken the decision to reschedule FIP’s 80th World Congress of Pharmacy and Pharmaceutical Sciences and Spain’s 22nd National Pharmaceutical Congress. Postponing these has been led by responsibility, trust and solidarity, they said.


News Medicines Coalition The HPRA has endorsed a joint statement on prioritisation of COVID-19 clinical trials published by the International Coalition of Medicines Regulatory Authorities (ICMRA). In their joint statement, international medicines regulators describe the key characteristics of clinical trials that are most likely to generate the conclusive evidence needed to enable the accelerated approval of potential treatments and vaccines against COVID-19. They also set out concrete actions that stakeholders involved with COVID-19 clinical trials should take to collect, analyse and report the data required to determine which investigational or repurposed medicinal products would be safe and effective for the treatment or prevention of COVID-19. Medicines Shortages The Health Products Regulatory Authority has been notified of a shortage of the following products: • Celecoxib 200mg Capsule – PA0711/241/002 • Deslor 0.5mg/ml Oral Solution – PA0711/202/002 • Estradot 37.5mcg/day Transdermal Patch – PA0896/010/001 • Gaviscon Advance Oral Suspension – PA0979/011/001 • Gaviscon Liquid Peppermint Flavour Oral Suspension – PA0979/015/002 • Lipantil 145mg Film Coated Tablet – PA2010/015/003 • Lyrica 75mg Capsule – EU/1/04/279/012 • Stilnoct 5mg Tablet – PA0540/160/001 • TOBI 300mg/5ml Nebuliser Solution – PA2010/063/001 The following shortage has been resolved and supply has resumed to the Irish market: • Amisulpride 200mg Tablet – PA0577/182/002 • Colofac 135mg Tablet – PA2010/007/001 • Neurontin 600mg Capsule – PA0822/015/004 • Septrin Forte 160mg/800mg Tablet – PA1691/010/002 • Valdoxan 25mg Tablet – EU/1/08/499/003 • Vancomycin 500mg Powder for Concentration for Solution for Infusion & Oral Solution – PA1122/008/001

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Huge numbers download Covid-19 Tracker App A new Covid-19 tracker app has been downloaded by more than 1 million people since it went live. The Department of Health and the Health Service Executive launched the app to help identify close contacts of people who test positive for the disease. Acting Chief Medical Officer Dr Ronan Glynn said, "This is one more example of the solidarity and collective spirit that has characterised the Irish public's response to Covid-19 to date. “The app is an important tool to support our contact tracing systems. It has the potential to reduce the time that people are active in the community with infection, which will have

a significant impact on the transmission of the disease. “The more people who download and use this app, the more effective it will be. It is a further opportunity for us to play our part in the response to Covid-19.” As the country reopens, contact tracing and the early identification of symptoms, will become increasingly important as more people are visiting family and

friends, exercising, socialising, shopping, returning to work and using public transport. The Covid Tracker App will allow each individual to play an important part in controlling COVID-19, helping everyone to stay safe and protect each other. The app will record if a user is in close contact with another user by exchanging anonymous codes that are held on the users’ phones.

Our Lady’s toy donation from Lynch’s Lynch’s totalhealth Pharmacy, Kells donated €800 of new toys & slippers to the Children’s Ward at Our Lady of Lourdes Hospital, Drogheda recently. Neil Sokay, proprietor of Lynch’s contacted the hospital to see if the children would benefit from the donation of all new toys and slippers and the response was so positive. Heather Murphy of the Children’s Ward was so excited to accept the donation on behalf of the hospital. Olivia Sokay, Lynch’s totalhealth Pharmacy, Kells, Neil Sokay, Pharmacist, Lynch’s totalhealth Pharmacy, Kells and Heather Murphy, Children’s Ward, Our Lady of Lourdes Hospital, Drogheda

One third of unused medicines are dangerously discarded One third of unused medicines in Ireland are either ‘flushed’ or thrown in bins according to new research from the Irish Pharmacy Union (IPU). This potentially dangerous revelation has led the IPU to call for the introduction of a national medicines recycling programme, known as a DUMP (Dispose of Unused Medicines Properly) scheme across the country to encourage people to dispose of their unused or out-of-date medicines safely. Key findings of the research conducted by Behavior and Attitudes on behalf of the IPU were: • 27% of unused medicines were discarded in bins; • Worryingly, as much as 6% are flushed down sinks or toilets; • Two out of five people were completely unaware of the dangers of incorrect disposal; • Over 65’s are four times more likely to return medicines to their community pharmacy.

Commenting on the findings, community pharmacist and IPU Vice-President Eoghan Hanly said, “There are real and significant risks to health and the environment from improperly disposing of medicines. Whether this is in bins or by flushing down sinks or toilets you are risking contaminating water systems and damaging biodiversity. Ultimately it risks impacting crops, animals and potentially increasing antibiotic resistance among humans. The more widespread the practice the bigger the potential risks.

should be a significant concern to the authorities in this country. To combat this very real threat we are calling on the HSE to urgently implement a nationwide DUMP scheme through local pharmacies to promote safe and appropriate disposal of medicines and allow for easy recycling of inhalers and other medicine devices. Given the low levels of awareness of the environmental risks, a DUMP scheme should include public awareness campaigns to boost compliance.”

“These findings are alarming and

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totalhealth Pharmacies and Safe Ireland join forces As the country moves towards fully re-opening after lock-down, Safe Ireland and totalhealth Pharmacies are launching a community-based initiative called Gateway to Safety, to help ensure that survivors of domestic violence can get access to expert support and advice on their main streets. John Arnold, Managing Director totalhealth Pharmacy, Anne Marie McMorrow, Safe Ireland and Rory O’Donnell, Chairman, totalhealth Pharmacy

People experiencing domestic violence and coercive control, and those close to them, are encouraged to come forward to talk in confidence to the team at their local totalhealth Pharmacy where they can be immediately connected with one of the 39 frontline specialist domestic abuse services across the country for free and confidential support and advice. totalhealth is the largest independently-owned pharmacy chain in Ireland over 80 branches,

many of which have been providing care, advice and support to Irish communities for many decades. The initiative is part of Safe Ireland’s Safe Homes Safe Communities programme, which aims to bring voice and visibility to the issue of domestic violence into communities by bringing together businesses, statutory groups, community organisations and civil society to change the culture of silence that allows domestic violence to continue.

An early hours burglary at Laois Pharmacy in Portlaoise left the owners with a bill for nearly ¤9,000 between stolen goods, cash and damage.

John Arnold, Managing Director of totalhealth, added, “Our pharmacies are rooted in their communities, for generations in some cases. They are involved in caring for local families, their own families have grown up in the area, and they care about the communities in which they live. This partnership is a natural extension of the community support we pride ourselves on.”

Judge Keenan Johnson said their crimes were an attack on rural Ireland. The two men pleaded guilty to stealing highend perfumes and after shave, plus cash. At each premises they smashed the door with a hammer in the middle of the night and loaded the items and cash into bags before driving away.

During the Covid-19 lockdown period, domestic violence was recognised as a national priority. An Garda Síochána has reported a 25% increase in domestic violence cases over the past three months.

The perfumes stolen from a pharmacy in the town of Longford had a cost price of nearly ¤12,000 but would have had a retail value of nearly ¤22,000, the court heard.

The European Medicines Agency (EMA) Management Board has nominated Emer Cooke as the new Executive Director of the Agency. At an extraordinary virtual session on 25 June, the Board selected Emer Cooke from a shortlist of candidates created by the European Commission.

Ms Cooke will now be invited to give a statement to the European Parliament’s Committee on Environment, Public Health and Food Safety (ENVI) on 13 July 2020. The appointment of the new

Executive Director will only be made after that meeting. Emer Cooke, an Irish national, is currently the Director of the Regulation and Prequalification Department at the World Health Organization (WHO) in Geneva, a position she has held since November 2016. In this role she leads on WHO’s global work on health technologies regulation, including prequalification, regulatory systems strengthening and safety activities. Her role also covers assurance of quality, safety, efficacy and performance of health technologies in close conjunction with member states and international partners.

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Two Romanian men, Sorin Aurelian Damaschin, 30, Crumlin Road, Dublin 12 and Matei Siminica, 30, of no fixed abode have been sentenced to 7 years in prison, with the final 2 years suspended, for offences across seven counties from pharmacies in counties Longford, Roscommon, Meath, Laois, Tipperary, Wexford and Waterford.

Commenting on the partnership, Rory O’Donnell, chairperson of totalhealth, said, “It’s so important that people who may have been living with an abuser know that help is available and that their community supports them. We are delighted to be able to join with Safe Ireland and its members in all of our communities to provide a safe, confidential gateway to professional domestic violence advice and supports.”

Emer Cooke to head up EMA

Emer has now become the first woman to lead the powerful regulatory body. The appointment comes at a crucial time for the agency, as it may take up an increasing role in securing supplies of medicines and streamlining research into new drugs as the European Union bids for increased powers in health to avoid pharmaceutical shortages and improve its future pandemic response.

Pharmacy Robbers Jailed

Ms Cooke has 30 years’ experience in international regulatory affairs, 18 years of which were in leadership roles. She worked for the pharmaceutical unit of the European Commission from 1998 to 2002 and at EMA between 2002 and 2016, where she held positions including Head of Inspections and Head of International Affairs. Ms Cooke holds a degree in pharmacy from Trinity College, Dublin in Ireland. She has additional Masters degrees in Science and in Business Administration, also from Trinity.

Laois Pharmacy was one of a number targeted by the men and a sitting of Circuit Court in Tullamore heard the value of stolen goods, cash and damage caused was about ¤128,000.

The total value of goods and cash stolen from a pharmacy in Cahir, Co Tipperary was over ¤35,000 while pharmacies in Enfield and the town of Roscommon were at a loss of nearly ¤11,000 in stock each and the cost price of stock stolen from a similar business in Dungarvan was over ¤28,000. The court heard with the exception of ¤100 worth of sunglasses taken from one pharmacy in Enniscorthy, nothing was recovered. The men were captured on CCTV wearing masks and gloves during the raids but in a couple of instances they were recorded looking at premises the day before the burglaries.


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Patient trust in Pharmacy remains high New research published this month, has shown that pharmacists are the second highest health professionals trusted most by patients as sources of information about a COVID-19 vaccine. Paul Reid, Country Manager, Pfizer Healthcare Ireland

Furthermore, the pharmacy was favoured by 91% of people as a convenient place to get a COVID-19 vaccine, according to the survey, followed by the doctor’s surgery, at 89%, and the nearest hospital at 59%. Almost three in four people are likely to get a COVID-19 vaccine if one is found, according to the results of the survey carried out by Ipsos MRBI for the Irish Pharmaceutical Healthcare Association which represents the originator biopharmaceutical industry. The survey found that 52% are very likely to get a COVID-19 vaccine while 21% are fairly likely. Almost one-fifth, or 17%, are unlikely to get the vaccine while 10% are unsure. Over four-fifths, or 81%, of people believe a COVID-19 vaccine will be found. But most of those people, or 62%, believe it will be next year before one is available to the public. Just 11% believe a COVID-19 vaccine will be available this year. One-quarter of people believe it will be 2022 or later before a COVID-19 vaccine is available. Over four-fifths, or 83%, of people believe certain groups should be prioritised when it comes to getting a COVID-19 vaccine. Frontline healthcare workers are most favoured by the public for prioritisation, with 75% of respondents saying they should get a COVID-19 vaccine either first or second. The next group prioritised by the public for a COVID-19 vaccine were people with underlying health conditions, followed by the over-70s. Of the four groups presented, the lowest priority was given to the under-18s. The survey found that the demographic groups most likely to get a COVID-19 vaccine when it is available are the over-55s, scoring 80%, and people who have either had COVID-19 or know someone who had the disease, registering 78%. According to the survey, the biggest potential barriers for

those unsure or unlikely to get a COVID-19 vaccine were that it would be too new or concerns about side-effects. Doctors and nurses emerged as the most trusted sources of information about a COVID-19 vaccine. Almost all respondents, or 94%, said they would trust them with the facts while 91% would trust healthcare experts. Pharmacists were next, at 88%, while patient groups scored 67%. Politicians and social media were the least trusted, registering 38% and 10%, respectively. The mainstream media were trusted with the facts by 48% of respondents. The pharmacy was favoured by 91% of people as a convenient place to get a COVID-19 vaccine, according to the survey, followed by the doctor’s surgery, at 89%, and the nearest hospital at 59%. The survey found that the biopharmaceutical industry has a 51% public approval rating - up seven points since Ipsos MRBI asked the same question in September 2018.

Paul Reid, Country Manager, Pfizer Healthcare Ireland, says, “At Pfizer, we are committed to developing potentially groundbreaking vaccines and medicines and we are collaborating across the health ecosystem like never before to meet this commitment. The virus and time are our enemies – and nothing unites humankind like a common enemy. The results from the IPHA Ipsos-MRBI survey reflect the strong expectation and appetite from the public for a COVID-19 vaccine. Globally, in collaboration with BioNTech, Pfizer is working at an unprecedented pace to research, develop and test a potential mRNA-based vaccine that, if approved, could be deployed at unprecedented speed for the prevention of COVID-19 infection. At the same time, we are actively scaling up our manufacturing capacity and distribution infrastructure to be ready to bring a candidate vaccine to the world faster than we have ever done before.” Jon Barbour, Director of Medical Affairs at GSK, added, “It is heartening to see the high levels

of favourable vaccine sentiment expressed in the research and that most people would avail of a COVID-19 vaccine once available. GSK believes the world needs several vaccine development programmes to successfully fight COVID-19 and therefore we are collaborating with several companies and institutions to make our pandemic adjuvant technology available to those working on promising vaccine candidates.”  88% trust pharmacists as sources of information about a COVID-19 vaccine  91% of people favour the pharmacy as a convenient place to get a COVID-19 vaccine  81% believe a vaccine will be found - but 62% of them believe it won’t be publicly available until next year  75% say frontline healthcare workers should be either first or second to get a vaccine

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New Managing Director for Navi Retail Navi Group, which owns the Axium Buying Group, and the CarePlus and StayWell retail brands, has appointed Eoin McCormack as its Managing Director for Navi Retail. Eoin has over 20 years leadership experience in the retail, wholesale and foodservice industry and has held many senior roles during his time with Musgrave Group. These included time as Managing Director of Superquinn and Donnybrook Fair. His role at Navi Group involves supporting and growing the CarePlus and StayWell pharmacy brands. Eoin McCormack, Managing Director, Navi Retail

Eoin says, “At Navi Retail we are all about working in partnership with independent community pharmacists. Our mission is to empower pharmacists to help their customers lead healthier and happier lives. We deliver on that mission everyday through our various product and partnership solutions. Our CarePlus and StayWell brands provide the help and support pharmacists need to ensure their businesses continue to grow and prosper. “Other players in the general retail sector have proven the power of partnership models and how they can enable independent

operators to compete and win against the large corporate brands. Navi Retail will continue to create mutually successful partnerships with the hundreds of independent community pharmacists throughout the country through the buying group and its retail pharmacy brands which are tailored to local pharmacists requirements.” CarePlus Pharmacy recently announced that it intends to double its number of outlets across Ireland to 120 by the end of 2021. StayWell is Ireland’s newest pharmacy brand for independent pharmacists who want enhanced independent branding with IT and training support. Next month’s issue of Irish Pharmacy News will carry a full profile of one of their newest store offerings.

Supporting Pharmacy Never has there been a more important time for the existence of the correct mechanisms to support community pharmacists and their teams as they deal with the global pandemic on the frontline. Allcare Pharmacy Territory Manager Louise Mooney is pictured on one of her regular visits

This is especially true for Allcare Pharmacy Group as their Allcare Territory Support systems have been proving crucial.

Support services from Allcare’s Territory Managers have proved vital during the COVID-19 pandemic. Pictured with Louise is

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Adrian Crehan, owner of Allcare Galtymore Road. Commenting on how necessary these supports have been, Adrian says, “It’s always important to have the security of Allcare’s territory manager but not least over the past few months. It’s been fantastic and has brought great peace of mind.” Supports such as, on the ground operational support, business intelligence reporting, retail expertise, marketing, training, regulatory and buying have been highlighted by Allcare pharmacies nationwide, as being essential hallmarks for protecting patients and customers and driving the pharmacy business forward.

New Analysis from HIQA The Health Information and Quality Authority (HIQA) has published a report examining the number of excess deaths that occurred during the current COVID-19 epidemic. This analysis has been provided to the National Public Health Emergency Team (NPHET) to inform the national response to COVID-19. The report assesses the number of deaths that occurred in Ireland from 11 March 2020 to 16 June 2020, relative to the expected number of deaths, using data from the death notices website RIP.ie. It also examines whether the reported COVID-19 death figures provides an accurate estimate of excess deaths during the epidemic. HIQA’s Chief Scientist, Dr Conor Teljeur, said, “There is clear evidence of excess deaths occurring since the first reported death due to COVID-19 in Ireland. There were about 1,100 to 1,200 more deaths than we would expect based on historical patterns; a 13% increase between 11 March to 16 June. However, the number of excess deaths is substantially less than the reported 1,709 COVID-19-related deaths over the same period.” HIQA found that the officiallyreported COVID-19 deaths likely overestimates the true burden of excess deaths caused by the virus. This could be due to the inclusion within official figures of people who were infected with SARS-CoV-2 (coronavirus) at the time of death whose cause of death may have been predominantly due to other factors. He continued, “In the last four weeks of the analysis, we have seen a reversal of that trend with fewer deaths than expected. However, it is also possible that the changes to healthcare delivery during the COVID-19 epidemic, such as the suspension of elective activity in public acute hospitals, may have a lasting impact on health outcomes, the effect of which may take years to be seen.”


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Cybersecurity – Safeguarding Pharmacy Are you alert to the cyber threat? - How safe is your pharmacy system and your patient data? As the pharmacy owner is the Controller of the data which they hold – both for their own employees and their patients – the responsibility to keep this data safe rests with them. 41% of Irish firms have experienced at least one cyber attack event in the six months from September 2019 to February 2020, according to recent report by the Hiscox Insurance Group. In addition, 6.5% of Irish firms had to pay a ransom following a ransomware attack, with the median cost of these attacks around ¤92,000.

comments from organisations which can help you improve your defences to cyber attack. 95% of all successful cyber attacks are caused by human error – are you and your staff doing everything you can to protect your patient data?

The cybersecurity landscape is continually changing and evolving, and cybercriminals are increasingly targeting private companies. This means that having good cybersecurity strategies and practices in place is more important than ever. A cybersecurity breach can wreak havoc on any pharmacy business.

• Only 26% of Irish internet users regularly change their passwords

In the next issue of IPN we will be looking in depth at the chief threats to your business, with links to and

• 57% of Irish people admit to opening emails from people they don’t know

• 7% were victims of Ransomware In recent years, England’s largest NHS trust was crippled as their entire IT system was assaulted by online hackers trying to copy, steal and lock access to confidential patient data. We look forward to bringing you a comprehensive overview of the

internet security issues and areas which you might wish to consider in a review of your own business. In the meantime, consider doing the following – changing

passwords, restricting internet usage, ask your PMR provider about ways to improve your security and train your staff on common internet dangers.

Transforming research into practice Researchers from The Irish Longitudinal Study on Ageing (TILDA) at Trinity College Dublin in partnership with the National Clinical Programme for Older People (NCPOP) have demonstrated an innovative system where evidencebased longitudinal research has been transformed into clinical practice to improve national patient care. A paper published in the Journal of Aging and Social Policy outlines how TILDA delivers the Recognising Frailty: Insights from TILDA education programme and has partnered with NCPOP to deliver a National Frailty Education Programme, which has now been completed by over 2,000 health care professionals in Ireland. Frailty is a common clinical syndrome that predisposes older

adults to an increased risk of adverse health outcomes such as falls, incident disability and hospitalisation. Previously released research from the Central Statistics Office, projects that Ireland will have close to 1.6 million people aged 65 and over by 2051. A growing ageing population will present increasing challenges for healthcare services. Different models of healthcare training and

provision are required to address these increasing demands. Dr. Diarmuid O’Shea, Consultant Physician in Geriatric Medicine at St Vincent’s Hospital, Dublin and co-author of the paper said, “One of the aims of the National Frailty Education Programme is a cross organisational collaborative approach to promote system-wide education and to encourage participation by

everyone delivering care to older people. This will equip healthcare professionals and workers with the knowledge to ultimately provide the right care, in the right place, at the right time, in line with the national Sláintecare policy. The National Frailty Facilitators play a vital role as they are championing this change and promoting a new way of working within and across their organisations.”

Clonmel Healthcare appointed distributor for Thermacare® We are pleased to inform you that Clonmel Healthcare has been appointed the distributor for the brand ThermaCare® by Angelini’s ThermaCare® partner in Ireland Carysfort Healthcare. Clonmel Healthcare will be distributing ThermaCare® from 1st July 2020. ThermaCare® is a medical device which delivers controlled therapeutic heat for 8 hours, right to the site of pain. For further information, please contact Clonmel Healthcare on 01 6204000 2020/ADV/THE/040H. Date prepared: June 2020

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News

Integrating Pharmacists Can Optimise Patient Care Research undertaken by RCSI University of Medicine and Health Sciences suggests that integrating pharmacists into general practice (GP) teams facilitates collaboration to optimise treatment plans for patients with long-term medical needs and alleviate pressures on GP practices. Professor Susan Smith, Professor of Primary Care Medicine, RCSI Department of General Practice

The study was conducted by researchers in RCSI's Department of General Practice and School of Pharmacy and Biomolecular Sciences. General practitioners (GPs) frequently manage medications for patients with multiple complex health conditions, further complicated by long-standing prescriptions from previous doctors and the evolving nature of treatment. Pharmacists are well placed to assist with this, working collaboratively with GPs to decide on the most appropriate treatment options. Although not yet introduced in Ireland, general practice pharmacists are common in other countries and have been shown to provide essential support to GP teams, with the potential to optimise treatment and lower costs. The pilot study led by RCSI is the first evaluation of pharmacists in this role in Ireland. Researchers selected four GP practices with approximately 35,000 patients to participate in the study over a six-month period. During this time, pharmacists were integrated into and worked in these practices reviewing prescriptions to support existing GP teams. They flagged 786 patients who had 1,521 potential issues relating to medication effectiveness or concerns over possible side effects. The most common medications involved were proton pump inhibitors

used to suppress stomach acid, benzodiazepines used to treat anxiety or insomnia and anti-inflammatory drugs. Over 50% of these issues resulted in a change being made by the patient's GP, such as reducing the dose or ending a prescription where the risks outweighed the benefits or the medication was no longer necessary. Overall, the changes to prescriptions in the four GP practices amounted to potential cost savings of approximately ¤57,000 each year. “Our findings clearly demonstrate the possible benefit of introducing general practice pharmacists to the Irish healthcare system. While further study is needed to establish the cost-effectiveness of such an initiative nationwide, implementing it would work towards alleviating the pressure our GPs are under and improving the quality of care for Irish patients,” said senior author Dr Frank Moriarty, a pharmacist and lecturer at the School of Pharmacy and Biomolecular Sciences. Leading the study alongside Dr Frank Moriarty are GP and Professor of Primary Care Medicine, Professor Susan Smith and research lecturer Dr Barbara Clyne, both from the RCSI Department of General Practice. “As demands on primary care increase, integrating pharmacists into GP practices has the potential to bring a more closely integrated

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"As demands on primary care increase, integrating pharmacists into GP practices has the potential to bring a more closely integrated model of care to patients with multiple complex needs"

model of care to patients with multiple complex needs. The best patient care in general practice includes multidisciplinary collaboration across healthcare professionals and I look forward to further studies in this area to explore the feasibility of introducing this practice in Ireland,” said Professor Smith. The research is supported by the Health Research Board (HRB), the Health Service Executive's National Quality Improvement team (HSE NQI Team), and the Royal College of Physicians of Ireland (RCPI) Research Collaboration in Quality and Patient Safety fund. Reference: Cardwell K, Smith SM, Clyne B, et al. Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study. BMJ Open 2020; 0: e035087. doi: 10.1136/bmjopen-2019-035087

Restore the Balance Last month saw International Men’s Health Week, and boys and men were encouraged to take time and ‘restore the balance’ as we emerge from the Covid-19 crisis. The Irish Pharmacy Union (IPU) has encouraged men to visit their local pharmacy for practical advice on a range of topics from health issues to fitness and nutrition. According to community pharmacist and IPU member Tomás Conefrey, “Men can often ignore concerns and miss signs of potentially serious healthcare problems. As part of International Men’s Health Week, we want to encourage men to speak up and seek advice when they need it. “The COVID-19 crisis has been challenging for everyone in Ireland, men and women. But it has also allowed many of us time to refocus on our wellbeing, introducing healthier work life balances and understanding what is important in life. As we begin to emerge from the crisis, men should maintain this focus and act consciously to ‘restore the balance’ in ways that work for them. “We would like men to know there is help available from your community pharmacy for any supports you might require. Local pharmacists can offer advice on topics including weight loss, how to quit smoking and managing mental health issues. Pharmacists can also provide advice on how to better manage conditions such as diabetes, asthma and high blood pressure. “Too often, men look for excuses rather than solutions to the problems that challenge them. Pharmacy staff are well positioned to talk to men about their health needs, explore possible options and, when necessary, suggest that they may need to seek further expert assistance.” Men’s Health Week is celebrated across Europe and in many other countries around the world.


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News

Boots Galway brings stores to 89 As part of Boots’ continued investment into the growth and expansion of stores around the country, the company is proud to announce the opening of its third store in Galway, bringing the total of stores across the Republic of Ireland to 89. Boots Galway Pharmacy store Manager David Boyce with Boots Ireland Managing Director Bernadette Lavery cutting the ribbon at their new store in Kocknacarra The health and safety of customers, patients and colleagues remains the highest priority and the Boots Knocknacarra team have been working incredibly hard to ensure that the store and pharmacy is the safest place for customers to shop, in line with government guidelines. Safety measures include a queueing system to control the number of people in the store at any one time and clear signage throughout the store to help maintain social distancing. Every purchase made in the store will be done in the safest way possible, with Perspex screens for counters, tills and self-checkouts.

Customers visiting the new store will have access to a full pharmacy service, including expert pharmacists who will be on hand to offer trusted advice and help with prescriptions. The impressive 478sqm of space will facilitate a wide range of health and wellness products, as well as top beauty brands including No7, Clinique, NYX Professional Make Up, and many more!

There are also free car parking spaces for Boots customers, meaning these services are even more accessible for the residents of Galway.

Customers will also be able to avail of the Boots Order and Collect service for ease and convenience, with all colleagues having access to the PPE they need to ensure they are safe to serve customers.

At this unprecedented time, Boots Ireland recognises its role as a valuable resource for patients and customers who are seeking support, reassurance and information.

Store Manager David Boyce is excited about the opening and what it can offer Galway: “We are delighted to open the doors to our new Boots Ireland store in Knocknacarra.”

New Approaches in Epilepsy Researchers have identified a critical new step in how brain cells function in people with one of the most common forms of epilepsy. This could lead to new treatment approaches for people with drug-resistant epilepsy. The study was led by researchers at FutureNeuro, the SFI Research Centre for Chronic and Rare Neurological Diseases, hosted by RCSI University of Medicine and Health Sciences with colleagues at Severo Ochoa-Centre for Molecular Biology (CBMSO) of Madrid and Institute for Research in Biomedicine (IRB) of Barcelona. Changes in gene activity are known to be important in the development of epilepsy. Normally, a molecule called messenger RNA is produced when a gene is active. This becomes the template for the production of the proteins that brain cells use to function. A critical step is the addition of a short sequence called a poly(A) tail. This has never been studied before in epilepsy. The team

discovered that this tailing process (polyadenylation) is dramatically altered for about one third of the genes of someone with epilepsy, changing protein production in the brain. “Our discovery adds another piece to the puzzle to help us understand why gene activity is different in someone with epilepsy,” said Dr Tobias Engel, FutureNeuro Investigator and Senior Lecturer in the School of Physiology and Medical Physics at RCSI. “It is remarkable that so many active genes in the brain show a change in this polyadenylation process. We believe that this could ultimately lead us to new targeted treatments, allowing us to investigate if we could stop a person from developing epilepsy.”

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Epilepsy is one of the most common chronic brain diseases, affecting over 65 million people worldwide. While current drug treatments are usually effective in suppressing seizures, they do not work in one third of people with epilepsy and have no effect on the underlying causes of the disease. “Regulated poly(A) tailing of messenger RNAs is a step in gene expression regulation barely explored in brain diseases, and our study should foster its investigation in other brain conditions in which gene expression alteration is suspected,” said Dr José Lucas, Research Professor at Severo Ochoa-Centre for Molecular Biology of Madrid.

Opiods most common drug problem The Minister for Public Health, Wellbeing and the National Drugs Strategy, Frank Feighan TD, has acknowledged the publication of the Health Research Board's (HRB) latest research into treated problem drug use in the seven year period 2013-2019. The National Drug Treatment Reporting System has shown an overall increase of 1,658 or 18% in the number of treated cases recorded between 2013 and 2019. These figures highlight the levels of increased demand for drug treatment services nationwide. Between 2018 and 2019 there was an increase of 3.8% or 390 cases in the number of cases presenting for treatment. Opioids continue to be the most commonly reported main problem drug at 39%, followed by cocaine and cannabis at 24% and 23.5% per cent respectively. Opioid use has decreased from 51% of cases treated in 2013 to 39% of cases treated in 2019. The increase in cocaine use stands out. It has increased from 8% of cases in 2013 to 24% of cases in 2019. The Minister of State with responsibility for Public Health, Wellbeing and the National Drugs Strategy Frank Feighan, said, “I welcome this data which has been released today by the HRB as it clearly illuminates a worrying development in relation to the continuing rise of cocaine use and crack cocaine use in Ireland. “The HRB data also highlights significant decreases in opioid use and just how well drug treatment services nationwide have responded to the increased demand. The investment in treatment services over the last number of years under Reducing Harm Supporting Recovery has enabled us to increase the capacity to meet the extra treatment demand.” The HRB plays an important role in supporting high quality monitoring, evaluation and research to ensure policies and practices are evidence informed.


Back2School

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Alcohol hand sanitizer The teen drug of choice If we could strip away the caricature images that flash to mind whenever Mr Trump offers his scientific insight, we should realise that he may be onto something here! Sanitisation practises are not going away anytime soon and with the qualified experts speaking of a possible second wave, now is the time to prepare. Written by John Fogarty BSc Pharm In order to make an educated decision moving forward we need to be able to predict and be aware of potential pitfalls and risks associated with each product. A good place to start would be with those who are least worried about the dreaded COVID-19 – the young people of this country.

as a result are at risk of accidents and exposure to poisons."

With the schools set to reopen the novelty of Covid-19 may begin to fade with the students even if the threat of the virus will not. The new trend with the young people? Maybe ingesting the alcohol based-sanitizers, inhaling the unusual odour of mutagenic compounds or even squirting the sanitizer at your colleague’s face and eyes.

"We would like to remind parents and guardians that all medicines, cleaning agents and hand sanitisers should be kept securely out of the reach of young children, as these can be very dangerous."

In a report carried out on adverse health effects in children due to alcohol-based sanitizers from 2011 – 2014 in America, 70,669 exposure events were recorded. 90% of these exposures occurred in children under the age of 5. However, more intentional ingestions of the sanitizer were seen in the 6 – 12 years age bracket with yet another significant increase of intentional ingestions seen in students from 12 – 18 years of age. These figures tell a story and shine a light on the older and bolder mentality of young adolescents. We were all young once and we can all recall how the approval of our friends and peers outweighed any other aspect of growing up – whether that be skipping a class, talking back to authority or even swallowing a bottle of alcohol sanitizer in an attempt to become “drunk”. If this can happen in America, surely a country with an alcohol-embracing culture such as ours is at an even higher risk of adverse events due to ingestion. Children's Health Ireland (CHI) has reported that the number of kids admitted due to poisoning during the coronavirus lockdown doubled in March. It said on April 10, "We know that children are inquisitive and adventurous and

Ireland's paediatric emergency departments "have noted an increase in children presenting with accidental ingestions of medicines and household items during the past few weeks.

Not to mention when these young adolescents begin to develop a social life. It is during this phase that the desire for popularity is at its highest. Every student in the country has his own tale of a friend or a classmate who had to be carried out of the local teenage disco having consumed too much alcohol earlier in the night. Keep in mind that sanitizer is going to be everywhere for young people to access. If we are going to have hundreds of litres of sanitizer available at cinemas, discos and GAA clubs, we had better make sure it is the safest one. It is not to say that all this behaviour is in bad spirit. Sanitizer sales have increased by 792% since the outbreak of the Pandemic earlier this year. With the vast volumes of product being used, it is only natural that more accidents are going to happen. It is our job to be informed and make sure the severity of these incidents are managed. Not all sanitizers are created equal and although the risk of ingestion may apply primarily to alcohol based products, it would be negligent to focus solely the risks associated with ingestion. Let’s take a chlorohexidine product for example. The toxicity resulting from ingestion of one of these products is significantly lower than alcohol but what about the eyes and the skin? There is

a high risk of ocular and dermal irritation with these products not to mention that they are absorbed through the skin and potentially can damage our organs. Compared to the hypochlorous acid products which are nonirritating, pH neutral, and safe if ingested, it seems an obvious choice once the research is done. Contact dermatitis and eczema outbreaks are going to be more prevalent than ever due to the increased use of these products. The sense of discomfort experienced when an irritating sanitizer product is applied to cracked or broken skin is not well tolerated by anyone, never mind children. And of course increased pain and irritation will result in non-compliance and less sanitization practise which will equate to more transmission and spread of the virus – which is the point of all this in the first place! While it may be possible to selfisolate and lower the transmission of the virus, there is no escaping the changes that it will bring to everyday life for the foreseeable future. We should commend

ourselves for our efforts this far in adhering to the guidelines, but it is also important that we open our eyes to the less obvious dangers that may present due to the increased availability of sanitizer products. The country is almost ready to restart and when the school gates open we will no longer be able to keep an eye on our children 24 hours a day. It is our job to minimise the possible risks associated with the increased availability of sanitizer by doing the necessary research. The time to prepare is now, and fail to prepare, prepare to fail. https://www.cdc.gov/mmwr/ volumes/66/wr/mm6608a5.htm https://www.pharmacytoday.org/ article/S1042-0991(17)30602-3/pdf https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3408316/ https://www.mdpi.com/16604601/17/9/3326/htm https://www.ncbi.nlm.nih.gov/books/ NBK144008/ https://community.aafa.org/blog/ eczema-wash-hands-coronaviruscovid19-prevention

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Back2School

Pharmacy ‘Education’ on the School children Market As summer comes to a close, there is always a lot to be done to get kids ready to go back to school. Returning to schools being fully open after the Covid-19 lockdown is going to be hard, and harder still to try and predict what it will look like. When children do return it will be to a very different experience than before and will carry greater complexities. However what will remain the same is the health and care of school children as they re-integrate with their peers and continue with their lifelong learning. This special feature takes a closer look at some of the most common presenting issues, ranging from headlice to hayfever and from injuries to skincare. Parents can help their kids have a great school year by making sure they are healthy and ready to learn – because healthy students are better learners. However, getting kids ready to start the school year involves more than finding the perfect backpack, buying school supplies, and shopping for new clothes. It means safeguarding their health so they’ll be physically ready for the challenges.

For community pharmacists, the event leads to opportunities for effective front of shop category management. Now is the time for retail pharmacies to get ready for the onslaught of pharmacy needs that crop up among their younger patients as they return to school. Children, ‘tweens, and teens cannot be underestimated, and need to be treated with importance. Pharmacists have a key role to play in advising the younger generation on how to take medications and how to stay away from toxic medications. Back to school is an opportune time to enhance that discussion. Providing customers with easy to navigate back-to-school sections in community pharmacy, with relevant point of sale and prominent window displays during August and September, will help remind parents and carers that preparation is key when it comes to the management of back-toschool self-treatable conditions.

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In addition, many parents worry about whether they should keep their children at home or send them to school when they are ill. Pharmacy teams should be prepared to ask appropriate questions and offer advice to help them to make that decision. For example, does the child seem well enough to carry out the usual day-to-day activities they would at school, or is their condition serious or contagious enough to be passed on to classmates or teachers? Helping people to make such decisions will add to their self care skills and knowledge for managing coughs and colds.

flu symptoms, there are many self-treatable conditions that can hit families hard when September comes. Consider these commonly presented concerns when thinking about your front of shop and category management within the community pharmacy.

Highlighting the availability of products, giving advice for back to school ailments and communicating the principles of self care to parents is an important service that community pharmacy offers families as the first port of call.

Nasal allergy in children, if unrecognised or badly managed, can have a significant toll on emotional as well as physical well-being.

From head lice and rotavirus, to stomach upsets and cold/

Managing Allergies The sun may still be out, and September historically sees some of our sunniest weather, so children will be out playing sports during school. This increases the risk of not only sports-related injuries but also exposure to allergens.

Kids allergies can leave sufferers incredibly troubled when it comes to getting through the school day. Itchy eczematous skin, snuffly


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Back2School • Dust irritation: reducing dust in the home will be helpful to most allergic family members. At school, children with allergy problems should sit away from the blackboards to avoid irritation from chalk dust. • School pets: furry animals in school may cause problems for allergic children. If your child has more problems while at school, it could be the class pet. • Asthma and physical education: sports are a big part of the school day. Having asthma does not mean eliminating these activities. Often medication administered by using an inhaler is prescribed before exercise to control their symptoms. Children with asthma and other allergic diseases should be able to participate in any sport the child chooses – provided the doctor’s advice is followed.

and irritable noses and wheezy chests, carry a significant burden of ill health. Dr Paul Carson of the Slievemore Clinic Ireland says, “If the nasal allergy is especially troublesome the child may get intermittent hearing loss. One day he’s bright and alert in class, inter-reacting and co-operating. Next day he seems distant and detached, ignoring questions or not fully grasping what’s going on. The teachers are at a loss to explain these variations in attentiveness and the boy’s parents can’t quite understand the situation either. It’s not uncommon for these children to be labelled ‘difficult’.

(factual, conceptual and knowledge application) compared with healthy children. • May suffer sleep apnoea, snoring and disturbed sleep pattern. This in turn leads to daytime drowsiness, grumpy mood and poor school performance. • In severe cases it may cause or at least contribute to attention deficit hyper-activity disorder (ADHD). • May cause impaired hearing if fluid collects in the inner ear (medical term: serous otitis media).

“Nasal allergy also provokes intense fatigue. If an affected child is not treated he misses out on ordinary children’s activities and can be isolated and ignored.

• May suffer repeated ‘head colds’ that go down to the chest (which is really an untreated nose and sinus allergy triggering early asthma).

“The term Allergic Irritability Syndrome (ARS) has been coined to explain the many unpleasant symptoms and features children with untreated nasal allergy show.”

• Nasal blockage and irritation (sneezing, rubbing at the nose to relieve itch); dark circles around the eyes with puffiness of the lower lids.

Children with un-recognised ARS have:

• Poor concentration; disruptive behaviour and unexplained mood swings.

• A significantly impaired quality of life. • Significant learning difficulties. • A lower ability to achieve different types of knowledge

Below are the common effects of persisting nasal allergy in children. Nasal Congestion Sometimes a child’s nose is

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congested (obstructed) to the point that he or she breathes through the mouth, especially while sleeping. If the congestion is left untreated this forces air currents through the mouth. The strength of the air changes the way the soft bones of the face grow. The features may become abnormally elongated in a pattern called ‘adenoidal face’. This causes the teeth to come in at an improper angle as well as creating an overbite. Braces or other dental treatments may be necessary to correct these problems. Nasal allergy and ear infections Nasal allergy can lead to inflammation in the ear and may cause fluid accumulation which in turn can trigger ear infections and decreased hearing. If this happens when the child is learning to talk, poor speech development may result. Hayfever can also cause earaches and ear itching, popping and fullness (‘stuffed up ears’). Nasal allergy while at school Nasal allergy can last throughout the school year. For some kids this means absences due to allergy flares. Here are some of the problems to look out for so that the condition can be properly diagnosed and treated, as well as several suggestions for helping the allergic child.

• Dry air: with the onset of cold weather using a humidifier to accompany forced air heating systems may be helpful in some regions of the country. Adding a small amount of moisture to dry air makes breathing easier for most people. However, care should be taken not to allow the humidity above 40%, which promotes the growth of dust mites and mould. • Change in behaviour: children cannot always vocalise their annoying or painful symptoms. Their discomfort may manifest as behaviour problems. Be on the alert for possible allergies if your child has bouts of irritability, temper tantrums or decreased ability to concentrate in school. These may be signs of ‘allergic irritability syndrome’ caused by nose and ear symptoms in allergic children. Sometimes allergic children are badly behaved and have short attention spans. Needless to say their schoolwork suffers. When a child’s allergies are properly treated, his symptoms, behaviour and school performance can improve dramatically. Urge parents to check the expiration dates on their children’s EpiPens Sports and Injuries It is important to have a healthy supply of allergy products on hand, such as nasal sprays and antihistamines. Exercise-induced asthma can also surface and so pharmacies should advise on the importance of having a rescue inhaler on hand, both at home and in school. This is expecially true for children ages 4 to 9.


    

  

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Back2School It’s also important that pharmacy staff keep up to date with first aid training, including administration of adrenaline/ epinephrine auto-injector. Sports-related injuries will also be common and so ensure your pharmacy is stocked with a ready supply of external analgesics and hot and cold treatments. First aid is easy to learn, easy to remember and easy to do. Pharmacists have the opportunity not only to demonstrate how easy first aid is, but also to advocate for the public to learn more themselves Cuts, scrapes, and bruises are among the most common injuries, and no family member is safe from minor accidents. Fortunately, these injuries usually can be treated at home without a doctor visit. Pharmacists need to be able to advise patients on how to treat these injuries if medical attention is not necessary, as well as to counsel patients as to when they should seek medical attention. Scrapes (or abrasions) are wounds in which layers of skin are scraped or torn. The most common sites for scrapes are the hands, elbows, and knees. These injuries often are the result of a fall. Although the scrapes may ooze blood, bleeding does not always occur. Objects penetrating the skin cause cuts (or lacerations). Depending on the depth, cuts often will bleed. Bruises are the result of hard contact with a person or an object. The impact causes an injury to the tissue beneath the skin, and blood from the injury settles near the skin. Bruises usually start out looking red, then within a few hours turn blue or purple, and finally appear yellow as they fade. Treating Cuts and Scrapes Minor scrapes and cuts are easily treated at home with basic woundcare or first-aid supplies. Because cuts can happen at any time, every home should have tweezers, gauze pads, bandages, and antibiotic ointment. Here are some steps that pharmacists should tell patients to follow in treating cuts at home: • Rinse a cut with cool water • Wash around the cut with soap; avoid getting soap into the wound • Remove dirt and debris from the wound with tweezers; clean the tweezers with rubbing alcohol before using them • Apply direct pressure with a clean gauze pad to a bleeding cut • Treat the cut with antibiotic ointment

• Cover the cut with a bandage (deeper cuts may require a butterfly bandage) • Do not pick at a scab while a cut is healing Treating Bruises Although bruises can be painful, treatment is limited. The best care for bruises involves rest and ice. Ice stops blood flow to the injury site, thus limiting the size of the bruise. Rest allows the site to heal. Here are some further guidelines for patients for treating bruises at home: • Apply ice packs or cold compresses as soon as possible • Reapply ice packs every hour for 10-15 minutes during the first day, if needed • With bruised legs or feet, elevate the legs as much as possible during the first day • Take acetaminophen, if needed, for pain; do not take aspirin • With large bruises, limit activity during the first day • Use heat packs after 48 hours to promote healing Here are some signs that bruises need medical attention: • The bruise swells • The bruise does not start to fade within a week • The bruise occurs easily or for no obvious reason Missing School September is Eczema Awareness Month and recent research has shown that 26% of parents and carers of children living with eczema reported that their children miss up to 1-2 days of school each month. Eczema is a chronic skin condition that affects 1 in 5 children and 1 in 12 adults in Ireland. The research, carried out by the Irish Skin Foundation, also found that 86% of parents of children with eczema reported interrupted sleep, as a result of the skin condition. According to the Irish Skin Foundation, atopic eczema occurs when the skin's protective barrier

is weakened allowing moisture to be lost, and irritants and allergens to pass through the skin more easily. Some common everyday substances, such as soap, bubble bath, shampoo, laundry detergents, fragrances, may irritate the skin and should be avoided. Instead, soap-free products and specially formulated products should be used on the skin. Consultant Dermatologist with La Roche-Posay, Dr Niki Ralph who treats patients living with eczema says, "The physical effects of eczema, including painful, inflamed itchy and cracked skin, may result in a range of hidden psychological impacts. These range from families with young children who are in such pain or discomfort that their sleep is interrupted. This leads to worn out children whose concentration is impacted at school. Such sleepless nights may have a negative effect on the entire family unit. What's more, eczema can affect all ages, including teenagers who may feel uncomfortable under the glare of strangers to adults who are suffering with sleep deprivation and stress from trying to manage their eczema both at home and at work. Regular emollient therapy, such as the use of specially formulated moisturisers, is the cornerstone of the management and treatment of eczema." Irish Skin Foundation CEO, David McMahon agreed, "The disruption and stress that moderate and severe atopic eczema can cause is very clear from the findings of our recent survey. And while we know that the family impact of atopic eczema can be profound, we were surprised how disturbed sleep, lost school days and productivity features so strongly. "Our work with families impacted by eczema, particularly at this time of the year as the school term starts back, focuses on supporting people to re-establish care routines that will strengthen the skin barrier. This is quite important in advance of the weather cooling and central heating being turned on again in the autumn, both of which challenge vulnerable skin and can lead to flares. Eczema Awareness Month runs until the end of September.

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Expansion of Care to Children The Government has last month made the decision to approve the publication of the Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020. This Bill provides the legislative framework for the phased expansion of GP care without charges to all children of primary school age and to increase the income limits for medical card assessments for people aged 70 or over. The expansion of GP care without charges is an important health measure and builds towards the Government’s commitment to ensure access to GP care for all children, as well as the Sláintecare Implementation Plan for universal access to healthcare. This Bill will provide for the extension of GP care without fees to 6 and 7 year olds in the first instance and provides the basis for further phased extension of GP care without fees to all children 12 years and under in the years ahead. The Bill also provides for the implementation of an increase in the weekly gross medical card income limits for those aged 70 or older to ¤550 for individuals and ¤1,050 for couples. Minister Simon Harris, following Government approval to publish this legislation, said, “The benefits of this legislation are twofold. It will significantly improve access to GP services for children and also increase the numbers of those over 70 who have access to a medical card. This Bill will therefore give effect to two welcome measures which are important steps to delivering on the Government’s commitment to ensure affordable access to healthcare for all. “Providing a legislative framework to extend free GP care to all primary school children is a significant milestone. It is a key step towards ensuring cost is no longer a barrier to accessing the appropriate healthcare when and where children require it.” “Likewise, the welcome increase in the medical card income limits is another important measure to support older persons in our community. It is estimated that up to an additional 56,000 older persons in our society could benefit from this measure, providing them with access to a range of health services at a time when their health needs are more complex and thereby improving their quality of life.”

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23

Getting Ahead of Lice While several health concerns come to the forefront as students head back to their classrooms, head lice seems to top the list at most pharmacies. Head lice are tan to grayishwhite, 6-legged, wingless insects typically measuring 2 mm to 3 mm in length, or about the size of a sesame seed. Because lice crawl and do not jump, head-to-head contact is the primary route of transmission. Once on the scalp, lice attach eggs to the base of hair shafts a few millimeters from the scalp surface. Once laid, eggs hatch within 9 to 12 days, and the resulting nymph matures into an adult louse over the subsequent 9 to 12 days, for a full reproductive cycle of approximately 3 weeks’ duration. Typical signs of head lice are usually itchiness on the scalp, around the ears and the back of the neck. However, some people may experience no symptoms at all. Because lice eggs are located on hair shafts approximately 4 mm from the scalp, it is often easier to identify eggs by searching at the back of the hairline, where they are most visible. Research suggests that wetting hair before combing improves diagnostic reliability. There are several methods that can be recommended for managing a head lice infestation. Pharmacy teams should help customers choose the most appropriate product for their child because not all treatments will be suitable for everyone. Understanding a person’s preference, medical and drug history, the product’s active ingredient, how the active ingredient works, how the product should be used and if anything has been tried previously will allow pharmacists and pharmacy staff to recommend and help parents choose the right head lice product. Mechanical removal involves systematically combing the whole head of wet hair with a detection comb to remove the lice. The comb must be cleaned after each pass through the hair to remove lice and eggs, which is best done by wiping it on clean white paper or cloth. The process must be repeated every few days for two weeks. Products containing dimeticone or isopropyl myristate kill the

lice through physical action. Dimeticone coats the surfaces of head lice and suffocates them, while isopropyl myristate dehydrates head lice by dissolving their external wax coating. The advantages of these products are that they are easy to apply, they have few side-effects, are odourless or have only a faint perfume, and the head lice are unlikely to become resistant to them. Instructions must be followed exactly otherwise the treatment won’t work. Some of these products don’t kill louse eggs either, so it is vital that the treatment is repeated after a week to kill any lice that have hatched since the first application. Many parents are looking for allnatural remedies, so it would be wise for pharmacies to stock up on both traditional and alternative choices. It’s also important to alert parents to this topic, as they need to be inspecting their children for ticks and lice and so whilst stocking up on head lice products, education shouldn’t be missed.

Make sure head lice products are prominently displayed, along with educational brochures. Remind parents that their children should not share hats and also point out places where lice can be contracted. Infections The threat of infections cannot be minimised. Pharmacies should ramp up their supply of antibiotics at this time of year. Children get back together and start spreading infections so the use of antibiotics is expected to increase. Common infections presenting to the pharmacy in September will be dermatologic infections, such as ringworm and athlete’s foot, as well as of eye, ear, nose, and throat infections. It’s important to communicate to younger customers the importance of taking their antibiotics as they are prescribed. It’s especially important that children between the ages of 4 and 12 are given the proper instruction with their parents at their side. Empowering the children—and their caregiver— can help increase compliance.

Most ear infections clear up within a couple of days. Paracetamol or ibuprofen (appropriate for the child's age) can be used to relieve pain and high temperature. Do not give aspirin to children under 16 years old. Antibiotics are usually only needed if symptoms persist or are particularly severe. Sore throat symptoms are easily recognised. The throat hurts and is irritated, swollen, or scratchy. Pain increases when sufferers swallow. They may also have tenderness in their neck. Strep throat is an infection caused by a type of bacteria (group A streptococcus). Strep bacteria cause almost a third of all sore throats. Strep throat usually needs treatment with antibiotics. With the proper medical care — and plenty of rest and fluids — most kids get back to school and play within a few days. Symptoms of strep throat include: • sore throat • fever • red and swollen tonsils

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Back2School person to person, sometimes when sharing infected hats, combs, brushes, and hair clips. The first signs of infection on the body are red, scaly patches. They may not look like rings until they’ve grown to half an inch in diameter, and they generally stop growing at about 1 inch. A child may have just one patch or several. These lesions may be mildly itchy and uncomfortable. Scalp ringworm starts the same way the body variety does, but as the rings grow, the child may lose some hair in the infected area. Certain types of scalp ringworm produce less obvious rings and are easily confused with dandruff or cradle cap. Cradle cap, however, occurs only during infancy.

• painful or swollen neck glands Kids who do have strep throat might get other symptoms within about 3 days, such as: • red and white patches in the throat • trouble swallowing • a headache • lower stomach pain • general discomfort, uneasiness, or ill feeling • loss of appetite • nausea • rash

Strep throat is very contagious. Anybody can get it, but most cases are in school-age kids and teens. Infections are common during the school year when big groups of kids and teens are in close quarters. Children who present with a scaly round patch on the side of their scalp or elsewhere on their skin, and they seems to be losing hair in the same area of the scalp, the problem may be the contagious infection known as ringworm or tinea. This disorder is caused not by worms but by a fungus. Scalp ringworm often is spread from

A single ringworm patch on the body can be treated with an overthe-counter cream. A small amount is applied two or three times a day for at least a week, during which time some clearing should begin. If there are any patches on the scalp or more than one on the body, or if the rash is getting worse while being treated, refer to their GP. Tinea pedis (athlete’s foot), corporis, cruris and manuum can all be successfully managed with over-the-counter products. Topical formulations include creams, sprays or powders. In most instances, treatment with a cream will be appropriate. Tinea capitis requires systemic therapy and if this is suspected patients should be referred to their GP.

First Aid Tips Cuts and grazes  Wash and dry hands; put on sterile gloves  Clean minor cut/graze under running water or saline solution to remove dirt. Don’t wash a wound that’s bleeding heavily  Pat dry with sterile dressing or clean, lint-free material  Cover with sterile adhesive dressing  Don’t remove embedded objects – get medical treatment Burns/scalds  Cool the burn under cold running water for at least 10 minutes.  Cover burnt skin with cling film or clean plastic bag  Treat pain with analgesics  Any burn larger than a postage stamp, or a deep burn, needs medical attention Bruises  Cool area with ice pack wrapped in towel or cold compress  Arnica cream/gel may help bruising heal faster Heavy bleeding  Use sterile gloves G Apply direct pressure to wound, using a clean absorbent pad  Elevate limb to slow bleeding  Bandage pad in place  Seek medical help

Pharmacy Role in the Self-Care of Warts Pharmacists are likely to encounter patients seeking advice on the best self-care and self-treatment options for common warts and plantar warts (verrucae). Most people will have warts at some time during their life. However, they are more common in school children and teenagers than in adults. It is estimated that 4-5% of children and adolescents will have them. Verrucas are very common in children and teenagers – around one in three will get them. They’re actually warts on the feet, caused by the human papillomavirus, but they don’t look like normal warts because they’re pressed in. Children tend to catch them more easily because their immune systems are not fully developed, and they’re more likely to have

cuts and scratches on their skin where the virus can get in. Teenagers who play contact sports can also be particularly prone. Warts are classified as noncancerous viral infections of the epidermis and mucous membranes that are caused by the human papilloma virus (HPV). At any given time, warts affect approximately 7% to 10% of the population. Warts and verrucae are both caused by the Human Papilloma Virus (HPV). Certain types of HPV have an affinity for certain body locations, for example hands, face, anogenital region and feet.

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Warts can look different depending on where they appear on the body and how thick the skin is. There are several different types of warts. The more common types include:  common warts  plantar warts (verrucae)  plane warts  filiform warts  periungual warts  mosaic warts

The appearance of each type of wart will depend on several factors:  where it is located on the body  the strain (type) of HPV that is responsible for the wart  factors such as whether the sufferers has a weakened immune system  whether they have rubbed or knocked the wart Warts are very contagious. The skin cells in warts release thousands of viruses, which means that close skin-to-skin contact can pass on the infection.


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Back2School

It is also possible for the infection to be transmitted indirectly from an object, such as a towel, or by contact with a contaminated surface, such as the surface surrounding a swimming pool. It can take weeks, or even months, for a wart or verrucae to appear after someone has caught the infection. Verrucae Plantar warts are found on the weight bearing areas of the sole and heel. Their appearance is different from the rest of the body owing to constant pressure imparted to the sole of the foot, causing the lesion to be pushed inwards. Pressure of the nerve pain causes considerable pain and patients often complain of pain when walking. Tiny black dots that characterise verrucas are the thrombosed capillaries. This may not be visible until the hardened skin is shed away. They are distinguishable from corns as they have a whitened appearance and remain soft. Corns appear as hard corns (top of toes) or soft corns (between toes). Callouses appear as flattened, yellow white thickened skin and are common on the balls of the foot. Like warts, they are 1cm in diameter and can occur singly or in crops. Most pharmacies now have a consultation room. These should be utilised for performing examinations, allowing the patient to feel at ease, reduce embarrassment at the counter and make it more comfortable to remove clothing, if this is necessary.

Examinations can be performed in the consulting room without the need for any specialised equipment, however on occasions a magnifying glass may be useful. Distribution of warts is generally asymmetric, and lesions are often clustered or may appear in a linear configuration due to scratching. Tips to Prevent Verrucas in Children • Don’t let them go barefoot in public places • Don’t let them use personal items that aren’t their own. • Keep their feet dry whenever possible – the virus spreads more quickly on wet feet. • Make sure any cuts or scratches are covered up if they’re going to any of the places mentioned above. • Check their feet regularly. Treatment Goals Treatment goals for warts include effective removal that produces no scarring and prevents reoccurrence or spreading to other areas of the body or to another person. Certain patients, including those with diabetes, peripheral vascular disease, and immunodeficiency disorders, as well as those on immunosuppressive agents, should never attempt to use these products unless they have been referred to their GP. Prior to recommending the use of products for self-treatment of warts, pharmacists should always make sure that self-treatment is appropriate. Since warts are contagious, patients should be

advised to wash their hands before and after having direct contact with the wart to guard against transmission of warts to other areas of the body or to other people. In addition, patients should be reminded to use a separate towel for drying the area that contains the wart to prevent warts from spreading to other areas of the body. Patients should also be warned not to manipulate the wart in any way. If plantar warts are present on the bottom of the foot, patients should make sure the wart is covered when walking barefoot.

first ruling out patients with any contraindications relevant to the use of salicylic acid. Other exclusions for self-treatment of warts include painful plantar warts, warts that occur extensively on 1 area of the body, and warts that occur on the face, fingernails, toenails, or genitalia.

Pharmacists should always stress the importance of using wart treatments properly and note that they must be used for the duration indicated in their instructions in order to be completely effective. Patients should be told that perceptible results are typically observed within the first or second week of therapy and that complete wart removal typically occurs within 4 to 12 weeks of starting therapy.

Poor methodology is the reason why treatment sometimes fails. Compliance with treatment has also been identified as a limiting factor in the cure rate for warts and verrucae.

Patients should be encouraged to seek medical care therapy if the wart remains after 12 weeks of therapy or if there are signs of infection, swelling, pain, or irritation. Salicylic Acid Products Products that can be used for self-treatment of common or plantar warts include plaster/ pad vehicles that contain salicylic acid, collodion-like vehicles that contain salicylic acid and karaya gum–glycol vehicles that contain salicylic acid. Prior to recommending the use of these products, it is critical that pharmacists determine whether self-treatment is appropriate,

Patients with these types of warts should be referred to a dermatologist for further treatment. In addition, topical salicylic acid should not be used on irritated or infected skin.

The affected area should be hydrated first by soaking in warm water for five minutes before application of a product containing salicylic acid. It is very important in the management of warts and verrucae that good skin is protected. This can be achieved by applying petroleum jelly eg Vaseline on the surrounding skin followed by application of treatment on wart or verrucae. Cryotherapy Products These are best for warts on hands. Cryotherapy has been used for several years and it used to freeze the wart. OTC products, marketed as home cryotherapy treatments, are available for home use. In offering guidance, patients should be advised to always adhere to the directions provided with these products, since improper use can cause damage to adjacent unaffected areas of the skin. Warts typically fall off 10 days after the application of the cryotherapy agent. A persistent wart can only be treated 3 times using these products. Formaldehyde is used for the treatment of verrucae. It is an irritant so is less suitable on hands. However, the thickened layer of skin on feet protects against this irritant. It is a gel formula. Glutaraldehyde is also used for treatment of verrucae and should be used twice daily. It is available in 5% and 10% percent strengths. It should not be used for anogenital warts only verrucae. It stains skin brown, although this is reversible.

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Empowering Pharmacy in Vaccination Role

Just last month, the Pharmacy representative body, the Irish Pharmacy Union (IPU) repeated their previous call to allow pharmacists to administer flu vaccines in nursing homes and workplaces.

In welcoming the announcement by the former Minister for Health, Simon Harris TD, to make the flu vaccine available to all children aged 2-12 and all at risk groups, they said it was a ‘step in the right direction.’ The news follows a recommendation by the IPU earlier for the flu vaccine to be made freely available to everyone who wants it during the coming flu season. Commenting, IPU Secretary General Darragh O’ Loughlin said, “While we would have liked to see the scheme extended further, making the flu vaccination available to children aged 2-12 and to all at risk groups without charge is definitely a step in the right direction. It will help increase our capacity to combat seasonal flu and prevent it from overwhelming the health system during the winter.” Last year, over 1.1 million flu vaccines were delivered in Ireland, an increase of over 60% since pharmacies were first permitted to administer the vaccine a decade ago. Given that the convenience and availability of the vaccine has led to greater uptake, the IPU believes that pharmacists should be allowed to administer the vaccine to people in nursing homes and workplaces. “Every year there is a spike in hospital admissions due to people suffering from flu and related complications. We can

and we should do much more to prevent this by making it easier for the vaccine to be offered to wider groups of people in a community setting. Increasing the locations where this is permitted to residential services and to workplaces would significantly increase uptake and help build a herd immunity. We can’t yet stop the coronavirus, but we can stop the flu,” concluded O’ Loughlin. The role of pharmacists in immunisation and vaccination varies across the world; in some countries pharmacists are primarily involved in ensuring the safe supply and dispensing of vaccines, as well as advocating for immunisation, while in other countries they are empowered to play a more active role, as they are legally authorised organise vaccinations activities and campaigns. Meningococcal disease is caused by infection with Neisseria meningitidis and presents as bacterial meningitis (15 per cent of cases), septicaemia (25 per cent of cases), or a combination of the two. It is the leading infective cause of death in early childhood. There are several strains or ‘groups’ of meningococcal bacteria (A, B, C, W, X and Y). Currently MenB accounts for the vast majority of meningococcal disease although we have recently seen an alarming rise in a particularly deadly strain of meningococcal W meningitis and septicaemia.

There are five main groups that commonly cause disease - MenA, MenB, MenC, MenW, MenY. • Around 10% of the population carries meningococcal bacteria in the back of their throats at any given time. This is usually healthy carriage and helps develop immunity • Occasionally the bacteria defeat the body’s defences and cause infection • The bacteria are passed from person to person by coughing, sneezing and intimate kissing • The bacteria break through the lining at the back of the throat and pass into the bloodstream • They can travel in the bloodstream to infect the meninges, causing meningitis, or while in the bloodstream they can cause septicaemia From September last year, secondary school children in firstyear are offered a meningococcal ACWY booster vaccination. This was rolled-out in February. The Meningococcal ACWY vaccine will boost children’s protection against group C meningococcal disease. It will also provide additional protection against meningococcal groups A, W and Y. In addition, this vaccine also reduces the risk of carrying the disease so can help protect other people too. MenACWY being used in Ireland

is Nimenrix. This is a conjugate vaccine containing Group A, C, W and Y polysaccharides conjugated to tetanus toxoid carrier protein. The vaccine protects against N. meningitidis Groups A, C, W and Y invasive disease. Since 2015 more cases of invasive meningococcal serogroups W and Y disease have been seen in Ireland. Prior to 2015 the annual number of both serogroups was low. Between 1999 and 2014 there was an average of two cases for both serogroups reported per year. Meningococcal disease can start very suddenly. Symptoms include fever, stiff neck, headache, joint pains and a rash. Meningococcal disease can occur at any age, but the highest rate occurs in children under 5 years of age, especially children under 1 year old. The next high-risk group are young people aged 15-19 years. Importantly for community pharmacists to be aware, they might have school children and/ or their parents presenting to the pharmacy with associated after effects. Some students can have an area of soreness, swelling and redness in their arm where the injection was given. This usually passes after a day or two. Some students may get a headache, feel sick in their tummy or run a slight temperature. If this happens, paracetamol or ibuprofen will help.

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Pharmacy signs MOU with Sports Ireland Almost 50% of people are exercising more than they normally would during the COVID-19 crisis. And with more than 50% of people now meeting recommended physical activity guidelines, this represents a significant, positive increase compared to what was seen in the last Healthy Ireland Survey conducted in 2019. These headline observations are among the key preliminary results from a survey assessing the amounts, motivators and barriers to physical exercise during the COVID-19 pandemic. Additionally, the survey results suggest that people are turning to new exercise options, such as online workouts, to ensure they get their exercise. With this upsurge in activity, comes an increased risk of sports-related injuries, presenting community pharmacists and their teams with an opportunity to treat and help with minor sports injuries. Knowing how to identify common sporting injuries and provide specific advice to patients on their effective management, including the role of over-the-counter treatments, as well as when to refer for specialist assessment and treatment, can help many steer clear of long-term muscular pain and joint damage. Led by researchers from the Discipline of Physiotherapy at Trinity, Drs Cuisle Forde and Emer Barrett, the national survey has gathered data from approximately 1,500 people across the country. Most responses came after government restrictions eased slightly on the 5th of May, enabling people to exercise within a 5 km radius of their homes. Just this month, the Pharmaceutical Society of Ireland (PSI) – the pharmacy regulator and Sport Ireland signed a Memorandum of Understanding (MOU) that will assist joint working between the agencies, particularly when there are overlapping interests or areas of mutual concern. The MOU has been welcomed by the Minister for Media, Tourism, Arts, Culture, Sport and the Gaeltacht, Catherine Martin TD; “We have seen over recent weeks and months that sport and physical activity plays an important role in our daily lives. As competitive sport resumes as we enter phase 3 of the Covid-19 restrictions, we need to make sure

that our collective fight against doping in sport continues to be relentless. The signing of the MOU between Sport Ireland and the PSI is a positive step for anti-doping in Ireland and an excellent example of agencies of the state working together for the greater good.” In signing the MOU, John Treacy, CEO of Sport Ireland, and PSI Registrar/Chief Officer Niall Byrne stated that the memorandum focuses on their common purpose as public bodies. It provides a clear framework that governs and strengthens the working relationship between the organisations, both of which are tasked with upholding standards of conduct and good practice in the public interest. “Our role in the PSI is to protect, maintain and promote the health and safety of the public by ensuring that the standards of practise and the reputation of the profession of pharmacy are upheld. I am pleased that the PSI can engage with Sport Ireland to exchange information that supports the wider public interest. This includes ensuring that those who are registered with the PSI conduct themselves in a competent and ethical manner, and in doing so contribute to reducing the scope for harmful and improper use of substances in sport,” Byrne added. Both the PSI and Sport Ireland work in conjunction with many organisations, including by way of MOUs in carrying out their respective roles. MOUs provide a clear basis for co-operation and collaboration on areas of mutual interest or public concern. Amount of exercise: key results  46% of people felt they were exercising more since COVID-19 restrictions were applied, while 28% reported the opposite  54% of people were meeting the recommended physical activity guidelines, which equates to a minimum of 30 minutes moderate intensity physical activity (enough to raise your breathing rate) on five days of the week  This is an improvement on the 46% of the population meeting the recommended guidelines in the last Healthy Ireland Survey 2019

PSI Registrar/Chief Officer Niall Byrne

Types of – and motivators/ barriers to – exercise: key results  Almost 90% of people reported walking in the last seven days  Almost 50% have found new ways to be active since the restrictions, with many using online workouts for the first time  Over 90% were physically active because it benefited their mental and physical health  Over 70% felt that it was more important to exercise since the outbreak  The main barrier to exercise was a person’s usual means of exercise being unavailable to them, with around 20% saying being unable to meet their friends was key

 Around 20% felt that an increased workload limited their ability to be physically active Dr Emer Barrett, Trinity, said, “The really striking positive result from this survey is the finding that almost half of all people report that they are exercising more during the COVID-19 restrictions. People haven’t let the closure of gyms, classes or the 5 km distance restriction limit their ability to exercise and are finding new ways to be active. “It is very encouraging to see that there is a strong awareness of how physical activity can positively impact mental and physical health particularly at this time of crisis. We need to understand the factors that have facilitated or motivated this increase in activity with a view to maintaining them once restrictions are lifted.”

PHARMACYNEWSIRELAND.COM


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CPD: STROKE Continuing Professional Development

CPD

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 BIO: Dr John Charles Corrigan; Consultant Stroke Physician and Geriatrician, Cavan and Monaghan RCSI Hospital Group; Honorary Consultant Neurologist Mater Misericordiae Hospital, Dublin; Stroke Physician on out of hours rota with Mater Misericordiae Hospital, Dublin; Registered BASP

Stroke:

a Bleeding Dilemma Introduction:

60 Second Summary Dilemma Stroke: a Bleeding

The treatment of acute ischaemic stroke (AIS) is well established since the introduction of The following article contains some the National Clinical Programme for Stroke thoughts on difficult clinical decisions (NCPS) in 2010. Moreover, in terms of acute Introduction: AIS it is moving very much in the direction that I have encountered in the taken in cardiology with primary percutaneous therapeutic management of acute The treatment of acute ischaemic stroke to (AIS) established since the(PCI) introduction of the intervention recognising that ischaemic stroke. It is intended beis well coronary the definitive treatment of AIS is to remove the National Clinical Programme for Stroke (NCPS) in 2010. Moreover, in terms of acute AIS it is moving educational but not comprehensive. clot. However with regard to acute assessment very much in the direction taken in cardiology with primary percutaneous coronary intervention The important message I feel is to and treatment the focus is still on thrombolysis be aware of thethe evidence much of AIS is (PCI) recognising that definitiveastreatment to the remove regard to and need the for aclot. well However organisedwith pathway as possibleand andtreatment use the clinical skills acute assessment the focus is still on thrombolysis anddecision the need for a well organised which facilitates making.

youwhich havefacilitates learned to help with difficult pathway decision making. It is the consequences of getting this decision scenarios and remember that with wrong and causing a fatal brain haemorrhage treatment of is more to do wrong and causing a fatal brain haemorrhage which It is thecare consequences gettinglikely this decision which attracts a lot of attention to the good not. to the treatment of acute stroke. attracts a lotthan of attention There is much to beThere gained and much at treatment of acute stroke. is much to be decision gained and much at and thisto stake and this can result in hesitation and delay regarding making. It isstake important in hesitation remember therefore that this treatment is more likelycan to result be beneficial thanand not.delay regarding

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.

decision making. It is important to remember

therefore that this treatment likely In relation to both treatment and prevention there are many drugs involved and isit more will help totohave be beneficial than not. knowledge of their indications, how they work and interact with each other and with other agents. relation to both treatment and prevention with It is well ofinclude haemostasis clotting cascade and the mechanisms Figureworth 1: Majorhaving classes knowledge of anticoagulants warfarin, andInthe there are many drugs involved and it will heparin, direct thrombin inhibitors, and factors Xa inhibitors. which the circulatory system responds to injury. Of course, it is worth remembering that bleeding This figure illustrates the sites within the coagulation help to have knowledge of their indications, cascade at which these major classes of anticoagulant results for iatrogenic reasons like over or inappropriate use of antithrombotic drugs. how they work and interact with each other exert their effects.

and with other agents. It is well worth having

knowledge of haemostasis and the clotting cascade and the mechanisms with which the circulatory system responds to injury. Of course, it is worth remembering that bleeding results for iatrogenic reasons like over or inappropriate use of antithrombotic drugs. The formation of a clot in the body is a complex process that involves multiple substances called clotting factors that work together in a coagulation cascade. Anticoagulent agents exert effects at various sites in this pathway (Figure 1). Tissue plasminogen activator (tPA), currently licenced to treat ischaemic stroke (IS), injected into artery or vein will bind to fibrin in the thrombus and initiates fibrinolysis therefore dissolving the clot and restoring blood flow. Getting the timing right i.e. within the recommended time window of 4.5 hours means that this ‘clot busting’ drug will have the best chance of dissolving a clot before it becomes established and before significant damage is done to the brain and where benefits still outweigh the risk of bleeding.

Figure 1: Major classes of anticoagulants include warfarin, heparin, direct thrombin inhibitors, and factors Xa inhibitors. This figure illustrates the sites within the coagulation cascade at which these major classes of anticoagulant exert their effects. The formation of a clot in the body is a complex process that involves multiple substances called clotting factors that work together in a coagulation cascade. Anticoagulent agents exert effects at


CPD: STROKE

33

Unfractionated heparin (UFH) is a naturally occurring glycosaminoglycan and low molecular weight heparin (LMWH) is UFH, which has undergone fractionation in order to make its pharmacodynamics more predictable. It acts ‘indirectly’ at various sites in the coagulation cascade preventing the formation of clots and extension of existing clots. Unlike tPA it does not break down clots that have already formed. It allows the body’s natural clot lysis mechanisms to work normally to break down clots that have formed. Its indications include prophylaxis and treatment of thromboembolis disease, for example, deep venous thrombosis (DVT) and pulmonary embolus (PE). Warfarin is a vitamin K antagonist (VKA) which is a synthetic anticoagulant that acts by inhibiting vitamin K-dependent coagulation Factors II, VII, IX and X. Unlike heparin and warfarin which act at multiple sites of the clotting cascade, direct oral anticoagulant (DOAC) agents are anticoagulant drugs that have only one site of action. Dabigatran is a direct thrombin (IIa) inhibitor and apixaban, edoxaban and rivaroxaban are factor Xa inhibitors. In terms of reversal of effect in ICH idarucizumab is approved as reversal agent for dabigatran and andexanet alfa or 4-complex PCC (prothrombin complex concentrate) for reversal of rivaroxaban, edoxaban and apixaban (Cuker et al, 2019). Remember that reversal agents are prothrombotic and carry a risk of lifethreatening thrombosis and should only be used in someone who is at imminent risk of death from bleeding. Antiplatelet drugs decrease platelet aggregation and inhibit thrombus formation. Aspirin inhibits the enzyme cyclooxygenase reducing the production of thromboxane A2, a stimulator of platelet aggregation. Clopidogrel is a thienopyridine that inhibits adenosine diphosphate-dependent platelet aggregration. They are used in primary and secondary prevention of thrombotic cerebrovascular and cardiovascular disease. Antiplatelet drugs can reversibly or irreversibly inhibit platelet aggregation, one of the initiating steps in clot formation, resulting in a decreased tendency of platelets to adhere to each other and adhere to damaged blood vessel endothelium. Regarding COVID 19, there are some suggestions in early studies of increased incidence of stroke but these tend to occur in cases associated with co-morbidities like hypertension and diabetes, this clouds the issue and further work is needed to clarify this. Acute Ischaemic Stroke: Stroke is common and rehabilitation of victims is a huge national drain on resources both financially but also in terms of health service resources and in terms of the physical and emotional well being of carers in the community. Over 80% of strokes are ischaemic, that is, due to a blocked blood vessel with the remaining to a burst blood vessel or haemorrhage (Adams et al, 1993).

Of the ischaemic strokes only a small percentage (10 to 20%) are suitable for thrombolysis. Key to success in the treatment of AIS is a well organised pathway that includes rapid assessment and access to imaging that prevents delays and allows appropriate selection of patients for treatment. Remember that outside the time window of 4.5 hours the risk of bleeding due to tPA outweighs the benefits of treatment. It is expected that each case will present unique difficulties to be overcome before a decision can be safely made, for example, a history of previous stroke including intracranial (ICH) will raise concern. Patients may present late or wake up with their symptoms or already be using anticoagulant medications. However the only absolute contraindication to thrombolysis is intracranial bleeding on the CT brain. Often the right decision is not to thrombolyse, however there should be a good reason not to offer this life saving treatment. Serious complications of treatment including ICH and allergic reaction may occur following treatment and patients need monitored in a high dependency area or high dependency stroke unit (HASU) for 72 hours following treatment. TIAs and small strokes: When does a stroke become a TIA or when is a stroke too small to treat with thrombolysis? An NIHSS < 3 implies a small stroke but when vital functions are like speech or limb weakness are an issue it might still be reasonable to treat with thrombolysis. A TIA is an impending stroke and an opportunity for prevention. The first few weeks after a TIA or a small stroke is the time of greatest risk of recurrence and so dual antiplatelets (DAPT) is becoming the typical of treatment. However, here the risk of IS must again be weighted with the risk of causing bleeding by doubling antiplatelet cover and so DAPT is usually limited to about three months after a TIA or small ischaemic stroke. DAPT is not an option for large strokes due to the risk of causing bleeding into the infarct (Clairborne el al, NEJM, 2018; Wang et al, NEJM, 2013).

For long term stroke prevention a single antiplatlet agent is recommended. The use of proton pump inhibitors is not routine among stroke physicians in preventing upper gastrointestinal bleeding but some would suggest that in the long run this is a cost effective option (Kaiser et al, 2019). More aggressive early anticoagulation for minor (NIHSS<3), non-cardioembolic stroke or TIA, beyond treatment with DAPT, has been reviewed (Seiffge et al, 2020) but larger trials are recommended. Atrial Fibrillation: Atrial fibrillation (AF) is relatively common in hospital medicine, its incidence increasing with age. It is associated with an increased risk of cardioembolic stroke which can largely be counteracted by oral anticoagulation (OAC) medication but this carries the risk ICH (Luengo-Fernandez et al, 2012). In general, OAC medication is tolerated well but following an ICH treatment it must be stopped. Where the indication for OAC still remains the risks of recommencing treatment must be weighed against the continued risk of cardioembolic stroke due to AF. Guidelines (Hawkes et al, 2018) are not explicit here but recommencing OAC should be considered depending on the case circumstances, for example, a spontaneous ICH might have greater chance of recurrence than a traumatic haemorrhage that is due to a fall. It is important to highlight out that antiplatelet agents give no protection against the risk of IS due to AF. Occasionally IS will occur despite OAC therapy and the question is what to do next? It is important to consider compliance as the cause of treatment failure and this needs to be discussed with the patient. In the case of patients on DOACs the short elimination half-lives mean that even short periods of non-compliance may rapidly result in subtherapeutic levels. Although compliance with DOAC treatment is better than with VKA,


34

CPD: STROKE

compliance can be as bad as 1 in 3 adhering <80% of the time and although it is convenient that DOACs do not require monitoring greater effort should be made to follow up to prevent poor compliance (Ozaki et al, 2020). In patients with AF who have an IS, despite being on OAC they are at a higher risk for recurrent ischaemic strokes. Simply changing the type of anticoagulation was not associated with a reduced risk (Seiffge et al, 2020). The risks and benefits of adding an antiplatelet might be discussed with patients but this treatment is outside current guidelines. Interestingly, while guidelines recommend anticoagulation for all AF patients over 75 years, the evidence for a net clinical benefit (NCB) is sparse and one study found the NCB of treatment decreases with advancing age due to the competing risk of death from other causes e.g. cancer. In general though, elderly patients have a lot to gain from OAC treatment to prevent IS in AF. Bridging Therapy: ‘Bridging Therapy’ is used prior to a procedure or surgery, where short acting heparin replaces anticoagulation to reduce the risk of thromboembolism due to discontinuation of treatment and to reduce the risk of excessive bleeding during the procedure. Long acting VKAs need to be stopped several days before a procedure and will take several days to become therapeutic again afterwards. Some authors have found that periprocedural bridging therapy does not significantly reduce thromboembolic events compared with no bridging, however, it significantly raised the risk of both major bleeding and minor bleeding (Kulkarni et al, 2019; Douketas et al, 2015 ). The American College of Cardiology (2017) produced a decision pathway for VKA in non-valvular AF using a patient’s estimated stroke and bleeding risk to determine whether bridging was indicated. For example, bridging was not recommended with a CHA2DS2-VASc of four or lower and no history of stroke, TIA or systemic embolism owing to their low day-to-day risk of thromboembolism without anticoagulants. Clinicians need to decide on individual cases; it may be that parentral bridging anticoagulation is not indicated in setting of a CHA2DS2-VASc <4 and no recent history of stroke and it may be reasonable to simply resume warfarin therapy without bridging. DOACs have shorter half-lives than warfarin and it is likely parentral bridging is less of an issue. Some feel that heparin bridging does not make pharmacological sense given the short, 8-14 hour DOAC elimination half-lives, its association with increased bleeding and its questionable efficacy. The PAUSE study (Douketis et al, 2019), for example, demonstrated that periprocedural discontinuation of DOACs without administering a bridging agent was associated with low thromboembolic and bleeding rates.

The risks and benefits of bridging with a shorter acting agent like heparin are unclear and a plan needs to take account for all factors in each case. ICH in the elderly and restarting OAC treatment: ICH accounts for 10 - 15% of all strokes and is associated with a high mortality rate of approximately 50% and a high functional dependency (approximately 2/3) in survivors. It is a recognised side effect of antithrombotic treatment that the incidence of ICH increases with age; probably the result of changes to blood vessels that are part of the aging process. Spontaneous ICH in the elderly can occur on a background of cerebral amyloid angiopathy (CAA) which tends to be lobular and in the general population hypertensive ICH tends to be in the region of the basal ganglia, thalamus or pons. The prevalence of both AF and of ICH due to CAA increases with age, confounding the problem of managing one without causing the other (Shah et al, 2019) and given the demographics of our western population, this is an issue which is likely to increase. As mentioned above, Maximailano et al (2018) found that most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted. Sometimes an aneurysm is noticed on CT brain, which raises the risk of causing ICH by treating with OAC (or indeed tPA). Again the individual circumstances need to be recognised but in general bleeding is made worse but not caused by antithrombotic treatment and the presence of an incidental aneurysm should not preclude treatment which is indicated. References 1. HSE National Clinical Programme for Stroke (2010) 2. Figure 1: Google: ‘Anticoagulent wikipaedia’; ‘coagulation cascade and major classes of anticoagulant’ 3. Cuker A, Burnett A, Triller D, Crowther M, Ansell J, Van Cott EM, Wirth D, Kaatz S. Reversal of Direct Oral Anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol 2019; 94(6):697-709 4. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Stroke. 1993;24(1):35. 5. Claiborne Johnston S, Easton D, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and Aspirin in Acute Ischemic Stroke and HighRisk TIA. NEJM 2018: 379:215-225 6. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q. Clopidogrel with Aspirin in Acute

Minor Stroke or Transient Ischemic Attack. NEJM 2013: 369:11-19 7. Seiffge D, De Marchis GM, Koga M, Paciaroni M, Wilson D, Cappellari M, Macha K, Tsivgoulis G, Ambler G, Arihiro S, Bonati LH, Bonetti B, Kallmunzer B, Muir K, Bovi P Gensicke H, Inoue M, Schwab S, Yaghi S, Brown M, Lyrer, Takagi M,Acciarrese M, Jager HR, Polymeris AA, Toyoda K, Venti M, Traenka C, Yamagami H, Alberti A, Yoshimura S, Caso V, Engelter ST, Werring D. Ischaemic Stroke Despite Oral Anticoagulant Therapy in Patients With Atrial Fibrillation. Ann Neurol 2020 8. Hawkes MA, Rabinstein A. Anticoagulation for atrial fibrillation after intracranial hemorrhage. Neurol Clin Pract 2018;8(1): 48-57 9. Kulkarni SA, Fang MC. Bridging Anticoagulation Therapy: A Teachable Moment. MAMA Internal Medicine 2019: November 25 10. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, Garcia DA, Jacobson A, Jaffer AK, Kong DF, Schulmon S, Turpie AGG. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. NEJM 2015;373:823-823 11. Douketis JD, Spyropoulos AC, Duncan J, Carrier M, Le Gal G, Tafur AJ, Vanassche T, Verhamme P, Shivakumar S, Gross PL, Lee AYY, Yeo E, Solymoss S, Kassis J, Le Templier G, Kowalski S, Blostein M. Shah V MacKay E, Wu C, Clark NP, Bates SM, Spencer FA, Arnaoutoglou E, Coppens M, Arnold DM, Caprini JA, Li N, Moffat KA, Syed Sm Schulman S. Perioperative Management of Patients with Ptrial Fibrillation Reciving a Direct Oral Anticoagulant. JAMA Intern Med 2019;179(11):1469-1478 12. Shah SJ, Singer DE, Fang MC, Reynolds AS, Eckman MH. Net Clinical Benefit of Oral Anticogulation Among Older Adults with Atrial Fibrill ation. Circulation: Cardiovascular Quality and Outcomes 2019;12


You know best how to protect your patients

EXTRA

‘GRANDAD’ MOMENTS THANKS TO THE PROTECTION YOU PROVIDE FOR YOUR PATIENTS

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 of the Summary of Product Characteristics (SmPC) for how to report adverse reactions. Xarelto 2.5 mg/ 10 mg / 15 mg / 20 mg film-coated tablets (rivaroxaban). Refer to full SmPC before prescribing. Presentation: Film-coated tablet containing 2.5 mg / 10 mg / 15 mg / 20 mg rivaroxaban. Contains lactose. Indications: 2.5 mg: Prevention of atherothrombotic events in adult patients after an acute coronary syndrome (ACS) with elevated cardiac biomarkers, co-administered with acetylsalicylic acid (ASA) alone or with ASA plus clopidogrel or ticlopidine. Prevention of atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischaemic events, co-administered with ASA. 10 mg: Prevention of venous thromboembolism (VTE) in adult patients undergoing elective hip or knee replacement surgery. Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE in adults. 15 mg/20 mg: Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation with one or more risk factors, such as congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack. Treatment of DVT and PE, and prevention of recurrent DVT and PE in adults. Special populations: (for 15 mg / 20 mg only): specific dose recommendations apply for patients with moderate to severe renal impairment and in case of DVT/PE-patients only if the patient’s assessed risk for bleeding outweighs the risk for recurrent DVT/PE. Patients undergoing cardioversion: Xarelto can be initiated or continued in patients who may require cardioversion. Patients with non-valvular atrial fibrillation who undergo PCI (percutaneous coronary intervention) with stent placement: There is limited experience of a reduced dose of 15 mg Xarelto once daily (or 10 mg Xarelto once daily for patients with moderate renal impairment [creatinine clearance 30-49 ml/min]) in addition to a P2Y12 inhibitor for a maximum of 12 months in patients with non-valvular atrial fibrillation who require oral anticoagulation and undergo PCI with stent placement. Dosage and Administration: ACS: Recommended dose is 2.5 mg twice daily. Patients should also take a daily dose of 75 - 100 mg acetylsalicylic acid (ASA) or a daily dose of 75 - 100 mg ASA in addition to either a daily dose of 75 mg clopidogrel or a standard daily dose of ticlopidine. Treatment should be regularly evaluated in the individual patient weighing the risk for ischaemic events against the bleeding risks. Extension of treatment beyond 12 months should be done on an individual patient basis as experience up to 24 months is limited. Treatment with Xarelto should be started as soon as possible after stabilisation of the ACS event (including revascularisation procedures); at the earliest 24 hours after admission to hospital and at the time when parenteral anticoagulation therapy would normally be discontinued. CAD/PAD: Recommended dose is 2.5 mg twice daily. Patients taking Xarelto 2.5 mg twice daily should also take a daily dose of 75 - 100 mg ASA. Duration of treatment should be determined for each individual patient based on regular evaluations and should consider the risk of thrombotic events versus the bleeding risks. In patients with an acute thrombotic event or vascular procedure and a need for dual antiplatelet therapy, the continuation of this treatment should be evaluated depending on the type of event or procedure and antiplatelet regimen. Safety and efficacy of Xarelto 2.5 mg twice daily in combination with ASA plus clopidogrel/ticlopidine has only been studied in patients with recent ACS. Dual antiplatelet therapy has not been studied in combination with Xarelto 2.5 mg twice daily in patients with CAD/PAD. Renal impairment: Limited clinical data for patients with severe renal impairment (creatinine clearance 15 - 29 ml/min) indicate that rivaroxaban plasma concentrations are significantly increased. Therefore, Xarelto is to be used with caution in these patients. Use is not recommended in patients with creatinine clearance < 15 ml/min. No dose adjustment is necessary in patients with mild renal impairment (creatinine clearance 50 - 80 ml/min) or moderate renal impairment (creatinine clearance 30 - 49 ml/min). Hepatic impairment: Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C. Paediatric population: The safety and efficacy of Xarelto in children aged 0 to 18 years have not been established. No data are available. Therefore, Xarelto is not recommended for use in children below 18 years of age. Prevention of VTE in elective hip or knee replacement surgery: Recommended dose is 10 mg

PP-XAR-IE-0153-3

rivaroxaban taken orally once daily. The initial dose should be taken 6 to 10 hours after surgery, provided that haemostasis has been established. Duration of treatment depends on the individual risk of the patient for VTE which is determined by the type of orthopaedic surgery. For patients undergoing major hip surgery, treatment duration of 5 weeks is recommended. For major knee surgery, treatment duration of 2 weeks is recommended. Prevention of stroke and systemic embolism: The recommended dose is 20 mg once daily, which is also the recommended maximum dose. Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE: The recommended dose for the initial treatment of acute DVT or PE is 15 mg twice daily for the first three weeks followed by 20 mg once daily for the continued treatment and prevention of recurrent DVT and PE. When extended prevention of recurrent DVT and PE is indicated (following completion of at least 6 months therapy for DVT or PE), the recommended dose is 10 mg once daily. In patients in whom the risk of recurrent DVT or PE is considered high, such as those with complicated comorbidities, or who have developed recurrent DVT or PE on extended prevention with Xarelto 10 mg once daily, a dose of 20 mg once daily should be considered. Renal impairment: No dose adjustment is necessary in patients with mild renal impairment. Xarelto is not recommended in patients with creatinine clearance < 15 mL/min. Xarelto is to be used with caution in patients with creatinine clearance 15-29 mL/min. Prevention of VTE in elective hip or knee replacement surgery: no dose adjustment is necessary in patients with moderate renal impairment (creatinine clearance 30 - 49 ml/min). Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation: In patients with moderate or severe renal impairment, the recommended dose is reduced to 15 mg once daily. Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE: No dose adjustment is considered necessary in moderate to severe renal impairment; although when the recommended dose is 20 mg once daily, a reduced dose of 15mg once daily should be considered if the patient’s assessed risk for bleeding outweighs the risk for recurrent DVT and PE. When the recommended dose is 10 mg once daily, no dose adjustment from the recommended dose is necessary. Hepatic impairment: Contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk, including cirrhotic patients with Child Pugh B and C. Contraindications: 2.5 mg only: Concomitant treatment of ACS with antiplatelet therapy in patients with a prior stroke or a transient ischaemic attack (TIA); concomitant treatment of CAD/PAD with ASA in patients with previous haemorrhagic or lacunar stroke, or any stroke within a month. 2.5 mg/ 10 mg/ 15 mg/ 20 mg: Hypersensitivity to the active substance or any of the excipients; active clinically significant bleeding; lesion or condition if considered a significant risk for major bleeding; concomitant treatment with any other anticoagulants except under specific circumstances of switching anticoagulant therapy or when unfractionated heparin is given at doses necessary to maintain an open central venous or arterial catheter; hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C; pregnancy and breast feeding. Warnings and Precautions: Clinical surveillance in line with anticoagulation practice is recommended throughout treatment. Xarelto should be discontinued if severe haemorrhage occurs. Increasing age may increase haemorrhagic risk. Xarelto should be discontinued at the first appearance of a severe skin rash, or any other sign of hypersensitivity in conjunction with mucosal lesions. Not recommended: in patients with severe renal impairment (creatinine clearance <15 ml/min); in patients receiving concomitant systemic treatment with strong concurrent CYP3A4- and P-gp-inhibitors, i.e. azole-antimycotics or HIV protease inhibitors; in patients with increased bleeding risk; in patients receiving concomitant treatment with strong CYP3A4 inducers unless the patient is closely observed for signs and symptoms of thrombosis; for patients with a history of thrombosis diagnosed with antiphospholipid syndrome; Xarelto should not be used for thromboprophylaxis in patients having recently undergone transcatheter aortic valve replacement (TAVR); not recommended due to lack of data: 2.5 mg: treatment combination with antiplatelet agents other than ASA and clopidogrel/ticlopidine; 2.5 mg/ 10 mg/ 15 mg/ 20 mg: in patients below 18 years of age, in patients concomitantly treated with dronedarone, in patients with prosthetic heart valves, 10 mg/ 15 mg/ 20 mg: in patients with PE who are haemodynamically unstable or may receive thrombolysis or pulmonary embolectomy. Use with caution: in conditions with increased risk of haemorrhage; in patients with severe renal impairment (creatinine

clearance 15 - 29 ml/min); in patients with renal impairment (Xarelto 15 mg/20 mg) or with moderate renal impairment (creatinine clearance 30 - 49 ml/min) (Xarelto 2.5 mg/10 mg) concomitantly receiving other medicinal products which increase rivaroxaban plasma concentrations; in patients treated concomitantly with medicinal products affecting haemostasis; when neuraxial anaesthesia or spinal/epidural puncture is employed. In patients at risk of ulcerative gastrointestinal disease prophylactic treatment may be considered. Although treatment with rivaroxaban does not require routine monitoring of exposure, rivaroxaban levels measured with a calibrated quantitative anti-Factor Xa assay may be useful in exceptional situations. Contains lactose. 2.5 mg only: Use with caution in patients ≥75 years of age or with lower body weight (<60 kg); in CAD patients with severe symptomatic heart failure. Patients on treatment with Xarelto and ASA or Xarelto and ASA plus clopidogrel/ticlopidine should only receive concomitant treatment with NSAIDs if the benefit outweighs the bleeding risk. Interactions: Use of Xarelto is not recommended in patients receiving concomitant systemic treatment with azole-antimycotics (such as ketoconazole, itraconazole, voriconazole and posaconazole) or HIV protease inhibitors (e.g. ritonavir). These active substances are strong inhibitors of both CYP3A4 and P-gp. The interaction with clarithromycin, erythromycin or fluconazole is likely not clinically relevant in most patients but can be potentially significant in high-risk patients. Co-administration of Xarelto with dronedarone should be avoided. Care is to be taken if patients are treated concomitantly with any other anticoagulants. Care is to be taken if patients are treated concomitantly with NSAIDs (including ASA) and platelet aggregation inhibitors because these medicinal products typically increase the bleeding risk. The possibility may exist that patients are at increased bleeding risk in case of concomitant use with SSRIs or SNRIs. Concomitant use of strong CYP3A4 inducers (such as rifampicin, phenytoin, carbamazepine, phenobarbital or St. John’s Wort) should be avoided as they may lead to reduced rivaroxaban plasma concentration unless the patient is closely observed for signs and symptoms of thrombosis. Clotting parameters (e.g. PT, aPTT, HepTest) are affected as expected by the mode of action of rivaroxaban. Fertility, Pregnancy and Lactation: Pregnancy: Xarelto is contraindicated during pregnancy. Breast-feeding: Xarelto is contraindicated during breast-feeding; a decision must be made to discontinue breast-feeding or discontinue/abstain from therapy. Fertility: No specific studies with rivaroxaban in humans have been conducted to evaluate effects on fertility. In a study on male and female fertility in rats, no effects were seen. Driving and using machines: Xarelto has minor influence on the ability to drive and use machines. Patients experiencing adverse reactions like syncope and dizziness should not drive or use machines. Undesirable effects: Common: anaemia, dizziness, headache, eye haemorrhage, hypotension, haematoma, epistaxis, haemoptysis, gingival bleeding, gastrointestinal tract haemorrhage, gastrointestinal and abdominal pains, dyspepsia, nausea, constipation, diarrhoea, vomiting, increase in transaminases, pruritus, rash, ecchymosis, cutaneous and subcutaneous haemorrhage, pain in extremity, urogenital tract haemorrhage (menorrhagia very common in women < 55 years treated for DVT, PE or prevention of recurrence), renal impairment, fever, peripheral oedema, decreased general strength and energy, post-procedural haemorrhage, contusion, wound secretion. Uncommon: thrombocytosis, thrombocytopenia, allergic reaction, dermatitis allergic, angioedema, allergic oedema, cerebral and intracranial haemorrhage, syncope, tachycardia, dry mouth, hepatic impairment, urticaria, haemarthrosis, feeling unwell, increases in: bilirubin, blood alkaline phosphate, GGT, LDH, lipase, amylase. Rare: jaundice, bilirubin conjugated increased, cholestasis, hepatitis (including hepatocellular injury), muscle haemorrhage, localised oedema, vascular pseudoaneurysm (uncommon in prevention therapy in ACS following percutaneous coronary intervention). Very Rare: Anaphylactic reactions including anaphylactic shock, Stevens-Johnson syndrome/ toxic epidermal necrolysis, DRESS syndrome. Frequency not known: compartment syndrome secondary to a bleeding, renal failure/ acute renal failure secondary to a bleeding. Prescription only. Marketing Authorisation Holder: Bayer AG, 51368 Leverkusen, Germany. MA numbers: EU/1/08/472/001-024. Further information available from: Bayer Ltd., The Atrium, Blackthorn Road, Dublin 18. Tel: 01 2163300. Date of Preparation: 07/2019


36

News

A new look for McLernons – but still a Continuous Commitment to Pharmacy McLernons has a long and proud history of serving community pharmacy on the island of Ireland and beyond – a history which dates back over a century and spans five generations. In that way, the business closely mirrors many of its pharmacy customers, working with the sons and daughters, grandsons and granddaughters of some of its original customers. Keith McLernon, Managing Director, McLernons

"This new brand is both a recognition of our work to date and a foundation on which to continue to build in the future, supporting our vision and strategic business growth”

It is this growth, alongside their customers, that informs and inspires everything McLernons do, ensuring a continuous evolution as they help other businesses to grow. In 2018, following a review of the company’s position and strategy for growth, they recognised that they needed a new brand identity to ensure that existing and potential new customers, as well as staff and recruits, fully understood what McLernons offered and the extent of their credibility and capability. From installing the very first computer in pharmacy back in 1982, the business has continuously innovated to bring the latest dispensary and retail technology to community pharmacy. The development

of McLernons Retail and McLernons Head Office provided their customers with complete control over every aspect of their business. A patient-centred App, Medi Marshal, was added to the portfolio most recently in 2019 and is now used by over 150,000 patients to reorder their prescriptions and access their dispensing history. McLernons also await the go ahead on their e-prescribing software which was recognised as the national standard for the Electronic Transmission of Prescriptions in Ireland and is ready to roll out as soon as the Department of Health provides the go-ahead for the national programme.

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Heather Dalzell, Client Services Director at The Foundation, part of the Pierce Partnership, said, “The new brand had to communicate the breadth and depth of the services that McLernons now provided and their continuous commitment to working in partnership with their customers to deliver the best support possible. Whilst the business had changed significantly since its inception, its commitment to its fundamental values of building lifelong relationships, providing a family work environment and working to support each other and its customers still remained at its core.” “McLernons is very much a people-based business and the commitment that they have to

their customers comes from their own internal teams and their background in pharmacy. They are uniquely placed to understand the challenges that their customers face and everything they do is designed to make their lives easier. The business is also focused on their wider impact on society as a whole, evidenced in their sponsorship of industry awards, recognising and supporting best practice, as well as donations to all six Schools of Pharmacy throughout Ireland. McLernons see the encouragement of innovation among pharmacists and learning among students to be intrinsic to the relationships they have with the industry.” She added, “It is this partnership approach and constant commitment to delivering for their customers that inspired the new brand identity, and the creation of a logo based on the infinity symbol, communicating continuous innovation and McLernons’ ability to not only meet their customers’ expectations, but to anticipate and exceed them. The brand identity has now been brought to life on a new website platform, with a bespoke video featuring the people behind the business.” Keith McLernon, Managing Director at McLernons, said, “We are delighted to have a new brand that communicates McLernons’ continuous focus and dedication to our customers and the pharmacy profession as a whole. Our people are passionate and uncompromising in delivering only the very best for the pharmacies we serve and we are immensely proud of what we have created in partnership with our customers. This new brand is both a recognition of our work to date and a foundation on which to continue to build in the future, supporting our vision and strategic business growth.”


New look McLernons Same Standards of Service

Continuously working for pharmacists

Visit our new website to find out more:

mclernons.ie


Pain Relief for the Family* Feeling better already

Easofen for Children Strawberry 100 mg/5 ml Oral Suspension and Easofen for Children Six Plus Strawberry 200 mg/5 ml Oral Suspension. Contains maltitol liquid & sodium. Sugar free and colour free. *Easofen for Children Strawberry is for infants from 3+ months and should only be given to infants aged 3-6 months who weigh more than 5 kg. Easofen 200 mg Film-coated Tablets and Easofen Max Strength 400 mg Film-coated Tablets are for adults and adolescents (over the age of 12 years). Contains ibuprofen. Retail sale through pharmacies only. A copy of the summary of product characteristics is available upon request. PA 126/60/1-4 PA Holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Date prepared: December 2019. 2019/ADV/EAS/140H


Topic Team Training – Targeting Pain in Children 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. 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 Pain in Children. Pain is defined as a highly unpleasant physical sensation caused by illness or injury. Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness and medical procedures. If a child's pain is not treated quickly and effectively, it can have long-term consequences, which may include anticipatory anxiety during future procedures, a lowering of the pain threshold and sensitisation to future pain, reduced effectiveness of analgesics and increased analgesic requirements subsequently. To adequately assess a child's response to treatment, it is necessary to have ongoing assessment of the child's pain. However, for children who cannot communicate this information due to age or developmental status, observational and behavioural assessment tools are acceptable alternatives when valid self-report is not available. Depending on the age of the child and his/ her ability to communicate the information to the health care provider, there are many reliable,

valid and clinically sensitive assessment tools available; for example, the Face, Legs, Activity, Cry and Consolability (FLACC) scale, which incorporates 5 pain behaviours that make up the scale's name: facial expression, leg movement, activity, cry and consolability. Fever Fever is a normal physiological response to illness that facilitates and accelerates recovery. Although it is often associated with a self-limiting viral infection in children, it may also be a presenting symptom of more serious conditions requiring urgent medical care. Therefore, it is essential to distinguish between a child with fever who is at high risk of serious illness and who requires specific treatment, hospitalisation or specialist care, and those at low risk who can be managed conservatively at home. It is vital that pharmacists, when assessing children who present with fever, can make appropriate decisions on when to refer, the appropriate use of medication and how to advise parents and caregivers. Discomfort during a febrile illness is often due to associated pain; e.g. myalgia, sore throat, headache. Ibuprofen and paracetamol may be considered to improve comfort (with accompanying improvements in feeding activity and irritability),

Consider:  Am I, and my team, aware of the different presenting symptoms of pain in children?  Are my pharmacy staff aware of suitable products they can offer to parents?  Is the pharmacy team aware of various aids designed to help administer medications to children, such as medicine soothers?  Conditions in children that cause pain and fever  What types of pain in children can be managed in the pharmacy  Which painkillers and cough and cold ingredients are suitable for children at different ages  The importance of not using ibuprofen and paracetamol together in children  The symptoms of meningitis and the importance of looking out for these  Normal body temperature for children and the temperature at which a child is deemed to have a fever.

because they may also provide relief from pain and may reduce the risk of dehydration. They should be used to make the child more comfortable and not used routinely with the sole aim of reducing the temperature. Both paracetamol and ibuprofen are safe and effective for short-term use in children.

Dose of antipyretic medication in children should be accurately based on body weight and should not merely be estimated. For accurate dosing, liquid medicines should be administered with a syringe. Learning - www.hse.ie/my-child - Guide to Pregnancy, Baby and Toddler Health

Key Points: Check your pharmacy team are aware and understand the following key points:  Customers that should be referred to the pharmacist  Those suffering with chronic pain symptoms should be referred to their GP  A good range of products for various childhood ailments is vital. All need to be clearly signposted in store to make it quick and easy to identify suitable treatments  Ensure effective category management with allied condition treatments close to hand  Remind parents to take care with child doses. Recent research suggests that parents can often misinterpret dosage instructions for liquid medicines

Actions:  Include POS that will allow children to feel comfortable and make shopping easier for parents by allowing room for manoeuvring pushchairs  Ensure that child and infant health products are merchandised together, along with related products such as thermometers, to help build sales  Ensure that this important category is fully stocked at all times and merchandising plans are amended based on school term times  Ensure that I know the recommendations for analgesic use following childhood vaccinations  Train the team to meet all the above considerations

PHARMACYNEWSIRELAND.COM | 39


40

Educational: Hepatitis C

Impact of Covid-19 on Hepatitis The 73rd World Health Assembly took place virtually on Monday 18 and Tuesday 19 May and the World Hepatitis Alliance submitted a written intervention, which drew on findings from their global Covid-19 survey, to highlight the impact of Covid-19 on people living with viral hepatitis and on hepatitis services.

Direct Acting Antivirals - DAA are the safest and most effective medicines for treating Hepatitis C today. Some types of hepatitis C can be treated using more than 1 type of DAA. Sofosbuvirvelpatasvir is a pangenotypic NS5A-NS5B inhibitor single-pill combination regimen that has potent activity against hepatitis C virus (HCV) genotypes 1, 2, 3, 4, 5, and 6. It provides a much-needed option for patients with HCV genotype 3 infection, including those with compensated cirrhosis.

The statement is part of WHA’s continuous efforts to ensure that hepatitis remains firmly on the global health agenda. It urges Member States to seize the unprecedented opportunity presented by the current pandemic to make the most of synergies in screening opportunities and embed hepatitis elimination within evolving health systems. The intervention states: “The Covid-19 pandemic presents the biggest global health threat in a generation. Whilst the pandemic is affecting nearly everyone, it is having the greatest impact on the populations most undeserved by health systems. These same communities are disproportionately affected by viral hepatitis, a disease that claims more than 4,000 lives every day. The viral hepatitis community stands ready to play its part in tackling the Covid-19 pandemic to safeguard the lives of these at-risk and marginalised populations.”

The Covid-19 pandemic has severely disrupted hepatitis elimination programmes across the world. Research conducted by the World Hepatitis Alliance reveals only 10% of services are still functioning as normal. Without the availability of effective prevention, testing and treatment services, hopes of eliminating hepatitis by 2030 are diminished, and thousands of people affected by viral hepatitis are left facing an uncertain future. Towards the end of last year, research showed that 78% of people using needle and syringe programmes in community pharmacies who opted to test for hepatitis C would prefer to receive their hepatitis C treatment from the pharmacy The findings came from the second phase of a pilot study carried out by the London Joint Working Group on Substance Use and Hepatitis C, which co-ordinates efforts to improve prevention, diagnosis and treatment of hepatitis C in people who use drugs in the capital.

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Hepatitis C is a viral infection, which causes inflammation of the liver. It is spread through contact with the blood of an infected person. Sharing injecting needles and equipment with someone who is infected is the most common way to get hepatitis C in Ireland. About 25% of people who are infected clear the virus within one year of infection. The remaining 75% develop chronic (long-term) infection. This can cause serious liver disease, including cirrhosis (scarring of the liver) and liver cancer. This liver damage occurs gradually over 20-30 years in people with chronic infection. Hepatitis C became a notifiable disease in Ireland in 2004. New treatments for hepatitis C have become available in recent years. These result in a cure for about 95% of people who are infected. In the last four years, over 4,000 people have been cured of hepatitis C in Ireland – but up to three times that number could be infected with the virus and not know.

Hepatitis is referred to as “a silent killer”, as the viral infection has no symptoms in many cases. It affects people in different ways and has several stages: • Incubation period. This is the time between first exposure to the start of the disease. It can last anywhere from 14 to 80 days, but the average is 45 • Acute hepatitis C. This is a short-term illness that lasts for the first 6 months after the virus enters the body. After that, some people who have it will get rid of, or clear, the virus on their own. • Chronic hepatitis C. If the body doesn’t clear the virus on its own after 6 months, it becomes a long-term infection. • Cirrhosis. This disease leads to inflammation that, over time, replaces healthy liver cells with scar tissue. It usually takes about 20 to 30 years for this to happen, though it can be faster for those who drink alcohol or who have HIV • Liver cancer. Cirrhosis makes liver cancer more likely.


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quantification at 12 weeks after the end of treatment and was the primary endpoint in all the studies.1

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et MAVIRET® is contraindicated in patients with severe hepatic impairment (Child-Pugh C) and not recommended in patients with moderate hepatic impairment (Child-Pugh B).1 *Refers to GT 1–6, excluding decompensated cirrhotic patients and liver or kidney transplant recipients. MAVIRET® is not indicated in decompensated cirrhosis. The recommended duration of Street with or without cirrhosis.1 Fleet recipients, MAVIRET® is 12 weeks in liver or kidney transplant ‡Tablets should be swallowed whole, taken at the same time with food and not chewed, crushed, or broken.1 Bar TempleITT=intent-to-treat. current clinical guidelines. Hepatic impairment: Maviret is not recommended in patients with moderate hepatic impairment (Child-Pugh B) and is contraindicated in patients with severe hepatic impairment (Child-Pugh C). Patients who failed a prior regimen containing an NS5A- and/or an NS3/4A-inhibitor: GT 1-infected (and a very limited number of GT 4-infected) patients with prior failure on regimens that may confer resistance to glecaprevir/pibrentasvir were studied in the MAGELLAN-1 study. The risk of failure was, as expected, highest for those exposed to both classes. A resistance algorithm predictive of the risk for failure by baseline resistance has not been established. Accumulating double class resistance was a general finding for patients who failed re-treatment with glecaprevir/pibrentasvir in MAGELLAN-1. No retreatment data is available for patients infected with GT 2, 3, 5 or 6. Maviret is not recommended for the re-treatment of patients with prior exposure to NS3/4A- and/or NS5A-inhibitors. Lactose: Maviret contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. INTERACTIONS: See SmPC for full details. Contraindicated: Dabigatran etexilate, carbamazepine, phenytoin, phenobarbital, primidone, rifampicin, ethinyloestradiolcontaining products, St. John’s wort, atazanavir, atorvastatin, simvastatin. Not Recommended: darunavir, efavirenz, lopinavir/ritonavir, lovastatin, ciclosporin doses > 100 mg per day. Use Caution: digoxin, pravastatin, rosuvastatin, fluvastatin, pitavastatin, tacrolimus. Monitor Levels: Digoxin, Monitor INR with all vitamin K antagonists. No dose adjustment: Losartan, valsartan, sofosbuvir, raltegravir, elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, levonorgestrel, norethidrone or norgestimate as contraceptive progestogen. FERTILITY, PREGNANCY AND LACTATION: Maviret is not recommended in pregnancy. It is not known whether Maviret and its metabolites are excreted in breast milk. No human data on the effect of glecaprevir and/or pibrentasvir on fertility are available. SIDE EFFECTS: See SmPC for full details. Very common side effects (≥1/10): headache, fatigue. Common side effects (≥1/100 to <1/10): diarrhoea, nausea, asthenia. Frequency not known (cannot be estimated from the available data): pruritus. ▼ This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance; website: www.hpra.ie. Suspected adverse events should also be reported to AbbVie Limited on 01-4287900. LEGAL CATEGORY: POM(S1A) MARKETING AUTHORISATION NUMBER/ PRESENTATIONS: EU/1/17/1213/001 – blister packs containing 84 (4 x 21) film-coated tablets. MARKETING AUTHORISATION HOLDER: AbbVie Deutschland GmbH & Co. KG, Knollstrasse, 67061 Ludwigshafen, Germany. Further information is available from AbbVie Limited, 14 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. DATE OF REVISION: January 2020. PI/1213/008.

Maviret® ▼ 100mg/40mg film-coated tablets PRESCRIBING INFORMATION PRESENTATION: Each film-coated tablet contains 100 mg glecaprevir and 40 mg pibrentasvir. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. INDICATION: For treatment of Chronic Hepatitis C Virus (HCV) in adults and in adolescents aged 12 to <18 years. DOSAGE AND ADMINISTRATION: Oral. Treatment to be initiated and monitored by physician experienced in the management of patients with HCV infection. See SmPC for full posology. Dosage: Adults and adolescents aged 12 to <18 years: The recommended dose of Maviret is 300 mg/120 mg (three 100 mg/40 mg tablets), taken orally, once daily at the same time with food. Treatment Duration: Patients without prior HCV therapy (GT 1, 2, 3, 4, 5, 6): No cirrhosis: 8 weeks. Cirrhosis: 8 weeks. Patients who failed prior therapy with peg-IFN + ribavirin +/- sofosbuvir, or sofosbuvir + ribavirin: GT 1, 2, 4-6: No cirrhosis: 8 weeks. Cirrhosis: 12 weeks. GT 3: No cirrhosis: 16 weeks. Cirrhosis: 16 weeks. Special Populations: HIV-1 Co-infection: Follow the dosing recommendations as above. For dosing recommendations with HIV antiviral agents, refer to SmPC for additional information. Elderly: No dose adjustment required. Renal impairment: No dose adjustment required. Hepatic impairment: No dose adjustment recommended in patients with mild hepatic impairment (Child-Pugh A). Maviret is not recommended in patients with moderate hepatic impairment (Child-Pugh B) and is contraindicated in patients with severe hepatic impairment (Child-Pugh C). Liver or kidney transplant patients: 12 weeks in liver or kidney transplant recipients with or without cirrhosis, with 16 week treatment duration to be considered for GT 3-infected patients who are treatment experienced with peg-IFN + ribavirin +/- sofosbuvir, or sofosbuvir + ribavirin. Paediatric Population: No dose adjustment required in adolescents aged 12 to <18 years. The safety and efficacy of Maviret in children aged less than 12 years have not yet been established. Diabetic Patients: Diabetics may experience improved glucose control, potentially resulting in symptomatic hypoglycaemia, after initiating HCV direct acting antiviral treatment. Glucose levels of diabetic patients initiating direct acting antiviral therapy should be closely monitored, particularly the first 3 months, and their diabetic medication modified when necessary. Suf within CONTRAINDICATIONS: to the active substances or to any of the excipients. Patients foHypersensitivity lk S (Child-Pugh with severe hepatic impairment C). Concomitant use with atazanavir containing products, t r eet etexilate, ethinyl oestradiol-containing products, strong P-gp and atorvastatin, simvastatin, dabigatran CYP3A inducers (e.g., rifampicin, carbamazepine, St. John’s wort (Hypericum perforatum), phenobarbital, phenytoin, and primidone). SPECIAL WARNINGS AND PRECAUTIONS: Hepatitis B Virus reactivation: HBV screening should be performed in all patients before initiation of treatment. HBV/HCV co-infected patients are at risk of HBV reactivation, and should, therefore, be monitored and managed according to W ic k lo w

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42

Feature

Women's Intimate Health Care

Written by Laura Dowling 'The Fabulous Pharmacist'

Many women present to the pharmacy with symptoms of irritation in the vulvo-vaginal area. Itching, soreness, dryness and discharge can be caused by a number of issues including, but not exclusively, thrush, bacterial vaginosis or genitourinary syndrome of the menopause. The Fabulous Pharmacist Laura Dowling

cells from transforming into hyphae and are available OTC. Oral treatments are available on prescription only. Pregnancy can increase the chances of women developing thrush. It is not harmful to the baby and can be treated with topical treatments and pessaries. Pregnant women should be advised to return if their symptoms have not resolved within 7-14 days.

Vulvovaginal candidiasis (thrush)

it becoming pathogenic.

Vulvovaginal candidiasis, or thrush, is the most common cause of vaginitis (inflammation of the vagina) and vulvovaginitis (inflammation of the vulva and vaginal region). Candidiasis is typically caused by an overgrowth of the fungal yeast Candidia albicans. The National Institute of Healthcare Excellence (NICE) states that C.albicans accounts for 80-92% of cases with a number of other fungal yeasts accounting for the remaining cases.

There are a number of risk factors that have been identified as leading to colonization and/or symptomatic candidiasis:

Candidiasis is very common, with 70-75% of women experiencing the condition at least once and 40-50% of women reportedly experiencing it two or more times throughout their lives. It is estimated that Candida species could be isolated from 20% of vaginal swabs form otherwise healthy, asymptomatic women of reproductive age at any one time. The lactic acid producing Lactobacillus species causes the acidic pH range of the vagina, although the vaginal microbiome is diverse. The composition of the vaginal microflora is dynamic and increased change occurs during menstruation and sexual activity. The majority of women are thought to be colonised with Candida species without symptoms at some point in their lives thus it is thought that the dynamic nature of the vaginal microbiome is a critical factor that leads to colonization by Candida, as well as contributing to

• Hormonal changes (e.g. pregnancy, combined oral contraceptive pill/ hormone replacement therapy, menstruation. • Immunosupression (e.g. HIV, corticosteroids) • Antibiotics (particularly broad spectrum) • Sexual activity (e.g. sexual intercourse, orogenital contact) • Diabetes (particularly when poorly controlled as high blood sugar levels lead to better conditions for the yeast to grow) • Changes in vaginal pH • Vulvardermatosis • Genetics There are a number of typical symptoms and signs of thrush: • Pruritis • Cheesy discharge • Irritation (redness, swelling) There are a range of OTC products available in pharmacies that pharmacists can recommend after establishing that a woman has presented with symptoms of thrush. Azole creams and pessaries inhibit Candida yeast

PHARMACYNEWSIRELAND.COM

Various lifestyle factors may contribute to the development of thrush and the discomfort associated with symptoms. Women should be advised to wear loose-fitting, cotton underwear, to use fragrance-free and soap-free cleansers and to have showers rather than baths. Advise women to keep their genitals clean and dry as Candida species, like most fungi, thrive in moist, warm environments. Dietary changes such as reduced sugar intake and use of probiotics have been noted to increase the rate of clinical cure and reduce short-term relapse. The effectiveness of probiotics is however, strain dependent. Bacterial vaginosis (BV) Bacterial vaginosis is a common cause of abnormal vaginal discharge in women of reproductive age. It is characterized by a white, nonirritating, malodorous vaginal discharge. This discharge commonly smells ‘fishy’ and this odour is often more noticeable after sexual intercourse. Women who experience repeated episodes of Bacterial Vaginosis may benefit from using lactic acid vaginal gels to facilitate the restoration of the normal vaginal flora. Repeated episodes are more frequent in women who practice vaginal douching. The diagnosis is made clinically on the basis of the description and appearance of the discharge. Typically, the normal pH of the vagina increased from <4.5 to above 4.5 and up to 6.0 reflecting the replacement of normal lactobacilli with anaerobic organisms.

Nitroimidazole antibiotics are usually prescribed orally to treat BV. Lincomycin is prescribed orally and/or topically. There is no benefit in treating male partners. Genitourinary syndrome of the menopause (GSM) Genitourinary syndrome of the menopause (GSM) or vulvovaginal atrophy, results from estrogen loss and is often associated with vulvovaginal complaints e.g. dryness, burning, dyspareunia (pain during sexual activity) and even pain and sensitivity when wiping post urination. Urinary frequency and bladder infections may also occur. It is important to consider the age of a women when she presents to the pharmacy with symptoms such dryness, excessive watery discharge, burning or pain during sexual activity. Advise on soap free cleansers, vaginal moisturisers and lubricants may be beneficial. These products are widely available OTC in pharmacies. The use of locally applied estrogen (either cream, gel or pessaries) in perimenopausal or post-menopausal women can considerably reduce symptoms of GSM. For some women oral or transdermal hormone replacement therapy (HRT) will be required. Many women with GSM (up to 80%) do not seek medical care or advise so it is important that when a woman presents to the pharmacy that the appropriate questions are asked and that she is referred to her GP when appropriate. Women’s intimate healthcare is a large and very relevant topic and one where Pharmacists can make a positive and lasting impact on the health of the women they are dealing with every day. References https://www.pharmaceuticaljournal.com/cpd-and-learning/ learning-article/thrushdetection-and-management-incommunity-pharmacy/20205309. article?firstPass=false https://www.uptodate.com/ contents/treatment-ofgenitourinary-syndrome-ofmenopause-vulvovaginalatrophy#H16 www.nhs.uk | www.hse.ie


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HELP BREAK THE ITCH CYCLE WITH VAGISIL INTIMATE CREME

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Under your Skin? A Pharmacy Guide to current skin conditions

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

Eczema (or atopic dermatitis) is a common, inflammatory skin condition characterised by red, dry, itchy skin. Those with eczema can experience acute worsening of their condition, which are referred to as flares. During flares the skin becomes red which can sometimes weep, become blistered, crusted and thickened. The symptoms of this skin disorder can range from mild to severe, and all forms of eczema can have a significant impact on the quality of life for the person with eczema, caregivers and their loved ones. Eczema can have a significant impact on a person's quality of life. It is important for all community pharmacists and their teams to refresh your knowledge of the condition's symptoms, treatments and self-care advice in this learning

article so you can pass on expert knowledge to customers. Prevalence Eczema affects approximately 1 in 5 children and 1 in 12 adults in Ireland. While the exact cause of eczema is not known, certain factors are thought to be important in its development, these include an inherited (genetic) predisposition to have a weakened skin barrier, as well as altered inflammatory and allergy responses. Atopic eczema can run in families and frequently occurs alongside other atopic conditions, including hayfever and asthma. Although there is no cure for eczema yet, treatment are available to manage the condition. Eczema is recognizable by the

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

Stress

Eczema Triggers

Emotional stress can aggravate eczema. Finding ways to reduce stress may lessen the frequency and, hopefully, the intensity of the flare-ups. Whilst stress is associated with flares of atopic eczema, it is not yet fully understood.

Irritants and allergens

Infection

Atopic eczema can be triggered or aggravated by exposure to a number of environmental irritants or allergens. Common irritants include soap, bubble bath, shampoo, laundry detergents, fragrances, clothing that feels ‘itchy’ next to the skin (e.g. wool), changes in temperature, or allergens like animal dander, the house dust mite or pollen, but sometimes no cause can be identified.

Atopic skin is more vulnerable to infection and infection is often associated with a worsening of eczema. Advise customers to seek medical attention if skin becomes: • Wet or weepy, with yellow/ brownish crusts • Very sore, with clusters of painful itchy blisters, particularly if there has been contact with someone who has a cold sore.


offering customers the right range of specialist skincare treatments to meet their needs.

under breasts, natal cleft (groove between the buttocks) and genitalia, or at the site of an injury

Moisturisers

• If the scales are gently scraped off, a number of small, bleeding points can be seen underneath

People suffering from dry skin, shouldn't use harsh, alcohol-based products as these can irritate skin and dry it out. People who have oily skin should avoid oil-based products and choose water-based ones instead. A good moisturiser is not necessarily an expensive one. Deciding what is best for skin depends on ingredients. There are various ingredients that provide different functions including: • Ceramides. Ceramides help the skin hold water and soothe dry skin. Synthetic ceramides may mimic the natural substances in the outermost layer of skin that help keep moisture in. • Dimethicone and glycerin. These draw water to the skin and keep it there. • Hyaluronic acid. Like ceramides, hyaluronic acid helps skin hold water. • Lanolin, mineral oil, and petroleum jelly (petrolatum). These help skin hold on to water absorbed during bathing. Psoriasis Psoriasis is a common, noncontagious, long-term, immunemediated inflammatory disease in which there is an increase in the rate at which skin cells are produced and shed from the skin. Psoriasis affects at least 100 million people worldwide, including upwards of 73,000 people in Ireland, suggesting a prevalence of close to 2% of the Irish population. It is estimated that around 9000 people in Ireland have severe psoriasis.

Dry Skin Dry skin occurs when the epidermis does not hold on to sufficient moisture, so skin can feel tight, rough, flaky and itchy. A number of things can contribute to its development, for example; too frequent bathing, use of harsh drying soaps, the ageing process (the production of natural oils in the skin slows as we age, and sun damage is cumulative so a lifetime of sun exposure and sun damage can result in thinner skin that doesn’t retain moisture so well), or certain conditions such as eczema or psoriasis. The average skincare category accounts for 5% of total OTC shelf space. It is important this space works hard for you and the range stocked provides maximum return in terms of profitability as well as

Psoriasis is a condition which tends to run in families. Several different genes have been identified but the exact way in which the disorder moves from generation to generation has not yet been established. What is known is that both the immune system and genetics are important in its development. So although the potential to develop psoriasis is genetically inherited, it is by no means certain that it will ever occur. Triggers for this abnormal immune reaction can include physical injuries or infections (in particular, a streptococcal throat infection), certain medicines, and emotional stress. Psoriasis varies in severity from person to person and can vary in severity in the same person at different times. Symptoms Red, scaly patches (also called plaques or lesions) with sharply defined edges, that occur most commonly on both elbows, both knees, the scalp, under arms,

• Nail changes – loosened, thickened or pitted nails (pits are small dents/ice pick like depressions on the surface of the nails) People who have psoriasis are at risk of developing psoriatic arthritis, which commonly affects the joints of the fingers, toes and spine. Psoriasis is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol, cardiovascular disease (angina, heart attack, stroke), and obesity. There is also a strong association between psoriasis and depression. Some symptoms that may be associated with psoriatic arthritis include; • Joint pain, especially with redness, swelling, and tenderness • Pain in the heel(s) or tennis elbow • A finger or toe that was completely swollen (sausage shaped) and painful for no apparent reason • Morning stiffness/pain in the back that improves with movement Those presenting into the pharmacy who suffer from psoriasis and exhibit any of these symptoms, should be referred to their local GP for follow-up. Role of Pharmacy In general practice, chronic disease consultations and medication reviews are increasingly being conducted by clinical pharmacists. Many pharmacists working in general practice come from community pharmacy backgrounds, and will therefore already have experience in supporting patients to manage their eczema. Before recommending any product, pharmacists should determine whether self-treatment is appropriate and refer patients to seek further medical evaluation when warranted, especially if signs of skin infection are present. Patients under the age of 2 years should always be referred to their primary health care provider for appropriate treatment. To avoid allergic reactions, patients with allergies to skin care products and cosmetics should be advised to use hypoallergenic products.

Staying SunSmart The HSE National Cancer Control Programme (NCCP), Healthy Ireland and partners have launched a SunSmart campaign, supporting people in the simple ways in which they can enjoy the sun safely, while protecting themselves and their family. With more people spending time outdoors within the 5km limit, whether in the garden, exercising locally or enjoying a runaround in the park with the children, it’s important to protect they protect their and their children’s skin. Pharmacists are also advising parents to be sun smart and protect their children’s skin when they are outside enjoying the fine weather, as children’s skin is very sensitive to the sun’s rays. Community pharmacist and IPU Executive Committee Member Ann Marie Horan said, “It is important that everyone knows how to enjoy the sun responsibly. While it is fantastic that we’re promised good weather this weekend, unfortunately by Tuesday, pharmacists will see many people suffering from the after-effects of sunburn. Our message is that we would much rather speak with you beforehand, when we can help you with all essential sun care products.” The SunSmart campaign, an action in the National Skin Cancer Prevention Plan, is supporting people to build skin cancer awareness into their everyday wellbeing routine. The simple SunSmart code messages are the 5 S’s: 1. Slip on clothing that covers your skin, such as long sleeves, collared t-shirts 2. Slop on sunscreen on exposed areas, using factor 50+ for children 3. Slap on a wide-brimmed hat 4. Seek shade - especially if outdoors between 11am and 3pm - and always use a sunshade on a child’s buggy 5. Slide on sunglasses to protect your eyes. Professor Anne-Marie Tobin, Consultant Dermatologist at Tallaght University Hospital, says, “Exposure causing sunburn is the most damaging to skin, but frequent non-burning exposures also significantly increase the risk of skin cancer. By adopting the SunSmart 5 S’s the majority of skin cancers caused by UV sun exposure could be prevented. “Children and young people are particularly vulnerable. UV exposure during the first 10–15 years of life makes a disproportionately large contribution to lifetime risk of skin cancer. Children have lower concentrations of the protective skin pigment melanin and thinner skin, therefore are more susceptible to the dangers of UV. Greater than three instances of severe sunburn during childhood doubles the risk of developing melanoma in later life. Protect yourself and your children today and your skin will thank you for the rest of your life.”

PHARMACYNEWSIRELAND.COM | 45


GENERAL PHARMACY SERVICES

The Irish Prison Service (IPS) intends to publish tenders, in the coming weeks, for the provision of General Pharmacy Services to: • Midlands Prison and Portlaoise Prison • Cloverhill Prison and Wheatfield Prison • Mountjoy Prison • Arbour Hill Prison • Dochas Centre This service will include the delivery of pharmaceutical care, on a patient centred basis, which complies with all professional, legal and ethical requirements. This contract will be managed by the Chief Pharmacist, Care & Rehabilitation Directorate, IPS. Tender documents will be available on www.etenders.gov.ie in due course. For further information, please contact Care & Rehabilitation Directorate, IPS, at crhealthcarequeries@irishprisons.ie.

Arkovital’s Acerola 1000 With immunity support supplements no longer being perceived as a seasonal range in the eyes of the consumer, a greater focus on the ingredients of such supplements are sure to follow. As we start to see a growing trend for natural VMS products by consumers in general its obvious that this will follow through to immunity support supplements. Arkovital’s Acerola 1000 – a 100% plant-based formula distributed by Pharmed, looks like the product to watch. With no chemical colorants or chemical ingredients and 100% natural form of vitamin C sourced from Acerola cherries indigenous to South and Central America, better recognised by the body and better absorbed it reduces fatigue and contributes to a healthy immune system, its sure to be a popular product with consumers for the duration of Covid19.

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