48 minute read
FEATURE: AGEING AND THE IMMUNE SYSTEM
FAST RELIEF OF ALLERGIES 24hr CONTROL
Cetrine Allergy 10mg Film-Coated Tablets available in packs of 7s and 30s. Always read the leaflet.
ABBREVIATED PRESCRIBING INFORMATION Product Name: Cetrine Allergy 10mg lm-coated tablets & 1 mg/ml oral solution. Composition(s): Each tablet contains 10 mg cetirizine dihydrochloride. One ml of the oral solution contains 1 mg cetirizine dihydrochloride. Description(s): White, oblong lm-coated tablets, scored on one side. Can be divided into equal halves. Clear, colourless liquid with banana avour. Indication(s): Tablets: Adults and paediatric patients 6 years and above. Oral solution: Adults and children 2 years and above. Relief of nasal and ocular symptoms of seasonal and perennial allergic rhinitis (hay fever); relief of symptoms of chronic idiopathic urticaria. Dosage: Tablets: Adults, elderly and children aged 12 years and over: 10 mg once daily. Children from 6 years to 12 years: 5 mg (half a tablet) twice daily. Moderate renal insu ciency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insu ciency (creatinine clearance ≤30 ml/min): 5 mg once every 2 days. Children under 6 years: Not recommended. Oral solution: Children aged from 2 to 6 years: 2.5 mg twice daily (2.5 ml oral solution twice daily (half a measuring spoon twice daily)). Children aged from 6 to 12 years: 5 mg twice daily (5 ml oral solution (a full measuring spoon twice daily)). Adults and adolescents over 12 years of age: 10 mg once daily (10 ml oral solution (2 full measuring spoons)). Not recommended in children aged less than 2 years. Moderate renal insu ciency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insu ciency (creatinine clearance ≤30 ml/min): 5 mg once every 2 days. In paediatric patients su ering from renal impairment: Adjust dose on an individual basis taking into account the renal clearance of the patient, his age and his body weight. Contraindications: History of hypersensitivity to the active substance, to any of the excipients, piperazine derivatives or hydroxyzine. Severe renal impairment < 10 ml/min creatinine clearance. Warnings and Precautions for Use: Cetirizine may increase risk of urinary retention, therefore caution in patients with predisposition factors of urinary retention (e.g. spinal cord lesion, prostatic hyperplasia). Caution in epileptic patients and patients at risk of convulsions. Discontinue use of cetirizine three days before allergy testing. Pruritis and/or urticaria may occur when cetirizine is stopped, even if the symptoms were not present before treatment initiation. In some cases, the symptoms may be intense and may require treatment to be restarted. The symptoms should resolve when the treatment is restarted. Tablets contain lactose. Oral solution contains sorbitol, propylene glycol, sodium (essentially ‘sodium free’), methyl - & propyl-parahydroxybenzoate. Interactions: Caution is advised when taken concomitantly with alcohol or other CNS depressants. Cetirizine does not potentiate the e ect of alcohol (0.5 g/l blood levels). The extent of absorption of cetirizine is not reduced with food, although the rate of absorption is decreased. Pregnancy and Lactation: Caution during pregnancy and breast-feeding. Ability to Drive and Use Machinery: Usually non-sedative, patients should take their response to the product into account. In sensitive patients, concurrent use with alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance. Undesirable E ects: Cetirizine at the recommended dosage has minor adverse e ects on the CNS, including somnolence, fatigue, dizziness and headache. In some cases, paradoxical CNS stimulation has been reported. Although cetirizine is a selective antagonist of peripheral H1-receptors and is relatively free of anticholinergic activity, isolated cases of micturition di culty, eye accommodation disorders and dry mouth have been reported. Instances of abnormal hepatic function with elevated hepatic enzymes accompanied by elevated bilirubin have been reported which resolves on discontinuation of the drug. Uncommon: Agitation, diarrhoea, pruritus, rash, asthenia, malaise, paraesthesia. See SPC for all adverse reactions. Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork. Marketing Authorisation Number: PA0711/075/002-003. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417 E-mail: rowex@rowa-pharma.ie Legal Category: Not subject to medical prescription. Date of Preparation: March 2021
54 Elderly Care
Falls in the Elderly
It is well documented that an expanding older population is putting a lot of pressure on community services and on hospital admissions either from care homes or from those living with more complex needs.
Community pharmacies could prove to be the vital link in this chain, by bringing their knowledge of older patients and skills into play more often and in new ways. Most communities in Ireland view their local pharmacist as an extended member of the family, and therefore are in an ideal position to be more directly involved in their care.
Osteoporosis
Osteoporosis is commonly known as “the silent disease” because there are no signs or symptoms before a person starts to break bones. However, this disease is NOT silent. The effects of undiagnosed/untreated osteoporosis are devastating.
20% of people aged 60+ who break their hip will die within 6 to 12 months, due to the secondary complications of breaking a bone.
50% of people aged 60+ who break a hip will lose their independence. They will be unable to wash or dress themselves or walk across a room unaided. These statistics are why it is so important that people take responsibility for their bone health and check to see if they are at risk.
Only 15% of people in Ireland are actually diagnosed with bone loss, leaving 280,000 undiagnosed and facing losing their independence.
Osteoporosis can affect the whole skeleton, but the most common areas to break are the bones in the back, hip and forearm. The disease affects all age groups and both sexes – it is not just a female or old person’s disease.
At present it is estimated that 300,000 people in Ireland have osteoporosis. One in 4 men and 1 in 2 women over 50 will develop a fracture due to osteoporosis in their lifetime. The disease can also affect children.
A broken bone from a trip and fall or less is known as: an osteoporotic fracture, a low trauma fracture or a fragility fracture.
However, broken bones can be prevented in most cases, and is a treatable disease in most people. Early diagnosis is essential for the best results.
Signs and Symptoms of undiagnosed osteoporosis
Usually the first sign of Osteoporosis is a fragility (low trauma) fracture e.g. a broken bone due to a trip and fall from a standing position or less.
Symptoms that a person may have undiagnosed osteoporosis include upper, middle or low back pain, especially if the pain is intermittent. Loss of height is another potential symptom. It should not be considered normal to lose height as people age.
Someone with their head protruding forward from their body, shoulders becoming rounded, the development of a hump on the back and / or a change in body shape (waist appears bigger or a pot belly develops) are also symptoms.
Most people have no pain till a fracture occurs, but a very small percentage of people have had back or hip pain, prior to a fracture.
Treatments and Vitamins
For both men and women at increased risk of fracture, the most widely prescribed osteoporosis medications are bisphosphonates. Bisphosphonates are also known as Antiresorptive medications. These are non-hormonal drugs which help maintain bone density and prevent further bone loss.
The patient receives this medication in the form of tablets, an injection or by means of infusions. Side effects such as nausea and abdominal pain are much less likely to occur if the medicine is taken properly and pharmacists can help advise patients on this.
Denosumab is a Monoclonal antibody which binds to RANK Ligand, inhibiting the maturation of osteoclasts, therefore protecting the bone from degradation.
Compared with bisphosphonates, denosumab produces similar or better bone density results and reduces the chance of all types of fractures. Denosumab is delivered via a shot under the skin every six months.
Those who take denosumab, might have to continue to do so indefinitely. Recent research indicates there could be a high risk of spinal column fractures after stopping the drug.
There are oestrogen replacement for women going through the menopause which help to maintain bone density and reduce fracture rates for the time they are on the treatment. Estrogen therapy and estrogen with progesterone hormone therapy are approved for the prevention of Osteoporosis in postmenopausal women provided there are no contraindications. They are usually recommended for postmenopausal symptoms to help improve the person’s quality of life. They may also be prescribed for premenopausal women who have amenorrhea and low levels of oestrogen.
In men, osteoporosis might be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help improve symptoms of low testosterone, but osteoporosis medications have been better studied in men to treat osteoporosis and thus are recommended alone or in addition to testosterone.
From my experience working in private podiatry practice, most podiatry treatment consultations end with instructions for the patient to attend their local pharmacy. Here, they can buy the necessary products needed to maintain their feet in good health in between podiatry appointments.
An example of this is a patient I recently advised of using 10% urea-based emollient for anhidrotic skin on their heels. This patient had Rheumatoid Arthritis and various other comorbidities. On instruction, this patient attended their pharmacy, where they were advised of an appropriate emollient with a pump handle and directions for use reiterated to them. The patient was then able to apply the emollient daily and prevent cracks in the skin of their heels. As a result, a break in the skin epidermis was prevented, meaning an ulceration and portal for infection prevented. This situation is one we see regularly as podiatrists, it is being prevented here though a multidisciplinary approach employed from podiatrist and pharmacist.
Patients see their podiatrists semi-regularly. It varies between 4-6 times a year with the medical card scheme, or privately when necessary. It would be rare for a patient to be attending their podiatrist more than once a month unless it is to resolve a particular ailment such as a verruca. Conversely, pharmacists may see patients much more regularly, up to multiple times a week. It is often the community pharmacists who direct many patients to the podiatrist when appropriate and recommend necessary foot health products to our patients. In Dundrum podiatry, we are lucky to have a good working relationship with our local community pharmacy and can see first-hand the difference the team makes to our patients’ (foot) health. As podiatrists, we often write the product name or type down for the patient who then brings it to their pharmacist. We are grateful to the pharmacist who takes the time to advise the patient accordingly and is readily stocked with the products which the patients require.
Written by Rebecca Conway – BSc (Hons) Podiatrist, Dundrum Podiatry Clinic
How can we promote foot care to patients?
As a podiatrist, one way we promote foot care to patients is through health education. This is not just by educating the patient about their foot health but also through educating ourselves as professionals. By keeping up to date with new treatments available to patients, continued professional development and relevant evidence-based articles, we can continue to broaden our knowledge of foot health.
Another way of promoting good foot health is by informing patients of foot health services which they can avail themselves of. People who have a health condition which is known to have a detrimental effect on their foot health such as Diabetes or medical card holders who are of a certain age (66+) may be eligible for the GMS (General Medical Services) Chiropody Card scheme. With a Chiropody card, patients can access 4-6 podiatry treatments annually, either for free or at a subsidised rate.There are also various circumstances in which people will have priority in accessing their local HSE podiatry services. Local HSE authorities and websites such as www.citizensinformation.ie can be a great resource for patients and professionals with detailed information on eligibility criteria for different services.
Is there potential for collaborative working and multidisciplinary teamwork in foot care?
As mentioned before, a collaborative and multidisciplinary approach is fundamental in achieving a high standard of care for our patients. Rarely do patients attend only one healthcare professional for resolution or management of a disease or ailment. Multidisciplinary teamwork across healthcare settings improves the quality of life and treatment outcomes for our patients.
Therefore, it is important for pharmacists and podiatrists to know when to refer patients to each other. From a podiatrist’s perspective, it varies for different common ailments.
For example, verrucae often start off being treated by patients with over-the-counter topical medicines, frequently consisting of a lower percentage of salicylic acid. However if a patient is compromised is immunocompromised, they must attend their podiatrist or G.P. Similarly, if the patient is reporting multiple verrucae on a foot, the chance is they are Mosaic Verrucae, which are much more resistant to over-the-counter treatments and may need podiatry or G.P services.
Another common example we see every day is Fungal Nails (Onychomycosis). The list of overthe-counter fungal nail remedies is endless. However, as it is a fungal infection, it can spread from nail to nail and person to person. It is important to prevent infection spreading, by ensuring that there is no cross-contamination present such as a nail file shared between family members. There are creams and powders useful such as Daktarin and Desenex in preventing Tinea Pedis. Fungal nail infections often cause painful, thickened nails which would need to be reduced and cut back by a Podiatrist.
There are several podiatrists in Ireland who are based on the site of the pharmacy, so interdisciplinary communication can be achieved without significant effort. More information about your local podiatrist can be found by using the Podiatry Ireland website (www.podiatryireland.ie), where there is a search bar to find podiatrists, either by name or area. This website has been created by The Society of Chiropodist and Podiatrist of Ireland and can be used to find out more about Podiatry in Ireland.
Scholarship Award for Aoife
Congratulations to Aoife Delaney, Chief II Medication Safety Pharmacist, Pharmacy Department, Cork University Hospital on being awarded an Employment-based PhD Scholarship for Health Science Professionals by the College of Medicine and Health UCC.
Aoife’s research is a collaboration between the Pharmacy Department Cork University Hospital and the School of Pharmacy, UCC. She will investigate medication safety communication strategies, and the development of a quality improvement intervention in an Irish hospital setting. This research will make an important contribution to new knowledge, and advance research in the area of medication safety, to improve patient outcomes. Aoife will be supervised by Dr Aoife Fleming Lecturer in Clinical Pharmacy Practice, UCC, Dr Kirstyn James Consultant in Geriatric Medicine, Cork University Hospital, Dr Suzanne McCarthy Senior Lecturer in Clinical Pharmacy Practice, UCC and Ms Deirdre Lynch, Chief Pharmacist, Cork University Hospital.
Dr Suzanne McCarthy, Dr Aoife Fleming, Ms Aoife Delaney, Ms Deirdre Lynch and Dr Kirstyn James
Second Annual Cancer Retreat
The second annual Cancer Retreat recently took place in the Royal College of Surgeons, Dublin 2, and saw a number of Irish and international speakers come together to discuss a range of current issues of interest to the cancer clinical trials community, as well as future challenges and opportunities.
Professor Seamus O’Reilly, Consultant Medical Oncologist, and Cancer Trials Ireland Clinical Leadership, Eibhlín Mulroe, CEO, Cancer Trials Ireland, Dr Paul Kelly, Consultant Radiation Oncologist, Bons/UPMC Cork, and Deirdre Somers, Chair, Cancer Trials Ireland Deirdre Somers, Chair, Cancer Trials Ireland, and Prof Ray McDermott, consultant medical oncologist, and Cancer Trials Ireland Clinical Leadership
Latest figures from Cancer Trials Ireland show that there were 364 people enrolled on clinical trials in Ireland in 2021, up from 320 in 2020. The retreat was supported by Pfizer, Roche, AbbVie, MSD, Novartis and Bayer. More information at www.cancertrials.ie
¤2.5 million for Women’s Health
Minister for Health Stephen Donnelly has allocated up to ¤2.5 million funding for priority areas within the Women’s Health Action Plan.
The Women’s Health Fund (¤10 million) will ring-fence ¤2.5 million for the National Women and Infants Health Programme in the HSE to accelerate service delivery in four critical areas in 2022.
Menopause: The Women’s Health Action Plan 2022-23 committed to developing 4 specialist menopause clinics nationally in 2022, this further investment will support 2 additional specialist Menopause Clinics, bringing a total of 6 such clinics nationwide for women who require complex, specialist care. Postnatal Care: The Women’s Health Action Plan 2022-23 committed to developing a new more holistic model for supporting women in the weeks after giving birth, this investment will support 2 additional community-based Postnatal Hubs for women, bringing a total of 4 hubs nationwide in 2022.
Endometriosis: The Women’s Health Action Plan 2022-23 committed to supporting the ongoing development of 2 supra-regional specialist centres for complex care for endometriosis for the firsttime. This latest investment will create a new tier of additional support at hospital level, by investing in resources for 6 additional interdisciplinary teams to support holistic treatment of endometriosis within each of the hospital networks.
Targeted Support for
Marginalised Women: The Women’s Health Action Plan 2022-23 put a clear focus on increasing supports for marginalised women and groups that face multiple disadvantages. This investment will support the implementation of additional medical social work resources across the six maternity networks, significantly enhancing this critical support at what can be a vulnerable time for many women. This ring-fencing marks the first allocations from the Women’s Health Fund for 2022 and will be supported throughout the year by other investments.
Improving Outcomes in Childhood Obesity
New research from RCSI University of Medicine and Health Sciences has analysed the impact of Ireland’s only obesity service for children and adolescents.
This study, conducted by the RCSI Obesity Research and Care Group and published in Frontiers in Nutrition, found that the W82GO Child and Adolescent Obesity Service at CHI Temple Street improves obesity-related outcomes for children and adolescents.
The W82GO Service is the only dedicated centre for paediatric and adolescent obesity management in the Republic of Ireland. It delivers tailored obesity interventions, including dietetic, psychological, medical, physiotherapy and medical social work support, as recommended by scientific guidelines. Dr Grace O’Malley, Lecturer in the RCSI School of Physiotherapy
As part of the W82GO Service, patients are referred by a paediatrician and then assessed by a physiotherapist, dietician and psychologist to develop personalised obesity treatment plans with the family, based on the child’s age and clinical need. In this study, the researchers looked at outcomes for almost 700 children and adolescents from a range of socioeconomic backgrounds who had engaged with the service over 12 years. By comparing growth chart data from the baseline and final visit, they demonstrated an overall reduction in sex- and age-adjusted BMI across the cohort, indicating that engagement with the W82GO Service is linked to improvements in health. The findings showed that younger children especially benefited from the treatment.
Dr Grace O’Malley, Lecturer in the RCSI School of Physiotherapy and senior author on the paper, commented on the findings, “Childhood obesity is a chronic disease that requires multidisciplinary and specialist intervention, however, access to treatment is limited globally. We must evaluate the impact of evidence-based interventions in real-world settings in order to increase the translation of research into practice and enhance child health outcomes.
“Our research shows that the W82GO Service is an important intervention for managing severe obesity in children and young people. In particular, we found that the intervention was especially impactful for younger service users, and those who engaged in the service for more than 12 months.”
Additional analysis revealed no significant association between change in BMI and any of the other parameters such as treatment type, sex, obesity category at admission or presence of comorbid conditions. Further research is needed to assess the impact of the W82GO Service on additional health-related factors, such as blood pressure, cholesterol levels, physical fitness and mental health.
The work described in the study was funded by The Temple Street Foundation, the Health Research Board of Ireland and the RCSI Strategic Academic Recruitment (StAR) Fellowship.
Another Piece Added to Covid Jigsaw
A large international study of hospitalised Covid-19 patients suggesting that the outcome to SARS-CoV-2 infection depends in part on the types of interactions occurring between the patients’ microbiota, metabolism and immune system has been published by APC Microbiome Ireland, SFI Research Centre at University College Cork (UCC).
In this well-controlled study of 172 hospitalised Covid-19 patients (from Cork, and Geneva, St. Gallen and Ticino in Switzerland), APC scientists demonstrated that hyperinflammatory responses and metabolic dysfunction were exaggerated in patients with a specific type of microbiota, and these patients were less likely to survive infection with SARSCoV-2.The research findings could mean that high-risk patients could be identified earlier through microbiome profiling, and could be afforded greater protection from severe Covid-19 symptoms by boosting their immune system with appropriately selected probiotics and/or prebiotics. The paper ‘A high-risk gut microbiota configuration associates with fatal hyperinflammatory immune and metabolic responses to SARS-CoV-2’ is published in the journal Gut Microbes and is co-lead-authored by APC Principal Investigators Liam O’Mahony and Paul O’Toole, both Professors in UCC. The research was supported by the SFI COVID-19 Rapid Response Research and Innovation Funding. Professor Liam O’Mahony APC PI and Professor of Immunology at UCC says, “This study further demonstrates that the microbes within us are intimately connected with immune and metabolic health. We now need to investigate how to positively influence these connections before a person becomes infected to help reduce risk of severe outcomes to infection.”
General Director of Science Foundation Ireland, Prof Philip Nolan, welcomed the findings, saying: “This research, undertaken by the APC Microbiome Ireland SFI Research Centre, provides new learnings into COVID-19 and demonstrates the continued important role of research in addressing the pandemic. SFI is proud to support excellent research that has the potential to sustain and further people’s health and wellbeing, while contributing to finding innovative solutions to this ongoing global challenge.” This paper is available as an Open Access article, A high-risk gut microbiota configuration associates with fatal hyperinflammatory immune and metabolic responses to SARSCoV-2, published in Gut Microbes, Volume 14 Issue 1, is now available to access via tandfonline.com.
Haemochromatosis Week
There are at least 20,000 undiagnosed cases of Haemochromatosis also known as “iron overload” in Ireland, the Irish Haemochromatosis Association (IHA) has said.
This year, to mark World Haemochromatosis Awareness Week, 1st – 7th June 2022, the IHA aims to raise awareness of the condition and is urging people to ‘Get Checked for Haemochromatosis,’ to highlight the symptoms in order to save lives – symptoms that range from chronic tiredness and joint pain to abdominal pain and sexual dysfunction.
Haemochromatosis is a genetic condition which causes the body to absorb too much iron. Over time this leads to a build-up of iron in the blood, bones, and organs like the liver and the heart. People with Haemochromatosis have a faulty gene which causes the normal system of iron absorption in the body to break down. Early diagnosis is vital and if left untreated, can lead to organ damage or even premature death.
While heart damage caused by haemochromatosis is thankfully not seen very often, when too much iron deposits in the liver it can cause cirrhosis and, in the heart, it can cause cardiomyopathy or problems with the heart muscle. It can also lead to heart failure.
Haemochromatosis is more common in Ireland than anywhere else in the world, as one in five people carry one copy of the gene and one in every 83 Irish people carry two copies of the gene, predisposing them to develop iron overload.
Professor Suzanne Norris, Consultant in Hepatology and Gastroenterology at St James’s Hospital in Dublin said, “Ireland has the highest rates of Haemochromatosis in the world. Ill-health from Haemochromatosis and the development of serious complications such as cirrhosis can be prevented by simple treatment and life expectancy in treated non-cirrhotic patients is normal. Early diagnosis is therefore critical.”
Obesity is a Complex Chronic Disease
Dr Conor Woods is a Consultant Endocrinologist in Naas General and Tallaght University Hospitals
Introduction & Definition
The myth of obesity being merely a lifestyle choice is slowly being debunked. People suffering with the chronic disease obesity are still not being listened to or given the right support or access to proven treatments. We need to rid all misconceptions regarding obesity. It is simply not a disease that anyone chooses, ever. Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health.1 This is an excellent definition although identifying ‘fat ….that poses a risk to health’ isn’t always easy! Athletes can be ‘heavy’ but may not have obesity. ‘Thin’ people can have metabolic dysfunction with fatty liver disease and Type 2 Diabetes mellitus (T2DM) from excess visceral adiposity. We use surrogate markers of excess weight such as body mass index (BMI) to help identify people at risk of the complications of obesity. The explosion of overweight and obesity has been seen across the world in both rich and poor economies. In Ireland, the numbers are sobering, with a majority is crucial in how these appetite & weight centres in the brain respond and control weight. Genome wide association studies, which examine thousands and thousands of genes and thousands of subtle gene alterations, show that persons with excess weight have multiple genetic alterations across hundreds of genes leading to increased susceptibility to weight gain. Interestingly the inverse is also true with ‘thin’ people having less of these genetic alterations; proving that thin people are not more virtuous, but instead have a different genetic make-up.4,5 Rarely, specific single gene abnormalities lead to significant obesity; examples include leptin deficiency and the melanocortin receptor 4 (MCR4) mutations in the hypothalamus.6 Genes change slowly and take hundreds of years to change – how has the epidemic of weight gain happened over recent decades?? Whilst our genetic make-up hasn’t changed significantly in recent times, the same is not true of our environment. The world we live in is very different compared to that of our ancestors! We have engineered our world to such a degree that a majority of us will rarely if ever experience hunger. Central heating, refrigeration, transport, elevators, sedentary work, supermarkets, the ‘western’ diet and advertising are just a few of the many environmental factors that impact on energy balance and our weight. Like any other complex chronic disease there are many other factors involved in excess weight and obesity. These include psychological issues around food (comfort or binge eating), mental health and medications such as steroids. More recently the gut microbiome has become a focus of attention for research and how different types of gut bacteria influence weight and health.
Consequences & Stigma
Obesity is proven to cause over 200 distinct health problems; from poor mental health, cancer, liver disease, T2DM, Obstructive Sleep Apnoea (OSA), cardiovascular disease and osteoarthritis. The full list of obesity related complications is extensive. Persons with obesity (PwO) are at higher risk of acute illness such as infection. Increased risk of ventilation and higher risk of death was clearly seen in PwO that contracted Covid-19.7 The number of cancer cases caused by obesity is estimated to be 20%.8 Obesity is strongly linked with endometrial, oesophageal, colorectal, postmenopausal breast, prostate, and kidney cancers. Society frequently judges those with excess weight and obesity in a negative fashion. This stigma is a very real and lived experience for those with this chronic disease.
Investment in the treatment of obesity has been negligible in Ireland to date. Despite both our government and the European Union recognising obesity as a disease, we still lack the necessary supports to help PwO treat their disease. Government policy needs to move on from just simple prevention, and properly invest in obesity treatments especially weight loss surgery. A small optimistic sign is the recent launch of the model of care programme for the management of overweight and obesity in Ireland.9 This is a positive 1st step in transforming Irelands approach to obesity. Despite the excellent and growing scientific body of evidence clearly showing the reasons why people gain weight and develop obesity – there is significant on-going stigma and resistance to investing in obesity treatments. It remains perhaps the biggest obstacle in the treatment of this disease both at government and societal levels.
Treatment
The good news is there are options to help patients treat obesity. Prevention is crucial and will hopefully be a key feature of govt. policy going forward. Prevention of a disease however, is not the same as treatment. Significant urgent investment is needed. It is also important to emphasise the need to gain health rather than just focus on weight loss per se. Broadly speaking there are conservative treatments such as dietary & lifestyle interventions and drug options. There are also more invasive treatments such as bariatric surgery. The ‘eat less and move more’ model widely preached across media and health services works for only a minority of patients. Supervised very low calorie diets and sustained
(>65%) of adults having excess weight or obesity.2
Pathophysiology
The reasons for obesity have been well described and although further detail is required, we know a lot about the factors that contribute to a person’s weight.3 The centres that control our appetite, energy intake and weight are based in the brain, in areas such as the hypothalamus and the arcuate nucleus. These centres output signals to trigger weight maintenance or weight gain via different mechanisms in the body including alterations in hunger and satiety hormones. Akin to the areas that control breathing or body temperature, these ‘appetite’ centres cannot be controlled by thinking or conscious mental effort at all – one cannot breathe less or reduce high temperatures by thought or simple will power; similarly we cannot think to eat less or burn more energy. The brain centres will react accordingly and make compensations elsewhere to maintain weight or trigger weight regain. Our genetic make-up plays a major role in our energy homeostasis and
significant weight loss over a 12 month period has been shown to revert T2DM in PwO.10
There are a number of medications available to help PwO, lose weight. Medical therapies include Glucagon Like Peptide–1 receptor agonists such as liraglutide 3mg, bupropion-naltrexone and Orlistat. Other gut hormone molecules and combination of gut hormones are in the pipeline and show extremely promising weight loss results. For full prescribing information please see www.medicines.ie or EMA website for product SmPCs. We cannot predict who will respond to a drug and frequently a trial of four to six months is required. Unfortunately, cessation of drug therapy usually results in weight regain. Weight loss surgery is an excellent treatment option for PwO. Bariatric surgery is generally recommended for those with a BMI greater than 40kgs/m2 or at a lower cut-off 35 kgs/m2 if there are metabolic complications such as T2DM or OSA. There are essentially two types of surgery carried out; sleeve gastrectomy and gastric bypass. Both are excellent in achieving significant weight loss and gaining health. Large international studies show the benefits of these procedures in extending life, reversing T2DM , reducing liver disease, reducing OSA, reducing heart disease among many other benefits.11-15 Elective bariatric surgery is extremely safe and nearly always carried out laparoscopically. Surgery does not cure obesity, but should rather be thought of as a treatment that helps patients lose significant weight and gain physical function and health.
Conclusion & Summary
Obesity is caused by a mixture of genetics, biology, environment and other factors all leading to excess weight gain. Despite maximal personal effort – it is extremely difficult for an individual to eat less and move themselves more, toward a leaner body. We all need to work hard at reducing stigma associated with obesity. Surgery for weight loss is proven and is excellent at improving health. Ireland needs increased weight loss surgery capacity. The newer medications that are beginning to come on stream offer a very promising future for PwO. Looking forward, we need to plan for increased access to obesity treatment and better prevention. Government needs to be proactive and get the model of care funded and fully operational. This article has been funded by Novo Nordisk. Novo Nordisk has not influenced the content of the article.
References
1. Obesity and overweight. https://www.who.int/newsroom/fact-sheets/detail/obesity-and-overweight. 2. Healthy Ireland Summary Report. Healthy Ireland
Summary Report https:// assets.gov.ie/41141/e5d6fea3a59a4720b081893e11fe299e.pdf (2019). 3. Upadhyay, J., Farr, O.,
Perakakis, N., Ghaly, W. &
Mantzoros, C. Obesity as a
Disease. Med. Clin. North Am. 102, 13–33 (2018). 4. Genetic architecture of human thinness compared to severe obesity - PubMed. https://pubmed.ncbi.nlm.nih. gov/30677029/. 5. Clément, K. et al. Efficacy and safety of setmelanotide, an MC4R agonist, in individuals with severe obesity due to LEPR or POMC deficiency: single-arm, open-label, multicentre, phase 3 trials. lancet. Diabetes Endocrinol. 8, 960–970 (2020). 6. Kühnen, P. et al. Proopiomelanocortin Deficiency Treated with a Melanocortin-4 Receptor
Agonist. N. Engl. J. Med. 375, 240–246 (2016). 7. Simonnet, A. et al. High Prevalence of Obesity in Severe
Acute Respiratory Syndrome
Coronavirus-2 (SARS-CoV-2)
Requiring Invasive Mechanical Ventilation. Obesity 28, 1195–1199 (2020). 8. De Pergola, G. & Silvestris, F.
Obesity as a major risk factor for cancer. J. Obes. 2013, (2013). 9. Model of Care for the Management of Overweight and
Obesity. https://www.hse.ie/ eng/about/who/cspd/ncps/ obesity/model-of-care/obesity-model-of-care.pdf. 10. Lean, M. E. et al. Primary careled weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.
Lancet (London, England) 391, 541–551 (2018). 11. Sarabu, N. Weight and Metabolic Outcomes 12 Years after
Gastric Bypass. N. Engl. J.
Med. 378, 93–4 (2018). 12. Syn, N. L. et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a
one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet (London, England) 397, 1830–1841 (2021). 13. La Sala, L. & Pontiroli, A. E.
Prevention of diabetes and cardiovascular disease in obesity.
Int. J. Mol. Sci. 21, 1–17 (2020). 14. Uhe, I. et al. Roux-en-Y gastric bypass, sleeve gastrectomy, or one-anastomosis gastric
bypass? A systematic review and meta-analysis of randomized-controlled trials. Obesity (Silver Spring). 30, 614–627 (2022). 15. Quintas-Neves, M., Preto, J. & Drummond, M. Assessment of bariatric surgery efficacy on Obstructive Sleep Apnea (OSA). Rev. Port. Pneumol. (English Ed. 22, 331–336 (2016).
Summary: The philosophy of the Hermitage Clinic at Blackrock Health is one of service and an acknowledgement of the holistic needs of patients, not just from a clinical perspective but also from a psychological, emotional and spiritual perspective also. In an effort to improve patient outcomes as well as providing a convenient service to patients, The Pharmacy Department launched the Discharge Medication (TTO) Service in 2021.
This new service aimed to bridge the gap between primary and secondary care, easing the transition for the patient from one setting to the other and aimed to replicate the National Health Service (NHS) provision of medication on discharge from hospital. The service provides for clinical pharmacist reconciliation of patient medicines on admission and discharge, and see’s pharmacy staff counsel patients at their bed-side with their new medications in-hand as a visual prompt. Benefits to the patient include a clinical pharmacist who is trained to interpret biochemical results and their effects on pharmacokinetics providing a ‘clinical screen’ of discharge medication with subsequent inhouse dispensing of the discharge prescription. In addition to this, the patient no longer has to find a community pharmacy that may or may not be open on their way home. This is not only convenient for the patient but also reduces any delays to the administration of time sensitive medications.
Background
A variety of clinical pharmacy services exist across the international healthcare landscape. Irish clinical pharmacy services are increasingly getting recognition for the wonderful output of clinical pharmacists in the secondary care setting. With more specialist roles being recognised and funded in Ireland e.g. Cystic Fibrosis or Hepatitis C Specialist Pharmacists, we are beginning to mimic frameworks that have existed in the NHS for some time. Another component of the NHS clinical pharmacy service is the pharmacist clinical screening, and subsequent provision of, medications on discharge, coined ‘To-Take-Out’ or ‘TTO’ medications. This service aims to recognise the potential multitude of changes to regular medications patients may experience during their inpatient stay, and to assess whether acute (or temporary) medications can be safely taken by the patient alongside their regular medication. Clinical pharmacists will make several interventions during the course of their day in order to optimise the prescribing and administration of medicines and reduce the incidence of harm. These may relate to simple prescribing errors like incorrect dosing, omitted drugs or contraindications. Interventions may also relate to the pharmacokinetic principles of medication which include the patient’s ability to absorb, distribute, metabolise, and excrete prescribed medications. During a hospital stay patients will commonly experience altered physiological states as a result of a variety of occurrences (e.g. blood loss post-op, infections etc). These changes will alter the patient’s abilities when it comes to pharmacokinetic principles. The interpretation of blood results for predicting a patient’s ability to excrete medication is a key part of a clinical pharmacist’s daily routine. With this information potentially unavailable to a community pharmacist when presented with a prescription, it means the same calculations cannot be completed and a potentially important second check may not be possible. Senior management within the Hermitage Clinic recognised the importance of bridging the gap between primary and secondary care and approved the business case for the implementation of a TTO-style service known as the “Discharge Medication Service”. One WTE pharmacy technician was appointed to assist with the dispensing of the discharge medications once they were screened by a clinical pharmacist. This appointee has been able to support trained medicines management
Figure 1 Pharmacist and Medicines Management Pharmacy Technician dispensing TTO's
Written by Patrick Foley, Head of Pharmacy, Blackrock Health at The Hermitage Clinic
Patient
Figure 2 Patient Information Leaflet Describing TTO Service
PHARMACY DEPARTMENT Discharge Medication Service
pharmacy technicians and clinical pharmacists in counselling patients wishing to avail of the service.
Research
A systematic review of quantitative literature relating to medication reconciliation at discharge from hospital was conducted in 2015 by Irish researchers. They found that among the 15 studies, 60% of the over 6000 patients, experienced a medication discrepancy on discharge from hospital. One of the studies breaks down likelihood of experiencing a medication discrepancy by age. Those over 75 years of age were almost twice as likely to experience medication discrepancies as patients under 60. This could be related to the requirement on patients with potentially reduced cognition to interpret written or verbal instructions on discharge from hospital which may differ between doctor’s intentions, discharge summary, and eventually prescription for dispensing. This data was strongly backed up by findings in the NHS by the National Patient Safety Agency (NPSA) who described 30-70% of patients as experiencing an error or unintended change to their medicines when transitioning through care settings. A collaborative service evaluation across 50 acute care trusts examined 8,621 patient’s prescribed medications and found 11,366 unintentional discrepancies, or 1.32 per patient. The Royal Pharmaceutical Society produced a report in 2012 titled, “Keeping patients safe when they transfer between care providers – getting the medicines right”, in an attempt to reduce the incidence of medication errors when patients are for example discharged from hospital. The report outlines key principles, responsibilities, and recommendations for effective transfer of medication information when discharging patients. The National Institute for Health and Care Excellence in their Medicines Optimisation guidance describe the importance of medicines related communication systems when patients move from one care setting to another. They state that organisations should ensure robust and transparent processes are in place. They also provide definitions of what robust and transparent processes must look like. The discharge system should ensure that patient safety is not compromised. Inappropriate care may result from inconsistencies in processes.
Effect on organisation
While the initiative is still in its infancy, a number of benefits to patients and the organisation have already been noted.
Improvements in Medication Safety for patients
Due to the enhanced role of the clinical pharmacist in reviewing medications on discharge, a number of potential medication incidents have been identified before the patient leaves the hospital. These incidents have ranged from relatively straightforward omissions of regular medication to contraindications and even the prescribing of non-steroidal anti-inflammatory medication to patients with chronic kidney disease.
Increased efficiency at ward level
A portion of the clinical pharmacist interventions would no doubt be picked up in the community. Often these may have related to omissions of medications or unclear plans in relation to for example tapering doses of medications. Previously this would have involved phone calls being placed by busy community pharmacists to the ward the patient may have been on. A nurse would then have had to contact the patient’s consultant for clarity and then relay this message back to the community pharmacist. This process invariably took many hours of time to resolve often resulting in delays to the provision of treatment to the patient in the community as well as adding to the nurse and community pharmacist’s workload. The introduction of the Discharge Medication Service has resulted in a decrease in such incidents
Improvements in antimicrobial stewardship
With a knowledge of the hospital’s antimicrobial guidelines and vital clinical information available to the clinical pharmacist numerous interventions relating to antimicrobial stewardship became evident e.g. a patient had sensitivity information available detailing they were resistant to the prescribed medication on discharge, the pharmacist was able to intervene and have alternative therapy prescribed. With discharge dispensing data now available to the hospital we can comment on and audit our provision of oral antibiotics. With this information not previously being available we can further improve our antimicrobial stewardship. Similarly, our provision of analgesics and hypnotics was now auditable from a central database. A significant volume of elective orthopaedic procedures are carried out at the Hermitage Clinic. The provision of potentially harmful potent opioid medications has gained great notoriety in the past decade particularly in the United States. It became apparent that we very rarely issue these types of medications on discharge, and when we do they are for a defined period, usually 72 hours.
Commercial Opportunities
The provision of a TTO service is already standard in the NHS and is also a requirement by them for any third parties providing care to NHS registered patients. The introduction of the Discharge Medication Service has allowed the Hermitage to bid for contracts to
Figure 3 Pharmacists work closely with their medical colleagues on the ward. Here Clodagh Dolan, Senior Pharmacist, clinically screens a TTO Prescription
provide care to patients who reside in Northern Ireland. These contracts require a service akin to that which exists in the NHS and therefore a 14 day supply of medication is made on discharge. This has led to an increase in the number of agreements the Hermitage has with Hospital Trusts in NI resulting in an increase in revenue across various relevant departments.
Revenue Generation
The project has generated revenue in the form of patients paying for their private prescriptions to be dispensed. These costs are comparable to those that would be paid in the community and often the patient will choose to avail of the service due to the overwhelming convenience. Patient’s will often cite the need to find a community pharmacy, find parking and queue up and wait in the shop as a motivation for availing of the service. The project although in its infancy, has already produced a positive net present value since uptake continuing on an upward trajectory. There are also substantial increases in revenue related to the organisations’ ability to bid for and fulfil NHS contracts.
Plans going forward
The Hermitage Clinic will continue to promote the service throughout the hospital. An information campaign is already in process that see’s patients being made aware of the service on admission. Patients are provided a patient information leaflet relating to the service, which outlines the benefits and what the service entails. It is anticipated that these measures will increase the uptake of the service, increase patient satisfaction and lead to growth in revenue generation for the pharmacy department and from gaining NHS contracts. The hope is that the new discharge medication (TTO) service will become embedded within the culture of the organisation. While the hospital will continue to provide the service and encourage as many patients as possible to avail of the service owing to its convenience for them, the service does not currently provide medications free of charge for medical card holders or patients on long term illness plans. We will look to address this as the service develops so that the scope can become more far-reaching. Another hurdle within the provision of the service is the requirement for the input of the clinical pharmacist on the ward to screen the discharge medications prior to dispensing. The requirement adds a new work stream for the clinical pharmacist. But on balance the improvement to medication safety, and the decrease in potential complications and resultant phone calls back to the ward to clarify ambiguities, make it a worthwhile endeavour for the clinical pharmacist. Costs are another obvious concern to any organisation wishing to embark on similar plans, but these may be underwhelming. The Hermitage Clinic found that per discharge the cost of the drugs supplied to patients availing of the service was around ¤14. As is the case in the NHS, a targeted ‘discharge formulary’ to avoid high-tech or very high cost medicines could be agreed upon which would aid a similar roll-out in the public sector. There is also a potential scope for revenue generation in the public sector for the cohort of patients that do not avail of HSE schemes.
Initial feedback from patients is overwhelmingly positive, with most citing the convenience of the service as the most positive aspect. All of these factors make a compelling argument for the roll out of the service in other Blackrock Healthcare sites. Plans are currently at draft stage and it is expected that they will be positively reviewed with a view to implementation at some point in the future. We would hope that the success of this service in a private sector acute hospital may prompt the question as to how it could be rolled out in other hospitals, including public hospitals, and how the Hermitage Clinic could inform this discussion and assist with implementation plans? A similar provision in the public sector would vastly improve medication safety at a key transition of care. Irish researchers in a 2015 review of published
Senior Pharmacist Clodagh Dolan and Head of Pharmacy Patrick Foley were finalists at the recent Irish Healthcare Centre awards for their part in the Discharge Medication Project
data relating to medication reconciliation at discharge identified the incidence of medication discrepancies at the point of discharge from hospital as a ‘problem and one that the healthcare system needs to address’. Some improvements and attempts to address the problem have been made since that review was published, but widespread introduction of a discharge medication service where patient’s prescriptions are routinely screened by Clinical Pharmacists with hospital provision of medication would be a significant step forward. The TTO service has been a tremendous improvement to medication safety, patient convenience and efficiency, and it is a service which will be embraced by Blackrock Health at the Hermitage Clinic long into the future.
Medication safety is paramount at every stage of the patient’s journey, and research has shown the positive effects of pharmacist-led medication reviews on inpatient adverse drug events. Extending this service to the screening of discharge prescriptions can further improve medication safety, due to the prevalence of medication errors on transfer of patients from secondary to primary care. The provision of a Discharge Medication Service (‘TTO’ service) adds a safety screen for patients on discharge. It allows for medication reconciliation on discharge and identifies any potential errors, interactions and monitoring requirements. It can aid patients’ understanding of their discharge medications, as well as the added convenience of providing them with their discharge medications before leaving hospital. In my experience from working in hospital pharmacy in both the UK and Ireland, screening of the discharge prescription by a clinical pharmacist – and indeed writing of the discharge prescription by a pharmacist prescriber – is common practice in the UK, but is yet to become a core service provided by clinical pharmacists in Ireland. Expanding the pharmacy service required a change in practice from the entire pharmacy team from their traditional roles of inpatient medication review and supply, including the dispensary team, Medication Management Pharmacy Technicians (MMPTs) clinical pharmacists and the wider hospital staff. Though the service is still in its development, it has been perceived positively by patients, particularly by our younger surgical patients and day procedure cohort, who pay privately for their medications. The service has also brought its own challenges and limitations. The service requires more clinical pharmacist and dispensary staff time and puts more onus on the pharmacy department to allow a safe and timely discharge for patients. Patients may prefer to visit their own community pharmacy to avail of the medication schemes available such as GMS and DPS which for the moment are unavailable form the hospital. Examples of recent interventions on discharge include the prevention of potentially elevated clozapine levels by co-administration of celecoxib; preventing the use of ferrous fumarate in a patient with family history of haemochromatosis; stopping tramadol in a patient with history of seizures and stopping the unintentional prescribing of aspirin to a patient who regularly takes a DOAC.
Clodagh Dolan, Senior Pharmacist
I believe the novel and unique Discharge Medication Service provided by Blackrock Health at the Hermitage Clinic is an essential service that is paramount to delivering the final step of a completed healthcare experience for patients admitted to hospital. This is a highly beneficial service for patients who can conveniently and comfortably obtain supply and thorough counselling of their discharge medications, by experienced pharmacists, medicines management technicians and Pre-reg pharmacy students. As a Pre-Reg pharmacy student operating within this service, I play a role in initially reviewing the prescription ensuring it is legally valid and that it is therapeutically appropriate for the patient, prior to the pharmacist’s clinical screen. Once I have completed dispensing the discharge medications, it then undergoes a final accuracy check in the dispensary prior to being released. I then play a huge part in counselling patients on their prescribed medication ensuring that I communicate effectively and confirm a counselling checklist which includes: their understanding on the use of the medicine, directions for use, how to administer it, duration of treatment, expected therapeutic benefit, potential side effects, any special precautions including those regarding food or drink, importance of compliance, storage and the correct use of a therapeutic device if applicable. My current role in the discharge medication service did not begin however until I had completed thorough training under the supervision of highly qualified and experienced pharmacists within our pharmacy department. I first had to ensure that I could competently dispense a variety of prescription types without mistakes and counsel patients at their bedside on a diverse range of medications while being supervised. This experience has been invaluable as it has allowed me to gain a huge insight into the counselling requirements for patients on high risk medications such as apixaban. I have become very confident when speaking to patients and have learned a significant amount particularly in relation to high risk medication like apixaban. I believe this is a remarkable service which should be employed in Irish hospitals nationwide to optimise the delivery of healthcare to patients and to enhance the training of Pre-Reg pharmacy students.
Clodagh McDermott, Pre-Reg (APPEL) Pharmacist
Figure 4 Patients are counselled on their medication at the bedside. Here, Clodagh McDermott, Pre-Reg (APPEL) Pharmacist counsels the patient on a newly prescribed anti-hypertensive
Undertaking my pre-registration placement at the Blackrock Health Group at the Hermitage Clinic (HMC) has given me the advantage of having an active involvement in the TTO (discharge medication) service. As this is my first placement in a hospital I was shocked to hear that such a service isn’t in place in every hospital; it makes perfect sense. Aside from the convenience of getting to go straight home, avoiding queues and parking-having a prescription dispensed in the HMC involves a clinical screen of the discharge prescription, with the patient's clinical details readily available. In order to be involved in the TTO service without being a qualified pharmacist I was required to complete various competency logs. Counselling sessions were observed by a pharmacist to prepare us, these witnessed counselling episodes had to contain as a minimum dose titrations of steroids, a NOAC, inhaler use, insulin administration and initiation and many more scenarios. A summary of the counselling had to be written into our log book including what went well, what could be improved upon and any learning points. Once completing the logs we were deemed eligible to dispense TTO prescriptions, once a pharmacist carried out a final check, and then counsel patients at their bedside. We could then take the medication to the patient and engage in counselling ourselves. The involvement in such a service has been highly beneficial to my training as a pre-reg pharmacist, without it I may not have the experience of considering a patient's situation beyond discharge or being involved in their education. I now believe it to be really important that patients receive a clinical pharmacist screen on discharge from hospital. I have seen numerous pharmacist interventions made for patients prescribed NSAIDs with diminished renal function for example. Prior to commencing a hospital placement I was apprehensive about the possibility of there being less patient counselling experience which I need to complete my final OSCE. The experience however is the opposite, at the Hermitage pharmacy department I am at the patient’s bedside on a daily basis helping them in their transition back to primary care. I will carry with me the learning I have gained from being involved in this service well into my future career.
Chloe Breen, Pre-Reg (APPEL) Pharmacist
Cosmetic Association Trade Fair
The Cosmetic Association, after an absence of two years returned at The RDS in Dublin from Sunday May 15th - Tuesday May 17th.
The event provided an opportunity for pharmacy to ensure their Christmas purchasing completed in one day under one roof rather than trying to execute the task in store with many suppliers in the coming weeks. The show was open from 10am to 6pm on Sunday, and until 8pm on Monday to facilitate those who are finding pharmacist cover difficult.
At the Blank Canvas Cosmetics stand were Susie Dwyre and Amanda Dwyre, Adrian Dunne Pharmacy, Trim
Green Angel Cosmetics visitors Beverely McGuckin, Sarah Kelly and Christine Farrelly from O’Kane’s Chemist, Draperstown with Tom Graham, Green Angel
Caroline Deady, BPerfect and Deirdre Richardson, Voduz Andra Rooney, Area Manager and Rhys Phillips, Revive Active
Caroline Deady, BPerfect and Deirdre Richardson, Voduz
Tina Buckley Sales Director UK and Ireland, Zoe Spillane, Key Account Manager East and Shirley Hornibrook Key Account Manager South Kare Cosmetics Belle Brush Stand
Eurosales International The team from Daarwood Pharmacy, Limerick
OPI Nail Demonstration Allegro Luxury Brands
John Paul Healy Munster Sales Representative for Uniphar Link Up Consumer
Jennifer Lyons and Aoife O’Melia from the Tan Organic stand Aoife Nic Chuirc Key Account Manager for Uniphar Link Up Consumer and Aine Devlin Uniphar Brand & Trade Marketing Manager
Allegro Nivea Gift Train Display United Drug Consumer Team
