IPN 2022 July

July 2022 Volume 14  Issue 7 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS: FMD Use and Learn Ends Page 5

REPORT: Price Variations in Pharmacy Medicines Page 10

AWARDS: LloydsPharmacy Recognition Awards Page 18

BACK2SCHOOL: Asthma and Allergies Page 31

CPD: Psoriasis and Eczema Page 41

MEDICINES: Discharge Medication: Bridging the Gap Page 64

EVENTS: Cosmetics Association Trade Fair Page 69

TEAM TRAINING: Pain in Children Page 74 This Publication is for Healthcare Professionals Only

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Contents

Foreword

Page 4: Value Added Medicines report published

In one of our lead news stories this month, on page 6, the Irish Pharmacy Union (IPU) has welcomed the recent announcement by the Minister of Health of his intentions to introduce an HPV vaccine catch-up programme and has called on the Minister for Health to utilise pharmacies which, it argues, are ideally placed to deliver the campaign. IPU President Dermot Twomey says Pharmacies are best placed to administer HPV vaccinations, particularly to women who, for any reason, did not receive one while at school.

Page 6: Minister visits Bray Pharmacy Page 8: Medicines spending in Ireland ‘stable’ Page 10: Lack of transparency in drug pricing

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Page 14: Event Day for staff at totalhealth and Haven Pharmacies Page 22: Mental Health in School Children Page 37: Pharmacy role in Migraine Pathway

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Page 47: Lifting the Fog on Chemobrain Page 64: Bridging the Gap in Medication Discharge PUBLISHER: IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

Meanwhile, a study from Trinity College Dublin and RCSI University of Medicine and Health Sciences made media headlines when it investigated the variation and availability of prescription drug prices in community pharmacies in Ireland. The study showed drug price variations and a lack of transparency with the authors noting “The large price variation for prescription drugs and the lack of transparency from pharmacies is a problem, as it may mean that some people are paying too much for their medication. Or worse, some people are not buying their medication because it costs too much.”

Turn to our report on page 10 to read the full story.

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MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

In this issue we carry a special focus section on the Back to School market, with some excellent contributed articles including Allison Dunne reflecting on the need to help families protect young people’s mental health on page 20 and Ruth Morrow, Respiratory Nurse Specialist with the Asthma Society of Ireland visiting common issues for children with asthma on page 24.

The pharmacy department at the Hermitage Clinic at Blackrock Health recently launched a Discharge Medication Service with the aim of improving patient outcomes as well as providing a convenient service to patients. Patrick Foley, Head of Pharmacy writes a detailed article explaining this service further, and the benefits it is bringing. Turn to page 64 to read more about this excellent work.

EDITOR Kelly Jo Eastwood: 00353 (87)737 6308 kelly-jo@ipn.ie ADVERTISING EXECUTIVE Amy Evans: amy@ipn.ie EDITORIAL/ EVENTS & MARKETING EXECUTIVE Aoife Jackson: aoife@ipn.ie

On page 8 we reveal that Ireland’s spend on medicines as a proportion of overall health expenditure is below the average of 15 other European countries, according an industry analysis of official Irish figures, alongside an international study. Last year, the State spent ¤2.54 billion on medicines, pharmacy and wholesaling costs – 13.4% of the overall health budget of almost ¤19 billion – according to estimated figures from Irish Government Economic Evaluation Service in the Department of Public Expenditure and Reform.

I hope you enjoy the issue.

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CONTRIBUTORS Dr Kate Gajewska Allison Dunne Ruth Morrow Bernie Carter John Halloran Shauna Monaghan Dr John Ashworth Dr Sarah-Jane Leigh Rebecca Conway Dr Conor Woods Patrick Foley

DESIGN DIRECTOR Ian Stoddart Design PHARMACYNEWSIRELAND.COM @Irish_PharmNews IrishPharmacyNews

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.

Regulars FEATURE: DIABETES IN CHILDREN

P20

FEATURE: SEXUAL HEALTH EDUCATION

P28

CPD: COMMON SKIN CONDITIONS

P41

FEATURE: AGEING AND THE IMMUNE SYSTEM

P53

TEAM TRAINING: PAIN IN CHILDREN

P74

CLINICAL PR:

P80

PHARMACYNEWSIRELAND.COM

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News

Pharmacy Shortages Raised in Dail Irish Pharmacy News understands that the Pharmaceutical Society of Ireland (PSI) is currently undertaking a project, due to run across 2022-’23, ‘Emerging Risks to the Future Pharmacy Workforce’. In 2022, this project is set to “assess emerging risks to the continued availability of a professional pharmacy workforce within community and hospital pharmacy in Ireland.”

Minister for Health Stephen Donnelly revealed this in answer to a question in the Dail posed by Deputy Catherine Murphy, who asked the Minister for Health his plans to address the shortage of pharmacists and pharmacy technicians in the State.

Minister Donnelly stated, “I understand that currently there are reports to the PSI of a current acute workforce issue, particularly in relation to community pharmacy, and indicate that this is being driven in part by an increasing number of pharmacists choosing to work in a locum capacity. This has a knock-on impact on pharmacist vacancies, and potentially on continuity and consistency of service. The PSI has been liaising with stakeholders, including the Irish Pharmacy Union (IPU) on efforts being taken within

the sector to understand and address the issue. In February 2022, PSI met with a number of superintendent pharmacists and the IPU. The PSI also circulated a survey on behalf of the IPU to all registrants to support in efforts in understanding and addressing the issue in the short term, the results of which are pending.

“I understand that the IPU are seeking to establish a stakeholder group to examine the issue.

“The PSI is currently undertaking a project, due to run across 2022’23, ‘Emerging Risks to the Future Pharmacy Workforce’.

“The European commission is also currently supporting a health and social care workforce planning strategy and action plan, a health and social care workforce planning model, health and social care

workforce projections and gap analysis project. Support includes recommendations for health and social care workforce reforms.

“This is a complex problem with many contributing factors and multiple stakeholders. Workforce challenges are being experienced in other sectors nationally, and in the pharmacy sector in a range of other countries. However, robust data for Ireland is needed to be able to determine the current landscape, assess future health system needs and understand existing sectoral challenges now and into the future. It will be on the basis of gathering and analysing this up-to-date, robust and relevant data, that recommendations can be proposed to address Ireland’s needs as Ireland’s healthcare system evolves, and in the context of Sláintecare implementation.”

New Pharmacy for Drumcondra The team at Keane’s CarePlus Pharmacy Group recently opened their new Drumcondra Pharmacy Store.

Pictured at Pharmacy team members Gillian, Supervising Pharmacist and Store Manager Hazel, Support Pharmacist Lara, Sandra and Jessica ready to welcome customers to their new store.

The new store opened its doors on June 7th and has many new exciting new smart features. It is located in the Lidl complex at Drumcondra Road Upper, Dublin 9.

New President at RCSI The RCSI (Royal College of Surgeons in Ireland) has announced the election of Professor Laura Viani as the new President of the College and Professor Deborah McNamara as Vice President.

Professor Viani takes up office following the College’s biennial Council Elections which have seen a female President and female Vice President taking up office together for the first time in RCSI’s history.

Professor Laura Viani is a consultant otolaryngologist and neurotologist at Beaumont Hospital and the Children’s University Hospital Temple Street. She is Director and Professor of the National Cochlear Implant Programme and Hearing Research Centre and is founder of this national specialty. She replaces outgoing President, Professor P. Ronan O’Connell.

Professor Deborah McNamara, a consultant general and colorectal surgeon at Beaumont Hospital, has been elected as the new Vice President. She has built a deep experience of the healthcare system as co-lead of the National Clinical Programme in Surgery and as a national healthcare quality improvement leader.

Speaking on her appointment, Professor Laura Viani said: “It is my great honour to be elected today as President of the Royal College of Surgeons in Ireland. My presidency of RCSI follows the global pandemic and HSE cyber-attack which have presented our surgical community with challenges that will shape the future of surgery for years to come.

“With unprecedented numbers of patients having operations cancelled and on surgical waiting lists, it is critical that we secure the future of surgical services for our patients.

Providing the highest standards of surgical training and fostering of surgical professional excellence is central to maintaining these vital services.

“I look forward to working with our community of 10,000 Fellows and Members across 87 countries and sharing our expertise as we build a virtual network for continuing surgical education.”

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News Medicines Shortages The Health Products Regulatory Authority has been notified of a shortage of the following products: • Anapen Junior 150mcg in 0.3ml Solution for Injection in a Pre Filled Syringe PA22580/001/001 • Androcur 100mg Tablets PA1410/001/001 • Caelyx 2mg/ml Concentrate for Solution for Infusion (10ml presentation) EU/1/96/011/001-002 • Cholestagel 625mg Film Coated Tablets EU/1/03/268/001-3 • Doxatan XL 4mg Prolonged Release Tablets PA0126/202/004 • Efient 5mg Tablets EU/1/08/503/002 • Emtricitabine/Tenofovir disoproxil Accordpharma 200mg/245mg Film Coated Tablets - PA2315/200/002 • Klacid LA 500mg Modified Release Tablets PA2010/004/004 • Palladone SR 8mg Prolonged Release Capsules PA1688/007/009 • Roactemra 162mg Solution for Injection in Pre Filled Pen EU/1/08/492/009 The following shortages have been resolved and supply has resumed to the Irish market: • Ceftriaxone 1g Powder for Solution for Injection or Infusion - PA0281/225/001 • Claforan Powder for Solution for Injection 500mg PA0540/037/002 • Genotropin MiniQuick 0.6mg Powder and Solvent for Solution for Injection PA0822/128/005 • Metaraminol 10mg/ml Solution for Injection/Infusion PA22893/001/001 • Perinal Cutaneous Spray PA0278/017/001 • Piriton 4mg Tablets PA0678/080/001 • Ultiva 5mg Powder for Concentrate for Solution for Infusion- PA1691/032/003

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The Value of Value Added Medicines A new report, which focuses on the benefits of using Value Added Medicines in an EU context, has been published by Medicines for Ireland. ‘Value Added Medicines: Advancing Medicine Repurposing in the EU’ builds on the 2021 published report ‘Discussion Document on the Contribution of Value Added Medicines (VAMs) in Ireland’. It has been produced in conjunction with sister organisation, Medicines for Europe.

Value Added Medicines (VAMs) are medicines based on known molecules that address healthcare needs and deliver relevant improvements for patients and healthcare professionals. VAMs are key drivers for access to medicines and are increasing patient quality of life for chronic diseases, while offering significant benefits to the healthcare community.

VAMs offer a wide range of benefits from ensuring better adherence and compliance, to keeping healthcare costs down by reducing the need for patients to be moved to expensive next line therapies. The importance of using VAMs to address unmet medical needs in a timely and cost-effective manner has been highlighted during the Covid-19 pandemic.

The 2022 report stresses that in order to make medicine repurposing a success on an EU level we need to employ all resources at hand to connect different actors. One such connection which can uniquely be addressed by the EU is to assist academia and non-commercial stakeholders in conducting research, as well as facilitating their partnering with the industry in making repurposed medicines available to patients.

The early involvement of industry in repurposing projects opens a range of opportunities like new indications, different/adjusted delivery forms, changing dosage and combining different therapies

Padraic O’Brien, Chairperson of MFI

to meet the needs of the patient community and to bring to market new treatment options in an accessible and affordable way.

Furthermore, for more repurposing projects to come to fruition, we need to adapt the EU pharmaceutical ecosystem, starting with recognising the need for a tailored development approach for VAMs, including repurposed medicines. VAMs should be acknowledged as a separate group of medicines in EU legislation.

“Ireland can learn a lot from our EU peers. The industry needs to continually innovate, meanwhile, the state and regulators still have an important role to play,” said Padraic O’Brien, Chairperson of MFI. “We need a system that rewards innovation with appropriate incentives, whilst recognising the potential longterm value and savings that VAMs can bring to the State.”

“At MFI, we are committed to improving patient care and delivering value to the HSE and are proud to drive stakeholder engagement on this important topic,” said Clodagh Kevans, Chair of the MFI VAM Committee.

“We believe that we need a new and simplified regulatory pathway for VAMs in Ireland, which would bring us into line with other major European countries to ensure that our patients and healthcare system is not left behind.

“We also need a shift in mindset from one that focuses purely on cost to an outlook that is centred around better outcomes for patients taking a holistic look at the whole patient journey,” she continued.

FMD Use and Learn Period Ends The Falsified Medicines Directive (2011/62/EU) ‘(FMD’) introduced new requirements from February 2019 for safety features on prescription medicines packaging, enabling the packs to be authenticated as genuine prior to supply to patients.

FMD has been in a ‘use and learn’ phase in Ireland since February 2019 due, in part, to the impact of Covid-19 and Brexit. The use and learn phase ended for wholesalers on 9th May 2022 and for pharmacies and hospitals for 30th May 2022.

After these dates, pharmacies, hospitals and wholesalers may not supply packs that generate alerts when scanned unless the alert has been fully investigated and a root cause has been found and falsification ruled out.

Detailed guidance has been developed for pharmacies, hospitals, wholesalers on what to do next if there is an alert and is available on the IMVO website (www.imvo.ie).

PHARMACYNEWSIRELAND.COM

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News

Calls to Utilise Pharmacy for HPV Vaccine The Irish Pharmacy Union (IPU) has welcomed the recent announcement by the Minister of Health of his intentions to introduce an HPV vaccine catchup programme. The IPU is now calling on the Minister for Health to utilise pharmacies which, it argues, are ideally placed to deliver the campaign.

HSE Capital Plan Minister for Health, Stephen Donnelly TD, has announced the approval of the Health Service Executive’s Capital Plan for 2022, which outlines the strategic priorities for the Health Investment Programme.

The campaign will involve the provision of the HPV vaccine to:

generation, but only if there is high uptake of HPV vaccinations.”

the easiest and most convenient route to access an HPV vaccine.”

• Girls and boys in secondary school who were eligible to receive HPV vaccine in 1st year but who did not receive it; and

According to Mr Twomey “Pharmacies are best placed to administer HPV vaccinations, particularly to women who, for any reason, did not receive one while at school. Pharmacies can provide the ideal environment for this service as they offer convenience, and flexibility and can support young people and their parents by answering any additional queries or concerns regarding this vaccine.

The importance of utilising pharmacies was highlighted by the played successful role in the COVID-19 vaccine campaign.

“Pharmacists have been vaccinating people in communities for over a decade. There is widespread public support for this service, and the response to pharmacy vaccination was overwhelming with over 850,000 COVID-19 vaccines administered by the pharmacy sector since June 2021.”

The 2022 Capital Plan reiterates the Government’s commitment to investing in our health and social care service. The plan builds on Minister Donnelly’s core priorities of access, affordability and quality in healthcare by supporting the delivery of strategic reform, a move towards better care in the community and building on the learnings and innovative changes during the COVID-19 pandemic.

Dermot Twomey concluded by cautioning against relying solely on GP practices to administer the catch-up vaccinations to women out of school. “GPs are consistently raising concerns about their workloads and waiting lists have continued to grow. Pharmacists are fully qualified and trained vaccinators, and there is simply no need to create a bottleneck to accessing the HPV vaccine.”

The health capital funding available in 2022 is ¤1.02bn, an increase of 4% on 2021. This investment will enable the HSE to progress projects in 2022, including Government priority programmes and major capital projects of elective care centres in Dublin, Cork and Galway as well as investment in primary and community care settings.

• Women up to the age of 25 years who have left secondary school and who did not receive the vaccine when eligible.

The IPU has commended the aims of this programme with IPU President Dermot Twomey saying, “The HPV vaccine is a proven, safe and effective vaccine. Not only does it protect women against the devasting impacts of cervical cancer, but it protects the entire population from many other side effects that can potentially result from an HPV infection. The decision to extend HPV vaccinations and provide this catch-up programme is extremely welcome. Ireland can eradicate cervical cancer within a

“The majority of the people eligible for this vaccine will either be students or those in early career jobs. Convenience will be key to maximising uptake, and that is what pharmacies offer to young adults with busy schedules There is a pharmacy in practically every town in Ireland, often with long opening hours and weekend availability, which would provide women with

Minister for Health visits LloydsPharmacy at Bray Primary Care Centre Pictured at the unveiling of the updated LloydsPharmacy located at the Primary Care Centre in Bray were Marie Keating, LloydsPharmacy Regional Manager, Evelyn Brett LloydsPharmacy Assistant Store Manager, Denis O’Driscoll LloydsPharmacy Superintendent Pharmacist and Minister for Health & Wicklow TD Stephen Donnelly

LloydsPharmacy is Ireland’s leading pharmacy chain with a strong presence in Co Wicklow for several years. Winner of the Retail Excellence award at this year’s InBUSINESS Recognition Awards with Chambers Ireland, LloydsPharmacy at Bray Primary Care Centre opened in 2020 and throughout the pandemic provided invaluable advice and patient care to customers in the area.

During a recent visit to Bray and official opening of the Bray Primary

Care Centre, Minister for Health and Wicklow Stephen Donelly TD visited the local store. The Bray location provides the local area with a wide range of services from emergency contraception, smoking cessation, blood pressure monitoring and BMI measurement, defibrillator, personalised health recommendations for vitamins and made to order gift hampers.

The store also features a wide range of products including skincare from top brands including,

PHARMACYNEWSIRELAND.COM

La Roche Posay, NUXE and Cerave and many more. LloydsPharmacy at Bray Primary Care Centre also offers a comprehensive range of medicines, skincare, vitamins, and baby range. Click and collect is available instore through www.lloydspharmacy.ie The highly trained team including Supervising Pharmacist, Joanne O Connor, offer extensive product knowledge, health advice and tips for all the family.

The large, bright and welcoming community pharmacy is conveniently located in the Bray Primary Care Centre, Killarney Road. The store offers ample car parking spaces and convenient opening hours.

Capital investment has a critical role to play in enabling and enhancing service provision, and to drive the reforms of universal healthcare, set out in Sláintecare.

This includes investment to facilitate reorienting the model of care away from acute hospitals and towards primary and community settings and addressing capacity and infrastructural deficits that exist in the system.

The Capital Plan provides for the spending of ¤1.02bn on health capital projects across the country in 2022 and includes: • New Children’s Hospital • Acute hospital projects including additional capacity, critical care capacity and maternity services • Primary care programme includes the building and equipping of centres across the country • HIQA Programme for community nursing units includes refurbishment to HIQA standard of units throughout the country • Disability includes continuation of the decongregation programme, respite and day services facilities • Mental health facilities including CAMHS units and acute mental health units across the country • Investment in trauma and rehabilitation projects

back to school

Kids’ everyday support Find out more at

www.haliborange.com The Haliborange range is available from BR Healthcare, United Drug & Uniphar For more information please contact your local BR Healthcare representative or our office on 01 - 885 0800.

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News

Ireland’s Spending on Medicines ‘Stable’ Ireland’s spend on medicines as a proportion of overall health expenditure is below the average of 15 other European countries, according an industry analysis of official Irish figures, alongside an international study.

In 2016, the State spent ¤1.9 billion on medicines while the overall health budget was ¤13.5 billion.

That means, based on current Government health expenditure estimates for 2021, we are spending almost 1% less on medicines today than we did five years ago as a proportion of the overall health budget.

EFPIA’s study finds that spending on medicines has been ‘stable’ as a share of total healthcare expenditure in surveyed countries for the past 20 years.

However, some countries that spend roughly the same proportion of their health budgets on medicines are much faster in making the latest treatments available to patients.

Last year, the State spent ¤2.54 billion on medicines, pharmacy and wholesaling costs – 13.4% of the overall health budget of almost ¤19 billion – according to estimated figures from Irish Government Economic Evaluation Service in the Department of Public Expenditure and Reform.

A new study by health analysts IQVIA for EFPIA, the biopharmaceutical industry’s representative organisation in Europe, called ‘Understanding Net Pharmaceutical Expenditure Dynamic in Europe’, shows that spending on medicines in 15 European countries is around 15% of total healthcare expenditure.

The surveyed countries were Norway, UK, Sweden, Demark, Slovenia, Belgium, Ireland, Croatia,

France, Italy, Germany, Spain, Hungary, Bulgaria and Czechia.

The IQVIA analysis shows that Belgium, France, Italy, Germany and Spain spend between 14% and 18% of their overall health expenditure on medicines. But all of these countries are, on average, faster than Ireland in making new medicines available to their patients.

Belgium is seven days faster, France is 44 days faster, Italy is 112 days faster, Germany is 408 days faster and Spain is 24 days faster. The figures are from the latest EFPIA Patient WAIT Indicator Survey which measured time to reimbursement of medicines newly authorised by the European Medicines Agency.

In the survey, Ireland places 24th out of 35 countries reporting data for time to availability for 160 innovative new medicines, with an average of 541 days to reimbursement.

“In that period, the innovation pipeline has been strong,” said a spokesperson for the Irish Pharmaceutical Healthcare Association, the organisation representing the research-based biopharmaceutical industry.

“But even when spending on medicines as a proportion of overall health expenditure is roughly in line with other western European countries, Ireland is much slower to make the latest treatments available to patients.

Through sustained Government investment and the new supply Agreement, Ireland should aspire to be among the fastest countries in Europe to adopt innovative new medicines.

“New lines of cancer medicines like targeted therapies and immunotherapies are improving patient outcomes. Hepatitis C medicines are curing patients and, sometimes, replacing liver transplants. Many rare diseases, which previously had no

treatments, can now be managed.

Despite these breakthroughs, spending on medicines in many European countries, including Ireland, has been stable.”

The EFPIA study finds that overall healthcare expenditure has been growing faster than medicines expenditure. It argues that health systems have a long-term sustainability problem driven by ageing populations and the burden of chronic disease and multi-morbidity.

“For many chronic diseases like diabetes and cardiovascular disease, the cost of medicines is a very small part of the overall cost of the disease, especially if you count the broader societal costs.

Medicines reduce unnecessary emergency visits, hospitalisations and complications.

“The recent visit to Dublin

by Emily Whitehead, the first paediatric patient in the world to receive a CAR-T, shows the impact of innovation. Emily, who had a rare cancer, is now 17.

Some advanced therapies, like CAR-T, come with high upfront costs. But they could off-set a lifetime of chronic treatment.

“That means they have long-term value – both for the patient and for the health system that pays for them. We need new payment models that are suitable for this new paradigm. These challenges can only be cracked through multi-stakeholder dialogue, especially between industry, State patients and doctors,” said the IPHA spokesperson.

Code of Practice Published Medicines for Ireland have announced the publication of the MFI, Code of Practice V2.0.

Medicines for Ireland are committed to ensure that all members advertising medicinal products aimed at both healthcare professionals and the public is conducted in a responsible, ethical, compliant and professional manner.

The Codes set out specific standards for pharmaceutical companies with regard to ethical and regulatory advertising and promotional interactions with the Healthcare Community. The Codes are not intended to address or regulate commercial terms and conditions relating to the price, sale and distribution of medicines, which must always be in compliance with applicable rules and requirements. The principles set forth in the Codes are mandatory and shall be implemented by all Members.

The organisation stated, “Medicines for Ireland and our parent association Medicines for Europe are committed to ensure that all members advertising medicinal products aimed at both healthcare professionals and the public is conducted in a responsible, ethical, compliant and professional manner.

“As a member of Medicines for Europe, all Medicines for Ireland members are committed to the ethical standards set out in Medicines for Europe Code of Conduct (www.medicinesforeurope.com). Medicines for Ireland has developed this supplementary Code of Marketing Practice to outline Irish specific requirements additional to the parent Medicines for Europe Code of Conduct. Both Codes should be read in conjunction and are intended to be a self-regulatory standard and are without prejudice to any existing or future legislation. Where there is any gap or inconsistency between standards, the stricter requirement shall always apply.”

The full document can be viewed at: https://www.medicinesforireland.ie/wp-content/uploads/2022/05/Medicines-for-Ireland-Code-ofPractice-V2.0.pdf

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✓ PLATINUM

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JOINT COMPLEX

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Report

Drug Price Variation and Lack of Transparency Prescription drugs are a major source of expenditure for patients in Ireland. High prices can lead to costrelated non-adherence and adverse health outcomes. Researchers at Trinity College and RCSI University of Medicine and Health Sciences (RCSI) investigated the variation and availability of prescription drug prices in community pharmacies in Ireland. The study is recently published in the journal Research in Social and Administrative Pharmacy.

Pharmaceuticals are one of the main sources of healthcare expenditure for people, with prescription drugs described as a major cause of unaffordable expenditure for the Irish public.

The question researchers sought to answer was: how much prices for commonly prescribed drugs varied between pharmacies?

The research team investigated the prices of 12 commonly prescribed drugs by calling 1,500 community pharmacies, emailing 320, and checking the website of 370. A community pharmacy is described as a retail shop which provides pharmaceutical drugs among other products to the public.

Community pharmacies can include both chain pharmacies and independent pharmacies.

Says the report, “The mean quoted price for each of the 12 drugs was higher than the HSE reimbursement price. The largest relative price difference was for Eltroxin (levothyroxine); the average quoted price was ¤13.21, which was 35% higher than the HSE reimbursement price of ¤9.80.

“This may be explained by pharmacies providing a price for one pack each of 100 μg and 50 μg tablets, with a dispensing fee added to each (with a HSE reimbursement price of ¤13.44), compared to the HSE reimbursement price used for three packs of 50 μg tablets (¤9.80). In absolute terms, the largest difference was found for famciclovir, where the average quoted price of ¤46.00 was ¤8.69 higher than the HSE reimbursement price of ¤37.31.

“Regarding price variation, aspirin was the drug with the largest variation in quoted priced; the 90th percentile price of ¤9.12 was 97% higher than the 10th percentile price of ¤4.62. Lansoprazole was the drug with the smallest variation in quoted priced; the 90th percentile price of ¤13.69 was 37% higher than the 10th percentile price of ¤10.00.

Fig. 1. Distribution of prices for all medicines (Overlaid boxplots show median, 25th and 75th percentiles, whiskers indicating 1.5 interquartile ranges above and below 25th and 75th percentiles, and outlying data points)

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KEY FINDINGS • 1,529 pharmacies responded to queries, 1,362 by telephone and 167 by email.

• Despite regulatory guidance stating pharmacies should provide medicine prices to patients, no pharmacies had prices displayed on their websites and 12% of pharmacies who answered a call/email did not provide a price.

• The study found that the most expensive pharmacies can charge over double the price of the least expensive pharmacies. For example: Researchers found a typical prescription of prednisolone (a commonly prescribed steroid) costs over ¤5 more (88% higher price) in the most expensive pharmacies, compared to the least expensive pharmacies in Ireland.

• The mean quoted cost for each of the 12 drugs investigated was higher than the HSE reimbursement price for medical card patients.

For famciclovir, the average price quoted to us was ¤46.00 which was ¤8.69 higher than the HSE reimbursement price of ¤37.31.

• For each drug, the average price quoted to researchers was higher than the price paid by the state for patients who can access subsidised medicines (medical card holders).

• For nine of the 12 drugs, the price was significantly higher for chain pharmacies compared to independent pharmacies.

11 In discussing the study findings, the report states, “This study found that 11.5% of the pharmacies that answered enquiries declined to provide a price. No pharmacies displayed their prices online.

Another notable finding was that for five of the 12 drugs, the 90th percentile of quoted prices was over 50% more expensive than the 10th percentile. For the other seven drugs, the difference was over 30%. In absolute terms, these differences ranged from ¤3.22 to ¤15.80.

“The authors consider this to represent a large variation in prices across pharmacies. To put this variation in context, percapita pharmaceutical spending, (including over the counter drugs but excluding hospital consumed pharmaceuticals) amounted to ¤44.12 per month in Ireland.

“Also, this study found that for all 12 drugs the mean quoted price from community pharmacies was higher than the estimated price paid by the state to pharmacies for patients with subsidised/ free cover. For 9 of the 12 drugs, when comparing the prices in independent pharmacies and chain/franchise pharmacies, the difference was statistically significant, and for all nine of these drugs, they were cheaper in independent pharmacies.

“Finally, a very small proportion of pharmacies, though not specifically asked, mentioned the availability of discounts when discussing prices.

The large variation in prices indicate that people in Ireland are paying very different prices depending on which pharmacy they attend. High prices can be problematic, as they are associated with cost-related non-adherence which can lead to adverse outcomes.

“The fact that the average quoted price was higher than the estimated price paid by the state to pharmacies for all 12 drugs, coupled with the fact that the prices of prescription drugs in community pharmacies in Ireland is higher than many other countries, indicates that there is potential for a large proportion of pharmacies to reduce their prices.

It also indicates that there is scope for patients to reduce their OOP expenditure on prescription drugs by contacting multiple pharmacies for the best price, although in doing so patients incur search costs.”

James Larkin, PhD Scholar, Department of General Practice, RCSI, and lead author commented, “The large price variation for prescription drugs and the lack of transparency from pharmacies is a problem, as it may mean that some people are paying too much for their medication. Or worse, some people are not buying their medication because it costs too much. This is particularly concerning given the current cost of living crisis and resulting cost pressures that many are facing.

Consideration needs to be given

by Government to measures that enforce price transparency or regulating prices.”

James O’Mahony, Research Assistant Professor in Cost Effective Analysis, Centre for Health Policy Management, School of Medicine, and senior author, said, “Awareness matters as patients can save money by shopping around. If the state were to regulate prices, or if there was more transparency on prices, it might lead to lower prices and more people taking their medications.

“The pharmaceutical regulator’s current requirements on pharmacies to make prices transparent does not really guarantee any easy access to prices for patients. We’d like to see a greater push for transparency on behalf of the Pharmaceutical Society of Ireland.”

The report adds, “Improved transparency could encourage people to choose different pharmacies for each of their prescription drugs. This practice could undermine the benefits of continuity of care involved in the pharmacist-patient relationship, including improved adherence, reduced inappropriate drug use and reduced use of other costly services.

“However, evidence suggests that patients are unlikely to choose different pharmacies for each of their medication based on price. Any potential harms could

be mitigated through a national system of shared electronic medicines records, updated in real time and available to community pharmacies as well as other healthcare providers.

“Enhanced price transparency will not provide benefits to those with limited choice of retail pharmacies, such as people living in rural areas.

Another way of addressing price disparities would be to legislate so that the public can avail of the same (or a similar) agreement to the one the HSE has made with pharmacists; a fixed price for medications and a variable dispensing fee which is based on the number of items a pharmacy dispenses in a month. Given that the average quoted price in this study was consistently higher than the HSE reimbursement price, this measure could lead to significant savings for patients. In Denmark, due to state regulation, the prices of prescription drugs are the same across all community pharmacies.

“However, it is possible that for some pharmacies in Ireland, crosssubsidisation occurs, whereby private patients are charged more than the HSE reimbursement price for the business to be viable. If this were the case then if the state mandated the same price for private patients, some pharmacies might cease operating.

There are several potential areas for future research. Firstly, research could be conducted to assess whether cheaper pharmacies were systematically cheaper across all products. Secondly, future research could assess the association between drug price and density of competing pharmacies or geographical features such as population density. Also, a study could assess the potential savings of contacting multiple pharmacies for prices compared to the time costs of searching for those prices.”

PHARMACYNEWSIRELAND.COM

12

News

Pharmacists Call for Better Smoking Support Access Community pharmacists are key to helping smokers who want to kick the habit, succeed in their endeavours.

Whilst it can be challenging to overcome a smoking addiction, local pharmacists help smokers understand what method will work best for them and to receive advice on supports such as NRT to help manage cravings.

Irish population are smokers, with those aged 45 to 54 the most likely to smoke. It is clear that we should be doing everything we can make quitting easier for those who are ready to attempt it.”

Mr Twomey continued, “NRT works and can significantly improve an individual’s chances of being successful when attempting to quit. We must encourage this. Unfortunately, medical card patients must go through their GP to access this treatment. At a time where GP shortages across the country have made it increasingly difficult to get an appointment, this is creating an unnecessary barrier for would-be quitters.

There is simply no clinical reason why a medical card patient should require a prescription to access NRT and this arbitrary rule is preventing Ireland from lowering its smoking rates.”

The Irish Pharmacy Union (IPU) has called on the government to make it easier for smokers to access support. According to the IPU, requiring medical card holders to attend a GP prior to being supplied with Nicotine Replacement Therapy (NRT) is an unnecessary barrier. The IPU is calling for pharmacies to be enabled to provide the service to all patients.

NRT is an effective approach to reduce the physical symptoms

associated with quitting smoking.

NRT has been available in pharmacies nationwide since 2014, however medical card holders are still unable to access this vital treatment directly from their pharmacies.

Community pharmacist and IPU President, Dermot Twomey said, “The rate of smoking has fallen steadily over the past five years in Ireland, and we must commend those who have given up smoking. However, 18% of the

Mr Twomey also commented on the health benefits for those looking to quit smoking, “While the risks associated with smoking are well understood the benefits from quitting are spoken about less often. A smoker who quits will experience almost immediate health benefits such as improved breathing and energy levels as well as reducing the risk of coronary heart disease. All smokers should be encouraged by the significant improvements to their health that can happen if they quit.”

Latest HSE Figures See below story for further details: (state-of-tobacco-controlreport-2022.pdf (hse.ie)) • Smoking prevalence increased from 17% in 2019 to 18% in 2021, and following a period of historic decline.

• People in more deprived areas in Ireland live 4-5 years less than those in more affluent areas.

• The causes of and solutions to these health inequalities are multiple and complex; however, smoking is responsible for over half of the health gap across social groups.

• Against a backdrop of declining smoking prevalence, the socio-economic gradient in smoking is getting wider.

• There was a two-fold difference in smoking between the highest and lowest socio-economic groups in 2015 (16% versus 29%). But in 2021 that gap has widened to become a three-fold difference (11% versus 31%, comparing the highest and lowest socio-economic groups respectively).

New Plan to Tackle Tobacco Related Harm On World No Tobacco Day (Friday, 31 May 2022), the HSE Health and Wellbeing, Tobacco Free Ireland Programme (TFI) hosted a Conference: “Tobacco Endgame: Nobody Left Behind” and published a new Programme Plan 2022-2025 setting out action across the health service to tackle the harm caused by smoking.

Also presented was an accompanying State of Tobacco Control Report which examines recent trends in smoking in Ireland, tracks progress and highlights emerging challenges, and the first study of public views on potential proposals which could help deliver the Tobacco Free Ireland goal of reducing smoking to less than 5% is also being published.

Reflecting on progress towards a Tobacco Free Ireland in a

virtual opening address at the TFI Conference, Taoiseach, Micheál Martin said, “Smoking rates have declined across the country, but it still causes too many preventable deaths and significant harm to the health of too many people today.

“I want to underline the importance of “Leaving No One Behind”.

“We must continue to work together to maintain the progress we have made - ensuring no one is left behind in our goal of a Tobacco Free Ireland.”

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Speaking at the TFI Conference, Dr Paul Kavanagh, Public Health Medicine Specialist, HSE explains how Ireland is still deep in a continuing epidemic of smoking related harm, “Overall, the proportion of people who currently smoke reduced from 23% in 2015 to 18% in 2021. This progress means it’s all too easy to think our work on tackling smoking is done.

But smoking prevalence increased from 17% in 2019 to 18% in 2021, and following a period of historic decline, it’s worrying to note that smoking has increased

in teenagers. Smoking continues to cause preventable harm on a large scale in Ireland, claiming over 4,500 lives each year. It’s clear that we cannot rest on past success. We need to double down on our efforts if we are to bring the harm caused by smoking to an end in Ireland for everyone.”

The State of Tobacco Control report, TFI Programme Plan 20222025 and Tobacco EndGame reports are available at https:// www.hse.ie/eng/about/who/ tobaccocontrol/news/

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Nicorette QuickMist1 mg/spray, oromucosal spray, solution and Nicorette QuickMist Cool Berry 1 mg/spray, oromucosal spray, solution. Composition: One spray delivers 1 mg nicotine in 0.07 ml solution. 1 ml solution contains 13.6 mg nicotine. Excipient with known effect: Ethanol (less than 100 mg of ethanol/spray). Propylene glycol, Butylated hydroxytoluene. Pharmaceutical form: Oromucosal spray, solution. A clear to weakly opalescent, colourless to yellow solution. Indications: For the treatment of tobacco dependence in adults by relief of nicotine withdrawal symptoms, including cravings, during a quit attempt (or to cut down smoking before stopping completely. Permanent cessation of tobacco use is the eventual objective. Nicorette QuickMist should preferably be used in conjunction with a behavioral support program. Dosage: Subjects should stop smoking completely during the course of treatment with Nicorette QuickMist. Adults and Elderly: The following chart lists the recommended usage schedule for the oromucosal spray during full treatment (Step I) and during tapering (Step II and Step III). Up to 4 sprays per hour may be used. Do not exceed 2 sprays per dosing episode and do not exceed 64 sprays (4 sprays per hour, over 16 hours) in any 24-hour period. Step I: Weeks 1-6: Use 1 or 2 sprays when cigarettes normally would have been smoked or if cravings emerge. If after a single spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Step II: Weeks 7-9: Start reducing the number of sprays per day. By the end of week 9 subjects should be using HALF the average number of sprays per day that was used in Step I. Step III: Weeks 10-12: Continue reducing the number of sprays per day so that subjects are not using more than 4 sprays per day during week 12. When subjects have reduced to 2-4 sprays per day, oromucosal spray use should be discontinued. To help stay smoke free after Step III, subjects may continue to use the oromucosal spray in situations when they are strongly tempted to smoke. One spray may be used in situations where there is an urge to smoke, with a second spray if one spray does not help within a few minutes. No more than four sprays per day should be used during this period. Regular use of the oromucosal spray beyond 6 months is generally not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Gradual cessation through progressive reduction in smoking (Nicorette QuickMist1 mg/spray, oromucosal spray, solution only) For smokers who are not willing or ready to quit abruptly. The oromucosal spray is used between periods of smoking in order to prolong the smoke-free intervals and with the intention to reduce smoking as much as possible. The patient should be aware that an incorrect use of the spray may enhance adverse effects. A cigarette is replaced with one dose (1-2 sprays) and a quit attempt should be made as soon as the smoker feels ready and no later than 12 weeks after start of treatment. If a reduction in cigarette consumption has not been achieved after 6 weeks of treatment, a healthcare professional should be consulted. After quitting smoking, gradually reduce the number of sprays per day. When subjects have reduced to 2-4 sprays per day, oromucosal spray should be discontinued. Regular use of the oromucosal spray beyond 6 months is not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Paediatric population: Do not administer this medicine to persons under 18 years of age. There is no experience of treating adolescents under the age of 18 with this medicine. Method of administration: After priming, point the spray nozzle as close to the open mouth as possible. Press firmly the top of the dispenser and release one spray into the mouth, avoiding the lips. Subjects should not inhale while spraying to avoid getting spray into the respiratory tract. For best results, do not swallow for a few seconds after spraying. Subjects should not eat or drink when administering the oromucosal spray. Behavioural therapy advice and support will normally improve the success rate. Contraindications: Hypersensitivity to nicotine or to any of the excipients. Children under the age of 18 years. Those who have never smoked. Special warnings and precautions for use: This medicine should not be used by non-smokers. The benefits of quitting smoking outweigh any risks associated with correctly administered nicotine replacement therapy (NRT). A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions: Cardiovascular disease: Dependent smokers with a recent myocardial infarction, unstable or worsening angina including Prinzmetal’s angina, severe cardiac arrhythmias, recent cerebrovascular accident and/or who suffer with uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions (such as counselling). If this fails, the oromucosal spray may be considered but as data on safety in this patient group are limited, initiation should only be under close medical supervision. Diabetes Mellitus. Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when smoking is stopped and NRT is initiated as reduction in nicotine induced catecholamine release can affect carbohydrate metabolism. Allergic reactions: Susceptibility to angioedema and urticaria. Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects. Phaeochromocytoma and uncontrolled hyperthyroidism: Use with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma as nicotine causes release of catecholamines.

Gastrointestinal Disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions. Paediatric population: Danger in children: Doses of nicotine tolerated by smokers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be handled or ingested by children. Transferred dependence: Transferred dependence can occur but is both less harmful and easier to break than smoking dependence. Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. The plasma concentration of other medicinal products metabolised in part by CYP1A2 e.g. imipramine, olanzapine, clomipramine and fluvoxamine may also increase on cessation of smoking, although data to support this are lacking and the possible clinical significance of this effect for these drugs is unknown.

Limited data indicate that the metabolism of flecainide and pentazocine may also be induced by smoking. Excipients: This medicine contains about 7 mg of alcohol (ethanol) in each spray which is equivalent to 97 mg/ml. The amount in one spray of this medicine is equivalent to less than 2 ml beer or 1 ml wine. The small amount of alcohol in this medicine will not have any noticeable effects. This medicinal product contains less than 1 mmol sodium (23 mg) per spray, i.e. essentially ‘sodium- free’. This medicine contains 12 mg propylene glycol in each spray which is equivalent to 157 mg/mL. Due to the presence of butylated hydroxytoluene, Nicorette QuickMist may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes. Care should be taken not to spray the eyes whilst administering the oromucosal spray.Undesirable effects: Effects of smoking cessation: Regardless of the means used, a variety of symptoms are known to be associated with quitting habitual tobacco use. These include emotional or cognitive effects such as dysphoria or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating, and restlessness or impatience. There may also be physical effects such as decreased heart rate; increased appetite or weight gain, dizziness or presyncopal symptoms, cough, constipation, gingival bleeding or apthous ulceration, or nasopharyngitis. In addition, and of clinical significance, nicotine cravings may result in profound urges to smoke. This medicine may cause adverse reactions similar to those associated with nicotine given by other means and these are mainly dose-dependent. Allergic reactions such as angioedema, urticaria or anaphylaxis may occur in susceptible individuals. Local adverse effects of administration are similar to those seen with other orally delivered forms. During the first few days of treatment irritation in the mouth and throat may be experienced, and hiccups are particularly common. Tolerance is normal with continued use. Daily collection of data from trial subjects demonstrated that very commonly occurring adverse events were reported with onset in the first 2-3 weeks of use of the oromucosal spray, and declined thereafter. Adverse reactions with oromucosal nicotine formulations identified from clinical trials and during post-marketing experience are presented below. The frequency category has been estimated from clinical trials for the adverse reactions identified during post-marketing experience. Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1 000 to <1/100); rare (≥1/10 000 to <1/1 000); very rare (<1/10 000); not known (cannot be estimated from the available data). Immune system disorders Common Hypersensitivity Not known Allergic reactions including angioedema and anaphylaxis Psychiatric disorders Uncommon Abnormal dream Nervous system disorders Very common Headache Common Dysgeusia, paraesthesia Eye disorders Not known Blurred vision, lacrimation increased Cardiac disorders Uncommon Palpitations, tachycardia Not known Atrial fibrillation Vascular disorders Uncommon Flushing, hypertension Respiratory, thoracic and mediastinal disorders Very common: Hiccups, throat irritation Uncommon Bronchospasm, rhinorrea, dysphonia, dyspnoea, nasal congestion, oropharyngeal pain, sneezing, throat tightness Common: cough Gastrointestinal disorders Very common Nausea Common Abdominal pain, dry mouth, diarrhoea, dyspepsia, flatulence, salivary hypersecretion, stomatitis, vomiting Uncommon Eructation, gingival bleeding, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral Rare Dysphagia, hypoaesthesia oral, retching Not known Dry throat, gastrointestinal discomfort, lip pain Skin and subcutaneous tissue disorders Uncommon Hyperhidrosis, pruritus, rash, urticaria Not known Erythema General disorders and administration site conditions Common Burning sensation, fatigue Uncommon Asthenia, chest discomfort and pain, malaise. MAH: Johnson & Johnson (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland. PA Number: PA 330/37/13 & PA 330/37/16. Date of revision of text: PA 330/37/13: December 2020. PA 330/37/16: November 2020. Product not subject to medical prescription. Full prescribing information available upon request.

IE-NI-2100083

14

News

Staff Event Day for totalhealth and Haven Pharmacies A staff training day for the totalhealth and Haven Pharmacies took place on May 18th, 2022, at the Sheraton Hotel in Athlone. The training day was a notable event as it marked the first in person training day since 2019 as well as the first joint meeting for the totalhealth and Haven Pharmacy teams since the two Groups merged.

John Arnold, CEO totalhealth and Haven Pharmacies, opened the meeting by welcoming the teams and presented a summary on group activity to date and announced some of the future plans.

The Pharmacy Managers and Supervisors had the opportunity to meet and greet their counterparts from all over the country from both pharmacy groups, as well as their Support Office staff and several suppliers.

The suppliers that attended the meeting shared their valuable knowledge and skills through presentations and exhibitions.

The presentations addressed a variety of topics, including skincare training, sun education, eyecare, pain relief and baby skincare as well as essential advice and guidance.

It was also an opportunity for the suppliers to showcase new products to the market.

Staff event day for totalhealth and Haven Pharmacies at the Sheraton Hotel, Athlone The teams were delighted with this excellent opportunity to broaden their knowledge on key topics and were looking forward to sharing this knowledge with their colleagues. totalhealth & Haven Pharmacies thank their suppliers and sponsors: GSK, Clonmel Healthcare, Reckitt Benckiser, Cosmetics Active, Scope Healthcare, Johnson and Johnson.

UCC MSc in Clinical Pharmacy Applications are invited for this two-year (part-time) distance learning Master’s Degree offered by the School of Pharmacy, University College Cork course, commencing in September 2022. The course is structured to provide specialist training to enable pharmacists working in hospital and community pharmacies, extend their professional role within the evolving clinical healthcare system.

Applicants must be registered as a pharmacist with the professional accreditation authority in the country in which they are practising.

Closing date for applications: 30th June 2022. Applicants must apply online at www.ucc.ie/apply. Full details of the applicant procedure are available at www.iiop.ie For further information please contact Dr Teresa Barbosa (Programme Director, t.barbosa@ucc.ie; + 353 21 490 1792), School of Pharmacy, University College Cork, Cork, Ireland.

Urgent Need for Hypertension Awareness Campaign To mark European Stroke Awareness Day on 10 May 2022, the Irish Heart Foundation has called on Government to develop a 5-year high blood pressure awareness and behaviour change campaign to raise awareness of this silent killer.

High blood pressure or hypertension is known as a ‘silent killer’ as almost half of sufferers are unaware that they have the condition, which is a key risk factor for stroke, the third-highest cause of death in Ireland.

A review of the 2016 Irish Longitudinal Study on Ageing (TILDA), published in the Journal of Public Health, revealed that 64% of over-50s have high blood pressure but 45% were unaware of it.

The review also found that 59% of people with hypertension were

taking medication for the condition but almost half did not have it under control.

Commenting Kathryn Reilly, Policy Manager with the Irish Heart Foundation said, “Many strokes are preventable and the principal risk factors – including high blood pressure – are increasing in prevalence. On European Stroke Awareness Day today, we are calling for a hypertension awareness campaign which will improve quality of life, reduce disability and mortality and prompt a reduction in costs to the health service.

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“Hypertension often goes unnoticed but it is among the leading modifiable risk factors for cardiovascular disease and premature death worldwide. The condition is often preventable but is exacerbated by policy and environmental factors which cause poor lifestyle behaviours such as unhealthy diet and physical inactivity.”

Ms Reilly added, “Currently in Ireland, only patients holding a medical or a GP visit card can receive check-ups for hypertension without charges and there are no

plans at present to introduce free check-ups for hypertension to the general population.

“As the threat from Covid-19 recedes, a hypertension campaign would be very timely to refocus on chronic disease risk factor identification, treatment and control,” she said.

Ms Reilly said the prevalence, functional consequences, disease risk, and associated mortality of hypertension placed a considerable burden on individuals and consumed major national health service resources.

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16

Awards

Mckesson Ireland Recognition Awards LloydsPharmacy teams acknowledged for their outstanding achievements in the McKesson Ireland Recognition Awards McKesson Ireland was delighted to host their second Employee Recognition Awards night on May 19th.

Consisting of LloydsPharmacy, United Drug, Median Healthcare and TCP Homecare, the leading healthcare group is keenly focused on employee engagement and recognition.

Customer First LloydsPharmacy Killbarrack Road.

“The team go above and beyond every day for their customers, with a smile, a compassionate ear, and professional service. Their dedication and ambition for excellence is an inspiration to all of us” The McKesson Ireland Employee Awards celebrates all those who embody their iCare and iLead values and behaviours each and every- day with colleagues invited to nominate their peers across the 13 award categories. United by these shared values across the group, the employees work every day to innovate and deliver opportunities to improve patient care in every setting – one product, one partner, one patient at a time.

Well done to all those nominated and to those who were chosen for an award. There were 612 nominations, and the McKesson

Ireland Country Board had the difficult task of reviewing all the exceptional submissions and achievements across the business and pharmacies and agree on the 50 colleagues to shortlist.

The attendance on the night was fantastic with over 100 employees in attendance at the live show which was hosted in Virgin Media studios. Over 900 colleagues also tuned in to watch the live event from their own homes.

An incredible night was had by all.

In addition to the awards ceremony, employees were also entertained

by TV host Darren Kennedy and the legendary Mario Rosenstock and those watching from home benefited from quizzes and draws with an opportunity to win an array of great prizes including holiday vouchers and iPhones.

The 13 awards winners were announced on the evening by our hosting panel (Country Board Members; Paul Reilly, Jim McAuliffe, Catherine Cummins, Stephen O’Donoghue, Christy Canavan, Elaine Condon, David Keyes, David Lawless and Hazel Sullivan).

Award Categories and Winners: Integrity: Catriona Devenney, LloydsPharmacy Letterkenny.

Catriona is long serving, respected and trusted in her local community in Letterkenny. She is always focused on the right thing to do when dealing with the needs of her customers and our business.

Integrity Catriona Devenney, LloydsPharmacy Letterkenny

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She is always innovating and developing better ways to serve her patients in Letterkenny.

Customer First: LloydsPharmacy Killbarrack Road. The team go above and beyond every day for their customers, with a smile, a compassionate ear, and professional service. Their dedication and ambition for excellence is an inspiration to all of us.

Accountability: Finance Department, McKesson Ireland. During a massive transformational change, the team completed a mammoth set of tasks while demonstrating respect to all involved.

Respect: Asta Tumyne, United Drug Wholesale Ireland.

Asta is the Supervisor on the UDW dayshift assembly team.

Supervising over 50 people, Asta encounters many challenges and through her respect and commitment she goes beyond the line of duty.

Excellence: Adam Brown, Procurement, McKesson Ireland.

Adam is the Insights manager for McKesson Ireland. The improvements he has brought to the department has allowed for the business to make better decisions.

Inspire: Maureen Reidy, LloydsPharmacy Knocklyon.

Maureen is a long serving member of the LloydsPharmacy team.

She has worked as a pharmacist for LloydsPharmacy for 35 years and holds a wealth of knowledge and expertise, inspiring the next generation to deliver best in class patient care. She is well known and respected in her local community and always goes the extra mile to provide advice to her patients.

Leverage: Aleksandra Rojek, LloydsPharmacy Ashe Street.

Leverage is all about looking at your own skills and capabilities and seeing how these can be adapted to be an asset.

Aleksandra does this while creating a welcoming, understanding, and safe place for all those she interacts with and always goes the extra mile to support and care for her patients and customers in the Tralee area.

17 Execute: Patient Care Bureau Referrals and Scheduling, TCP Homecare. The team work magic on a day-to-day basis while displaying both professionalism and compassion towards their customers.

Leverage Aleksandra Rojek, LloydsPharmacy Ashe Street.

Advance: Pharmacist and Pharmacy Technicians, Median Healthcare Services. Against the backdrop of the pandemic and its significant impact on their business they used it as an opportunity to make significant changes to their business and operating model.

Develop: Vaida Kareiviene, United Drug Wholesale. Vaida has worked within United Drug for over 16 years and runs the UDW evening shift. Vaidas dedication, leadership and accountability during the pandemic saw her lead the effort that utilised efficiently the available resources.

The People’s Choice: Jenni Margrate, Store manager at LloydsPharmacy Dungarvan.

Jenni joined LloydsPharmacy in 2015 initially on the Clarins counter but several promotions later was appointed store manager in 2019.

The local community know when they step inside the door they will be met with a welcoming smile and are in safe hands. With over 40% of the employees vote, Jenni was chosen by her peers for her positive and infectious attitude and work ethic.

The People’s Choice Jenni Margrate, LloydsPharmacy Dungarvan

Team of the Year: United Drug Vaccine Rollout Team, United Drug Distributers for their participation in the Vaccine rollout in Ireland. Their collaboration and trojan work and their honourable work ethic throughout the pandemic has impacted the entire nation, potentially saving lives and reducing hospital admissions.

Employee of the Year: Rachael Stewart LloydsPharmacy Nutgrove.

Say Hello to Rachael Stewart, Supervising Pharmacist and winner of the Employee of the Year Rachael started working with LloydsPharmacy in 2015 as a relief pharmacist, moving quickly to a support pharmacist role, and later supervising pharmacist. Rachael was awarded Employee of the Year 2022 as she exemplifies all the values and behaviours McKesson stands for, having stepped up to the plate not just for her own area but the entire business. She is known to actively seek out those who need extra help and offer her support. During the pandemic she initiated and led Covid and seasonal influenza vaccination clinics in her pharmacy, providing an extremely important service for her local community.

“Rachael was awarded Employee of the Year 2022 as she exemplifies all the values and behaviours McKesson stands for, having stepped up to the plate not just for her own area but the entire business”

Employee of the Year Rachael Stewart LloydsPharmacy Nutgrove

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Type 1 Diabetes in Children

New HSE Guidelines for Managing Children with Type 1 Diabetes during School to follow actions to help school staff to understand Type 1 diabetes and the needs of their pupil. The document sets out clear guidelines that will help structure the conversation and preparations between the family, diabetes team, and school staff. It explains diabetes and diabetes management to teachers and school staff, sets out clear lines of responsibility for all partners. It also helps to helps to determine the need for nonteaching support (Special Needs Assistance) and for the first time presents different levels of support needs for children with diabetes based on age and diabetes management skills.

Written by Dr Kate Gajewska, Clinical Manager for Advocacy and Research

School time for parents, children and teachers can be a fantastic experience, but it has its challenges if a pupil has or has only recently been diagnosed with Type 1 diabetes. Returning to school or joining a new class or school, in the beginning, it can be a bit stressful and busy for all involved.

Preparing for back to school means organising books, uniforms, school lunches and much more. For children living with diabetes, it also means managing or changing insulin regimes and thinking about blood glucose monitoring in school. There can be an added concern for parents, as well as for the teachers if a child with diabetes is starting school for the first time or changing to a new class with a teacher who may not be yet familiar with diabetes or even moving on to post-primary school. The younger the child, the greater the involvement in care of school staff it is, often including Special Needs Assistants.

The HSE ‘Schools’ document’

As part of this very comprehensive document, a scheme of a Personal Pupil Plans is included, which can be a very helpful tool to agree on current diabetes management and needs of a child. This includes information such as personal hypoglycaemia symptoms, what to eat during hypoglycaemia, when to check glucose levels and deliver insulin.

The school can have such a personalised ‘information pack’ handy for all their students who have diabetes.

Document to improve collaboration Professor Nuala Murphy, Consultant Paediatric Endocrinologist and National Clinical Lead for Paediatric Diabetes commented: ‘I hope that school leaders and every family of a child with diabetes will familiarise themselves with these recommendations and find the practical tools helpful in managing the care needs of children with diabetes during the school day”.

Diabetes Ireland was heavily involved in the development of this document. ‘We are delighted, that after years of preparation and the involvement of many people, the document has been launched. Parents of children with diabetes, teachers, SNAs call us frequently for support and advice. This

Knowing that it can be an anxious time for parents and children, as well as for the school staff, the document including tips and tools to help all concerned with this challenge has been prepared by the HSE Paediatric Diabetes Working group.

It is important that parents/carers engage positively with the school, and ensure the teachers understand the condition and how they need to act, bearing in mind that they have other pupils to care for as well. Good written and verbal communication between parents and the school is key. To improve the communication, the ‘Meeting the Care Needs of Primary School Children with Type 1 Diabetes during School Hours’ guideline has been released earlier this year.

New guidelines recently published by the HSE strongly recommends involving the child’s diabetes team early in the process and provides a number of tools and easy

18 | PHARMACYNEWSIRELAND.COM

document will be a tremendous resource for everyone in ensuring the safety of the child and their happiness in school - highlights Dr Kate Gajewska, Diabetes Ireland Research and Advocacy Manager.

Diabetes Ireland has developed a resource for parents and teachers on their website https://www.diabetes.ie/living-withdiabetes/child-diabetes/school-and-diabetes/ where the Meeting the Care Needs of Primary School Children with Type 1 Diabetes during School Hours document can be downloaded, and with and find lots of useful information on caring for a child with diabetes in the classroom.

Tips for parents and schools at www.diabetes.ie There are separate sections for parents and carers, and for the teachers and school staff.

The first one includes tips on how to start planning for back to school early, explains how to prepare the school and what to expect, provides information on special needs assistance and requires non-teaching support, gives tips on healthy lunch time snacks, and how to support the child from the mental health and well-being side. In the section for teachers, SNAs and other staff educational materials about type 1 diabetes, hypo- and hyperglycaemia and diabetes management are provided, as well as information on how important it is for their mental health and well-being to be included in the school-life.

This section provides tips on what can schools do to support the child and their family, explains how to determine the non-teaching support. All the information is in line with the HSE guidelines.

Prof. Murphy also adds: ‘We hope that this guideline will improve communication between parents, school staff and diabetes teams and that it will be a helpful resource in maintaining the safety and diabetes control of the child with diabetes during the school day.”

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Back to School?

Don’t Forget about Mental Health Going back to school can trigger feelings of worry and anxiety in some children.

In the pharmacy you may meet several parents of children who are concerned about their children experiencing stress during this period. Understanding the causes of common worries can help you to support parents and children during this time.

Some of the more common concerns are discussed here.

Exam Stress Written by Allison Dunne BPharm MSc MA. IUHPE accredited health promotion practitioner At this time of year you may see several articles about how you, as a pharmacy team, can help families preparing to go “back to school”. Common topics include the use of vitamin supplements, prevention of head lice and preparation for in the inevitable cold and flu symptoms. Indeed, these are all important factors for physical health. But what about mental health and wellbeing?

This article will consider the mental health impact of the return to school and how pharmacy teams can support families during this exciting, but often challenging, time of year.

When we think about mental health we should consider both the positive and negative aspects. Positive mental health, sometimes called mental wellbeing, includes factors such as happiness, life satisfaction and quality of life. Positive mental health can be protective against some mental health conditions and is important for child development (Department of Children and Youth Affairs, 2014). Young children who have positive relationships with their parents, and teenagers who have supportive peer groups, tend to experience good mental wellbeing (Nolan & Smyth, 2021). The quality of relationships with teachers has also been shown to be important for good mental health, especially among adolescents (Nolan & Smyth, 2021).

Mental health conditions such as depression and anxiety affect a significant number of children. A recent report notes that 16% of 13 year olds in Ireland are at risk from depression (Department of Children, Equality, Disability, Integration and Youth, 2021) while over 11,700 young people accessed HSE Child and Adolescent Mental Health Services in 2021 (Pollak, 2022).

Parents who are concerned that their child has a mental health condition should speak to the pharmacist about whether referral to the GP is appropriate.

Worries about exams and school performance are normal (Duvall & Roddy, 2021). While a small amount of stress around exams is common, if the levels of stress are affecting sleep and daily tasks it is time to encourage parents to take action. Schools can offer support to students who are worried about exams. If additional help is needed the GP is the first port of call for children who are experiencing high levels of anxiety.

In a small number of cases children can be diagnosed with anxiety disorders requiring medical intervention or counselling.

Bullying The Irish government framework for the health of children and young people is called Better Outcomes, Brighter Futures (Department of Children and Youth Affairs, 2014). The framework identifies bullying as a common concern for school children. The most recent progress report, using data from 2018 noted that 31% of 11-17 year olds have been bullied in school, with 13% stating that they have acted as a bully (Department of Children, Equality, Disability, Integration and Youth, 2022). Worries about bullying may lead to increased stress in the lead up to return to school. Parents can support their children with regular conversations about school worries and encourage reporting of bullying to the school. Each school should have an anti-bullying policy.

Parents can access these (often available online) and should speak to school staff about any concerns.

Sleep Reduced sleep has been linked to poor concentration and learning during school hours (Hayes & Bainton, 2020). Over the summer holiday it is normal for sleep patterns to be different to during the school term. Bedtimes may be later with the long summer evenings, and a morning lie-in may become a regular occurrence. As the end of the school holiday approaches, bedtimes can be gradually adjusted to match the school routine. Pharmacy staff can remind parents of the importance of good sleep hygiene in the preparation for the return to school. This will make the first few days of term easier

20 | PHARMACYNEWSIRELAND.COM

to cope with and start the school year with good sleep habits. Primary school children should sleep for between 9 and 12 hours per night, with teenagers aiming for between 8 to 10 hours (Great Ormond Street Hospital, 2020). Some sleep hygiene tips from Great Ormond Street children’s hospital are; • Reduce caffeine intake; watch out for caffeine in fizzy drinks as well as tea and coffee.

• Timing of meals; a large meal just before bedtime can disturb sleep. Aim for the main meal to be earlier in the day and give a small snack or warm drink before bedtime.

• Physical activity; sports or a walk in the fresh air during the daytime can help with sleep at night. Avoid vigorous activity just before bedtime.

• Technology; bright lights from mobile phones, televisions or other electronic devices can keep the brain alert. Keep the hours before bedtime device-free. Try a book or relaxing music at bedtime instead of an electronic device.

• Routine; going to bed and waking at the same time every day (even at weekends) can help with good sleep (Great Ormond Street Hospital, 2020).

Social media While social media can be a good way for young people to keep in touch with friends, parents may find that children are spending long periods of time online during the holidays. As a return to school date gets closer, the pharmacy team can remind parents to try to gradually reduce screen time to make the transition back to school easier. Late night screen time should be minimised to support good sleep.

Support groups for children and parents The pharmacy team have an important role in understanding the role of health services and support groups, to enable staff to direct parents and young people to access these services. The HSE provides an up-to-date list of supports for school aged children at https://www2.hse.ie/wellbeing/mentalhealth/supports-for-young-people.html Some of the supports are listed here: Childline provides free listening services to children and young people up to the age of 18. The Childline helpline is open 24 hours every day and can be accessed by Online chat at www.childline.ie, Freephone 1800 666 666 or by texting the word “Talk” to 50101

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Department of Children and Youth Affairs (2014). Better Outcomes, Brighter Futures.

Jigsaw is a national centre for youth mental health. They use early intervention to support the mental health of young people aged 12 to 25 years of age. Jigsaw has 13 centres across Ireland. They offer a place that young people can visit for free with confidential support from trained mental health professionals. They can also be accessed online at www.jigsaw.ie BeLonG To youth services is the national organisation supporting lesbian, gay, bisexual, transgender, and intersex (LGBTI+) young people between 14 and 23 years in Ireland. Services include support groups for young people and parents. The services are confidential, free-of-charge and welcoming to all young people. www.belongto.org In summary, the end of the summer holidays can bring mixed emotions for children and their parents. The pharmacy team are ideally placed to support families during this period and to signpost to local services where appropriate.

Action points for continuing professional development After reading this article you could: • Discover more about local and national supports for young people and parents.

Find out where your nearest branch of Jigsaw is.

• Think about your local schools. Is there an anti-bullying policy on the school website? Does the school offer a wellbeing programme?

• Read more about child mental health and wellbeing using the references below.

References Department of Children, Equality, Disability, Integration and Youth (2022). An indicator set for Brighter Outcomes, Better Futures. 2021 update.

Department of Children, Equality, Disability, Integration and Youth (2021). Growing Up in Ireland. Social-Emotional and Behavioural Outcomes in Early Adolescence.

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Duvall, A., & Roddy, C. (2021). Managing anxiety in school settings : creating a survival toolkit for students. London ;: Routledge, Taylor & Francis Group.

Great Ormond Street Hospital. (2020). Sleep hygiene in children and young people: information for families. Retrieved on 18th May 2022 from https://media.gosh.nhs.uk/ documents/Sleep_hygiene_F1851_FINAL_ Jun20.pdf Hayes, B., & Bainton, J. (2020). The impact of reduced sleep on school related outcomes for typically developing children aged 11–19: A systematic review. School psychology international, 41(6), 569-594. doi:10.1177/0143034320961130 Nolan, A., & Smyth, E. (2021). Risk and protective factors for mental health and wellbeing in childhood and adolescence.

Economic and Social Research Institute.

Research series number 120.

Pollak, S. (2022). More than 11,700 children and teenagers accessed mental health services last year. Retrieved on 19th May 2022 from https:// www.irishtimes.com/news/health/more-than11-700-children-and-teenagers-accessed-mentalhealth-services-last-year-1.4779390.

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Back2School Asthma

Back to School Checklist for Children with Asthma Asthma is the most common chronic condition among children, affecting one in 10 children and adolescents under 18. Children with the condition miss on average five days of school each year, making it one of the leading causes of absenteeism.

Written by Ruth Morrow, Respiratory Nurse Specialist, Asthma Society of Ireland

• Explain what their triggers are and what to do if your child has an asthma attack • Check if there is a School Asthma Policy in place • If your child is starting a new school, speak to teachers about your child’s asthma, even if they are well right now Asthma Policy for Schools

There is a dramatic rise in the number of children admitted to hospital for their asthma in September each year known as the “September spike”. Triggers which are commonly found in schools include:

• If your child is participating in PE or other activities, place a reliever inhaler and spacer in their bag

• Chemical fumes

• Show them how to wash their hands correctly and explain why this is important

• Perfumes • Aerosols • Chalk dust In addition, changes in weather, an increase in fungal spores, moulds and in an increase in circulating viruses such as RSV all contribute to an increase in asthma symptoms at this time of year.

Advice for parents: This checklist should help you control your child’s asthma during September and into the winter months.

• Have your child’s asthma reviewed by your GP in August/September • Ensure your child has an Asthma Action Plan and it is up to date • Use the inhaler technique videos on asthma.ie to help your child take their inhaler properly • Make sure your child carries their reliever inhaler (usually blue) at all times • Check that they take their medication every day with a fridge planner • Leave a spare reliever inhaler and spacer in the school, with their name clearly labelled

• Never send a sick child to school

• An older child/teenager often require extra supervision and cannot be relied on to selfmedicate independently - put systems in place as they may avoid taking their medication • Visit the school and make sure your child’s teacher is aware that they have asthma

The Asthma Society of Ireland recommends that all schools have an Asthma Policy in place that is reviewed regularly. As part of their Asthma Policy, it is also recommends that schools create an asthma record sheet for all students with asthma. The Asthma Society is warning teachers to be vigilant for asthma triggers at this dangerous time of year and to talk to parents to ensure you are aware of any students with asthma in your class.

Students with Asthma – advice for teachers When a student with asthma joins your class, there are a number of steps can be taken to ensure they are supported as much as possible which include: • Familiarise yourself with the school’s Asthma Policy • Always ensure that students with asthma have access to their reliever inhaler including during school trips, sports and PE. Relievers should never be locked away.

• Tell parents when their child has an attack or needs their reliever inhaler in school and encourage older students to tell you or another staff member if they use their reliever.

• Speak to parents about concerns over missed days, tiredness in class due to night-time symptoms or lack of concentration due to asthma.

Students with severe or poorly controlled asthma may require extra support due to missed school days.

• Monitor students with asthma to ensure they don’t feel excluded or experience bullying.

• Provide opportunities for all students to learn about asthma in class.

• Think about requesting resources from the Asthma Society of Ireland to ensure the school is well informed about asthma and how to manage the condition.

Once you know what triggers the child’s asthma, you can take practical steps to reduce their impact.

• Damp dust chalkboard and classrooms regularly to get rid of dust mites and pollen • Don’t keep furry or feathery pets in the classroom.

• Try to avoid fumes in science and art classes.

25 • Rigorously enforce a non-smoking policy on school grounds.

• Make sure the school is cleaned regularly.

• Heating and ventilation systems should be well maintained.

P.E. and Sports Exercise improves lung function and is an important part of a healthy lifestyle. Asthma symptoms shouldn’t stop children from taking part in sport and PE, provided that certain precautions are taken.

• Air classrooms to avoid mould and condensation.

Asthma Safe Schools in 2021

• Avoid plants that give off high amounts of pollen

This programme is run by the Asthma Society of Ireland. 32 schools in total were funded to take part in the Asthma Safe Schools Pre Hospital Care Council (PHECC), approved, and certified training in basic life support and the administration of Salbutamol for emergency treatment of adults and children (< 16 years) with an acute asthma attack. Schools were selected on a first come, first serve basis and each school nominated one teacher/SNA to attend the training day. The training was provided by the Irish Ambulance Training Institute. It involved an Asthma Safe School Webinar, Asthma Safe Schools Training Day and an Asthma safe school Pack.

• Use non-latex gloves.

• Make sure that play areas and sports fields are free of autumn leaves as they are full of mould and fungal spores.

• Avoid mowing sports fields or grassy areas during school hours.

• Make sure changing rooms and bathrooms are well ventilated.

• Avoid opening windows and allow students with pollen allergies to stay indoors when pollen is high, such as during and after thunderstorms.

A survey carried out by the Asthma Society on the Asthma Safe Schools Programme 2021 showed that: • 55.5% of teachers who participated in the programme identified themselves of having gained considerable asthma management knowledge.

• 89% of participating teachers believe that they have been provided with the training and tools to provide a supportive and safe environment to children with asthma.

• 78% of teachers gave a star rating of 4 or more when asked how confident that they would be in the management of another person who is having an acute asthma attack in the out-of-hospital environment until handover to an appropriate person.

• When asked if the Asthma Safe School’s Programme has increased teachers overall

knowledge of asthma, 45% agreed and a further 46% strongly agreed.

• 90% of teachers said that they would recommend this programme to others and it was found that both the webinar and the training day were found to be the most beneficial aspects of the program.

• 100% of respondents said that they would use the Asthma Adviceline (1800 44 54 64) and the WhatsApp Messaging Service (086 0591032) if they had any asthma related queries.

This article has addressed managing asthma in schools at a time of year when asthma can be increasingly problematic.

Strategies for children, parents and teachers were discussed.

Pharmacists and technicians can send a message to the WhatsApp service on 086 0590132 if they have questions/queries about asthma/COPD and an asthma nurse will respond.

Back2School Headlice

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.

dehydrates head lice by dissolving their external wax coating.

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

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.

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.

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.

PHARMACYNEWSIRELAND.COM

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Back2School Sexual Education

Pharmacy Role in Sexuality Education Tips from Relationship & Sexuality Educators, to Pharmacists Written by John Halloran and Shauna Monaghan, Education Facilitators, Sexual Health West We get asked a lot of questions in our line of work, and often we have to pause for thought. Dealing with young people, they can often blindside you with a question. So, take a breath and remember at the root of every question is an unknown. Here are 5 qualities we try to lean into in our workshops.

4. Guidance Part of your role is to give options, give appropriate information and allow them to make an educated decision.

Through patience, time and support you can explain how sexual health checks are carried out, what happens next, what if they are positive? / How do they access treatment?

In this moment, try and place yourself in their shoes, think about the myths and untruths you held as fact when you were young. Understand this young person needs; clear language, a supportive yet not dismissive attitude, a realistic approach (yes, some STI’s are lifelong, yes some require treatment, yes you might have to have difficult conversations), they need you to speak in a way they can understand.

1. Time Although hard to come by when working in a pharmacy, it is important that the time you can give is dedicated to this person.

In this case quality of the time, matters just as much as quantity.

This person may be in an anxious state asking about STI’s, because they feel they are at risk and a pharmacist is easier to access than their family GP. (If is a more serious issue- i.e. sexual violence, then each pharmacy should have a protocol to follow in contacting the Gardaí and the SATU).

2. Patience Routine questions are only routine to the professionals.

A young person may not understand what questions they

are being asked- what to ask the pharmacist- or how to ease their own concerns or anxieties.

Honour their enquiry and understand that the question may be rooted in a concern much deeper.

3. Support Listen and try to understand the root of their concerns. Their knowledge of sex and sexual acts may be limited, and sometimes, they might have the complete wrong information.

Myths, gossip and tall tales from school can always influence people’s thoughts, and mixed with the shame and stigma that can be held around sex in Ireland, it can lead them to believe they have done something wrong.

As long as it was freely consenting sex, by in large, there should be no guilt associated with it.

PHARMACYNEWSIRELAND.COM

As medical professionals, often the comfort zone of patient interactions can be to drift into the medicine and the science of things, but, in this instance, if you can remove those blocks and speak person to person

your interaction will be helpful, impactful and affirming for the person seeking care 5. Openness How are we asking questions?

So! We’ve given them time, we’ve possibly had a private area to speak, we are in a situation where we are actively listening and using empathy to guide us.

However, we need to ask a question and we are unsure how to do so.

As a health professional, you probably handle this in a day-to-day setting.

How can we get the information we need, without offending the person?

Asking, plainly, in a respectful tone and supporting your statement with qualifying information can help this person get the correct treatment/ support they need.

This is important when it comes to things like, a person’s gender identity and expression, and who they are sexually active with.

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No other emergency hormonal contraception (EHC) is more effective than ellaOne®.1 REFERENCES: 1. Glasier A et al. Lancet 2010; 375 (9714): 555-62 PRODUCT INFORMATION ellaOne® 30 mg film-coated tablet (ulipristal acetate). Refer to the SmPC for further information. INDICATION: Emergency contraception (EC) within 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure. DOSAGE: one 30mg tablet taken orally as soon as possible, but no later than 120 hours (5 days) after unprotected intercourse or contraceptive failure. Another tablet should be taken if vomiting occurs within 3 hours of intake. Can be taken at any time during the menstrual cycle. Not recommended for women with severe hepatic impairment.

CONTRAINDICATIONS: Hypersensitivity to the active substance or excipients. SPECIAL WARNINGS AND PRECAUTIONS: Occasional use only. Use reliable barrier method after use until next menstrual period. If next menstrual period is delayed >7 days or is abnormal or suggestive symptoms occur then perform pregnancy test. Consider ectopic pregnancy. If pregnancy confirmed, woman should contact their doctor. Concomitant use with EC containing levonorgestrel not recommended. Does not contraindicate the continued use of regular hormonal contraception but reliable barrier method should be used until next menstrual period. Not recommended in severe asthma treated by oral corticosteroids. Concomitant use of CYP3A4 inducers [e.g. barbiturates (including primidone and phenobarbital), phenytoin, fosphenytoin, carbamazepine, oxcarbazepine, herbal medicines containing Hypericum perforatum (St. John’s wort), rifampicin, rifabutin, griseofulvin, efavirenz, nevirapine] not recommended (may decrease efficacy of ellaOne). Long term use of ritonavir not recommended. Not recommended for women who have used enzyme-inducing drugs in the past 4 weeks. Nonhormonal emergency contraception (i.e. a copper intrauterine device (Cu-IUD)) should be considered. Contains lactose. FERTILITY, PREGNANCY AND LACTATION: Not intended for use during existing or suspected pregnancy. Limited human data does not suggest safety concern. Does not interrupt existing pregnancy. No teratogenic potential was observed; animal data insufficient with regard to reproduction toxicity. Marketing Authorisation Holder maintains a pregnancy registry (www.hra-pregnancy-registry.com) to monitor outcomes of pregnancy in women exposed to ellaOne®. Patients and health care providers are encouraged to report any exposure. Ulipristal acetate is excreted in human breast milk; breastfeeding is not recommended for one week after intake. Breast milk should be expressed and discarded. A rapid return of fertility is likely following ellaOne use; regular contraception should be continued or initiated as soon as possible; subsequent acts of intercourse should be protected by reliable barrier method until next menstrual period. UNDESIRABLE EFFECTS: Always consult the SmPC before prescribing. Only the most common side effects and those which are rare but may be serious are listed below. Most commonly reported adverse reactions: headache, nausea, abdominal pain and dysmenorrhea. Common (≥1/100 to <1/10): mood disorders, dizziness, vomiting, abdominal discomfort, myalgia, back pain, pelvic pain, breast tenderness and fatigue. Rare (≥1/10,000 to <1/1,000): ruptured ovarian cyst. RETAIL PRICE: ellaOne 30 mg single film-coated tablet blister pack; € 35.

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Date of last revision of text: May 2019 Unique ID: IE/ELLA/0112 Adverse events should be reported. Reporting forms can be found at www.hpra.ie or email: medsafety@hpra.ie.

Adverse events should also be reported to HRA Pharma UK & Ireland limited on Freephone: 1800 812 984 or email med.info.ie@hra-pharma.com IE/ELLA/0200 Date of preparation: November 2020

Back2School Sexual Education i.e. if there is a young woman who is lesbian, explain that asking about chances of being pregnant are due to possible medical interactions, and not judgements about their relationships.

BREAKING DOWN SOME WOES AND WORRIES: Helping parents lessen the stress: Starting your period can be a very stressful time for most young girls but also for those around them. On average they tend to start around 12-13 years of age, however for some people they can start as early as 8 years old.

For those kids it’s often a big shock for them as well as their parents who may feel unprepared to be crossing that bridge at that age with their child. Sometimes parents may reach out for advice and support. https://www.sexualwellbeing.ie/ for-parents/ is a fantastic resource that can help inform and support parents through this.

Talking about products: A key thing is knowing what options are available for period products, how to use them and what may be an age appropriate product (and feeling comfortable talking about them!)

Many young people feel more at ease starting out with pads before moving onto tampons and much later exploring reusable methods such as menstrual cups.

For some young people periods can bring along cramps which can be debilitating, being able to

advise on what painkillers to take either alone or in combination can be vital information as a lot of people still believe you can only take one type at a time.

Young people and parents alike may have questions around hormonal contraceptives and the pros and cons of starting these as well as all the different varieties available as often doctors may prescribe them without explaining all that goes with them. https://www.sexualwellbeing. ie/for-professionals/ can offer training for professionals to increase their knowledge and understanding, but perhaps also their comfort levels in being able to discuss these items!

Challenging misconceptions: Speaking of hormonal contraceptives, a lot of young people have questions around the side effects that come with them. Often questions around the likelihood of weight gain, depression or blood clots as a result of the pill come up, as do questions around skipping periods or what to do if they miss a pill. Being able to inform these young people in a kind and caring way will go a long way in ensuring that they are making an informed decision around what contraception will work for them and that they will use them correctly.

Often most young girls are prescribed the combined pill as a starting point for contraception, because of the professionals familiarity with it- but a lot of young people aren’t aware of the varieties out there, both with

different pills but also options such as the implant, vaginal ring, patch or IUD. It is worth knowing that if a client is complaining of side effects from their current hormonal contraceptive that you can advocate for them to explore their options as a lot of people don’t realise it can be trial and error when it comes to finding the correct method for themselves.

Making sure we are reducing stigma and increasing access: When it comes to other forms of contraception the use of condoms is incredibly important due to their dual purpose of protecting against both pregnancy and STI’s.

29

In regards to putting a condom on, if a young person is looking for advice, two key pieces of information are 1) that condoms have an inside and an outside, it’s okay to take some time to make sure you have it the right way around and 2) you have to pinch the tip of the condom while putting it on to ensure that there’s no air and that there’s enough space left for ejaculation to collect because if not there’s a risk the condom could burst. Providing this kind of information in an open and practical way can make all the difference as to whether a young person is comfortable purchasing contraception.

Our work as RSE educators means we are well used to hearing the rumbling giggle when we even mention condoms, because they are still seen as a covert item.

Relevant Services:

Buying condoms can be a tricky and embarrassing act for a lot of young people, there can be a lot of confusion in regards to what kind to buy, how to put them on or what size to buy.

sexualhealthwest.ie/stisand-testing-options/

As professionals, we have the ability to change this, and encourage conversation about them, and addressing questions that may come up!

https://www. domesticviolenceresponse. com/

For the most part, so long as condoms have the CE mark or Kite mark and are in date that is enough indication to ensure they’re up to the job. When it comes to sizing this is actually in reference to width rather than length which is news to a lot of people. If a condom is too tight or too loose it will not stay on, so it’s important to get the correct size.

https://www.mensaid.ie/

Sexual/ Relationship Health Services in Ireland Links:

https://www.copegalway.ie/ domestic-abuse-service/

www.womensaid.ie

www.sh24.ie www.myoptions.ie Promoting at home Sexual Health Checks: SH24.ie Changing the game of understanding sexual health and testing, is the HSE service.

An at home test, discreetly delivered to your home within days of ordering online (FOR FREE!). The swabs are easy to use, come with great descriptive infographs and instructions.

Arriving in discreet packaging, a follow up text to say the lab has received your samples and a text of results (with links and numbers to use *if* you test positive for anything).

Reliable, Free, Easy to use, Trustworthy- Thumbs up from Sexual Health West

30

Back2School Sun Care

Skin Sun Safety for Children Skin cancer is the most common cancer in Ireland. Almost 13,000 cases are diagnosed each year. This is twice the number compared to 10 years ago and is projected to more than double again by 2045. Yet most skin cancers could be prevented. Nine out of every ten skin cancers are caused by Ultraviolet (UV) rays from the sun or sunbeds.

Written by Bernie Carter, Assistant Director of Nursing Services at the Marie Keating Foundation UV Exposure in childhood

There are 3 main types of UV rays: UVA, UVB and UVC. UVC is blocked out by the ozone layer and doesn’t reach the earth’s surface.

What is skin cancer?

Skin cancer is generally classified into two main types: Melanoma and Non-melanoma skin cancer (NMSC).

Non-melanoma skin cancer (NMSC) is more common but less aggressive than melanoma skin cancer. It slowly progresses over months or years and accounts for 11,763 cases each year in Ireland.

Non-melanoma skin cancer affects more men than women and is more common in the elderly. It includes basal cell carcinoma and squamous cell carcinoma.

Children and young people are particularly vulnerable to UV skin damage. Exposure to UV radiation in childhood is particularly harmful, hence skin protection in childhood is extremely important. Children have lower concentrations of the protective skin pigment melanin.

The outer layer of children’s skin is also thinner than those of adults. This allows UV radiation to penetrate more deeply through the layers of the skin. Sunburn during childhood is associated with a higher risk of developing melanoma later in life. Three or more instances of sunburn before the age of 20 is associated with two to four time’s higher risk of developing melanoma skin cancer in later life.

Risk of sunbeds to young people’s skin Just one sunbed session increases a person’s chance of developing melanoma by 20%.

Each additional session during the same year may increase the risk by another two per cent.

Young people are particularly at risk when they use sunbeds. The WHO recommends that no person under 18 should use a sunbed! The International Agency for Research on Cancer (IARC) classified

Melanoma is the least common but the most aggressive form of skin cancer because it is more likely to spread to other parts of the body if not caught at an early stage. It accounts for over 1,156 cases each year in Ireland. When detected early, it has a high 5-year survival rate of 93%. Melanoma starts in cells in the skin called melanocytes. Melanocytes make a pigment called melanin. This gives skin its natural colour. This pigment helps to protect the body from ultraviolet light (UV radiation) from the sun. Melanoma may occur at any age. It is more common in older people, however, in comparison to most other cancer types, it is also quite common in younger people.

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sunbeds as ‘carcinogenic to humans’. IARC research indicated that the risk of skin melanoma increases by 75% when sunbed use begins before the age of 30. The average skin cancer risk from sunbeds can be more than double that of spending the same length of time in the Mediterranean summer sun at mid-day!

The Irish Public Health (Sunbeds) Act 2014 banned the use of sunbeds under the age of 18 in Ireland. It also prohibited the sale or hire of sunbed to person under 18 years of age.

Protect your skin and that of your children by following the 5 S’s of the SunSmart code.

1. Seek Shade - especially if outdoors between 11am – 3pm when the sun is at its strongest.

Always use a sun shade on a child’s buggy. Babies and young children should stay in the shade as much as possible 2. Slip on some clothes - protect your child’s skin with loosefitting comfortable clothing made from tightly-woven fabrics 3. Slap on a wide brimmed hat to protect the face, back of the neck and ears 4. Slide on sunglasses - protect your child’s eyes by with childsize UV protective sunglasses 5. Slop on sunscreen - apply a broad-spectrum (UVA/UVB) sunscreen with a high sun

protection factor (SPF) 50+, with high UVA protection (and ideally water-resistant sunscreen, particularly if swimming). Apply generously on your child every 2 hours at least or more often if swimming, perspiring or towelling off.

Sunscreens are not usually recommended for babies younger than 6 months as they have very absorptive skin. Cover with appropriate protective clothing and a hat. Apply sunscreen on small exposed areas only when sun avoidance is impossible.

Know the UV Index The UV index is a scale that measures the UV radiation level at the surface of the Earth. It ranges from zero upwards – the higher the number, the greater the risk.

When the UV index is 3 or above you need to protect children’s skin.

In Ireland, the UV radiation levels are high from April to September, even when it is cloudy. Stay safe by limiting time in the sun when UV is strongest, typically between the hours of 11:00am-3:00pm.

Playing and spending time outdoors is such an important part of childhood but it is crucial that children are protected and safe in the sun.

For all other information and education around skin cancer prevention, information, and support, visit www.mariekeating.ie

Back2School Allergies

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An Overview of Allergies in Children Allergens are therefore responsible for allergic rhinitis, food allergy and anaphylaxis, and contact dermatitis.

They are often also a contributing factor to atopic conditions such as asthma, atopic dermatitis (eczema) and urticaria.

10% of children and young adults have more than one allergic disorder, such as eczema, asthma and nasal allergy and therefore pharmacy teams are critical to addressing demand and easing concerns.

Below, Dr Paul Carson gives an overview of allergies in children.

“Nasal allergy makes people feel quite miserable. Of that, there is no argument. However, nasal allergy in children, if unrecognised (maybe it’s been misdiagnosed as a summer head cold) or badly managed, can have a significant toll on emotional as well as physical well-being.

“For years I’ve been dealing with kids allergies, children troubled by multiple allergy problems and wondered how they get through a full school-day? What with their itchy eczematous skin, their snuffly and irritable noses and wheezy chests, they carry a significant burden of ill health. Adults know how to complain (and rarely hold back), whereas some children don’t know any better. They think everyone goes around with a bunged up nose, wheezy chest and an almost perpetual tiredness.

“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 cooperating.

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’.

“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.

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

Allergic rhino-sinusitis (ARS) is a fancy medical term for allergy driven nose and sinus problems.

Children with un-recognised ARS have:  A significantly impaired quality of life.  Significant learning difficulties.

 A lower ability to achieve different types of knowledge (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).  May suffer repeated ‘head colds’ that go down to the chest (which is really an untreated nose and sinus allergy triggering early asthma).  Nasal blockage and irritation (sneezing, rubbing at the nose to relieve itch); dark circles around the eyes with puffiness of the lower lids.  Poor concentration; disruptive behaviour and unexplained mood swings.

Nasal Congestion “Sometimes a child’s nose is 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. Hay-fever can also cause earaches and ear itching, popping and fullness (‘stuffed up ears’).”

Allergies are either seasonal or non-seasonal. Mould, animal dander, dust, and pollen are the most common.

The first year of life is crucial when it comes to setting off allergies in those with a genetic predisposition. For example, a child who’s been exposed to lots of house dust mite allergen in their first year has a higher chance of developing asthma later in childhood compared to a child who hasn’t been exposed to such high levels of the allergen.

Recognising the Symptoms This is an area that pharmacists are well placed to identify. Selfreporting of allergy is common, with some patients already having an allergy diagnosis. It is important for pharmacists to consider whether management in the pharmacy is appropriate, to acknowledge expertise limitations and know when to direct a patient to their GP. Patients who may require specialist management include those without a definitive diagnosis or those from specific patient groups with specialised treatment pathways, for example pregnant women.

Patients with a suspected food allergy should always be advised to see the GP for an allergyfocused clinical history.

Symptom recognition in food allergy is an important aspect of patient education, so the patient knows when to use an adrenaline auto-injector. This is as important as knowing how to use it.

Symptoms depend on which part of the body is affected. For example, hay fever (also known as seasonal allergic rhinitis, because it is mainly triggered by pollen) affects the eyes and nose, causing sneezing, a runny nose, watery, itchy eyes, irritated and itchy throat and, sometimes, a stuffy, blocked nose.

Perennial allergic rhinitis (a condition that causes symptoms all year round) often causes a stuffy, blocked nose.

Eczema (also called dermatitis) can affect the skin causing itchy, red rashes. Allergic contact dermatitis (a condition which is caused by the skin coming into contact with an allergen, such as nickel) is characterised by red, scaly skin that itches where it has made contact with the allergen.

Asthma affects the respiratory system causing wheezing (a whistling sound in the chest), breathlessness, chest tightness and a cough.

Allergies to some foods, bites or stings can cause urticaria (itchy blisters and red patches on the skin).

Available Treatments The choice for treating allergic rhinitis can be confusing.

Pharmacists are well placed to recommend a product that is matched to symptoms and their severity. It is beneficial to start treatment before symptoms begin.

Eye symptoms are common in allergic rhinitis, with patients reporting red, watery and itchy eyes in addition to nasal symptoms. If this is the case, eye drops may be required.

Antihistamines are the first line of defence for many allergic conditions. When helping patients choose an antihistamine, it is important to be aware of the sedative effect of first-generation drugs, as well as the short duration of action. The benefit of second-generation antihistamines is the rapid onset, which is good for compliance, as is the daily dosing and the fact that they are non-sedating.

On occasion, patients may require high doses of antihistamines to manage allergic or potentially nonallergic symptoms – eg in chronic spontaneous urticaria. Although these doses should be prescribed, it is important to provide reassurance that they are safe and within national guidelines.

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Back2School Dental Care

Education is Key in Dental Care September is just around the corner, which means children heading back into the classroom. Having spent a summer of cooling drinks and snacks, it’s important parents are reminded as to the importance of making sure they have a healthy smile.

Pharmacy teams have a important role to play in helping with the oral care and health of our younger population. Pharmacies are often the first point of contact for healthcare advice for many people. This puts all of the members of your team in a powerful position to offer preventative and emergency advice to patients and parents (including expectant parents) when it comes to oral health care.

The earlier the prevention begins, the better!

Smile agus Sláinte, published in 2021, provides the guiding principles to transform Ireland’s current oral healthcare service over the next eight years. The policy states that, “People in Ireland have benefitted greatly from the improvements in oral health over the past thirty years.

It is vital that these improvements continue and benefit all our population. This will require a wide range of healthcare professionals, in dental and general health, across community, hospital and public and private sectors, working together for the benefit of all our people.”

Teething Children have a total of 20 primary (baby/milk) teeth. These begin to appear through the gums at approximately 6 months old, with the last ones coming in at 2.5-3 years old. Every child is different, and many parents will appreciate reassurance that there are several variations of ‘normal’ when it comes to tooth eruption.

Children may excessively dribble, experience mild soreness of their gums, and have flushed cheeks.

Sugar-free analgesics (such as paracetamol and ibuprofen) can be recommended for short term use, while teething rings cooled in the fridge can soothe irritated gums. It is important to advise parents that diarrhoea, fever, or

other systemic symptoms are not caused by teething, and that teething is responsible for only a very mild and transient temperature elevation.

The permanent dentition begins to come in at around age six, and this can begin with either the exfoliation of the front teeth and replacement with new teeth (incisors), or the appearance of new permanent molars behind the baby molars. The last baby tooth tends to fall out at around age 12, however there can again be wide variation in this. By age 12-13, most children will have 28 permanent teeth present.

Brushing A soft-bristled, age-appropriate toothbrush, wetted with tap water, should be used as soon as the first tooth appears. The teeth and gum pads should be brushed twice daily, with bedtime brushing being the priority. If brushing proves a challenge, playing music or singing a song as a distraction can help for the two minutes it takes.

From the age of 2 until 7 years old, a pea-sized amount of fluoridated toothpaste (>1000ppm fluoride) should be used on a soft brush, with parental assistance (until children can tie their own shoelaces). The toothpaste can

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be a ‘children’s’ toothpaste, but ensuring the correct fluoride concentration (>1000ppm) is key.

As children get older, they may be able to brush unsupervised, using a pea sized amount of >1000ppm fluoridated toothpaste, however, every child’s development is different, and some may need assistance for a little longer.

Many children will report a ‘spicy’ taste from mint toothpastes, and some children with oral sensitivities may not be able to tolerate any toothpaste flavoursthere are options of flavour-free toothpastes and these have changed toothbrushing time for the better for many parents!

Diet With regards to caries development, the frequency of food/drink consumption is the most important factor. Sugar consumption should be minimised, but this is especially important between meals. It can take saliva up to 60 minutes to return to its optimum pH, therefore if snacking occurs more frequently than this, the mouth does not have an opportunity to recover fully before the next acid attack.

Parents and patients can be made aware of ‘good snacks’ such as whole fresh fruit, raw vegetables,

unsweetened popcorn, cheese and yoghurt. Raisins and other dried fruits are best avoided, due to their high sugar content and very sticky consistency.

Medications Where possible, sugar-free versions of medication should be considered. Many over the counter vitamins and oral liquid medications have high sugar concentrations to make them more palatable. Sometimes it is not possible to substitute medications, therefore rinsing with water, or wiping the mouth out following medication administration should be encouraged.

When to refer Analgesics recommended by dental practitioners for dental pain are paracetamol and ibuprofen.

These can be alternated to avoid breakthrough pain prior to the next dose administration. Parents should also be advised to bring their child to the dentist as soon as possible to assess and address the source of the pain.

Children will occasionally develop swelling associated with their dental pain. This can develop and progress very rapidly and be very dangerous, therefore, emergency attendance with a dentist or to a local Emergency Department is required. This is especially important if patients present with systemic symptoms such as a fever, vomiting or nausea, or difficulty opening their mouth/ swallowing/opening their eye, or visible swelling of the face.

Antibiotics are generally not recommended for small localised swelling in the mouth, but are reserved for spreading infection resulting in facial swelling. They will not remove the source of the problem, therefore a dental visit should always be advised.

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Back2School Digestion

The Importance of Good Gut Health in Children The bacteria in a child’s gut plays an important role in keeping them healthy, both mentally and physically.

Though it is unclear if probiotics benefit children, it’s clear they typically won’t cause harm in healthy children. However, pharmacy teams should recommend parents wait until a child is over 1 year of age before giving probiotics.

Children who are seriously ill or who have a compromised immune system should consult their GP before taking probiotics. Some studies suggest that children with a central line or port should also avoid probiotics. In children with these medical devices, there have been reported cases of sepsis.

Fibre A child’s diet should contain fibre as an essential component. It is required to achieve good gut health in children and different fibres help the gut in their own unique ways.

Gut health has become a hot topic in recent years and the discussion is usually about gut microbiome which are the trillions of bacteria that live inside our gut. These bacteria play a key role in keeping children mentally and physically healthy and also reduce the risk of illness and disease.

regular (and prevent uncomfortable constipation), encourage a diet with plenty of fibre. For instance, include wholegrains, veggies and fruit in their diet. This will keep the bowels regular and also feed the healthy gut bacteria. Water is also important to help keep bowel movements soft and regular.

brain. Many of these are produced in the gut. A thriving, healthy gut microbiome contributes to production of chemicals and signalling messages for good mental and physical health in children.

Symptoms of a poorly functioning gut include uncomfortable digestion, stomach aches, poor nutrient absorption, poor immunity and sleep, mood fluctuations and general fatigue. All can have a detrimental impact on children.

The Immune System

Probiotics are the “healthy” bacteria that make up the gut microbiome.

Probiotics work to maintain health and immunity. They also fight inflammation and disease.

Parents can boost the good bacteria in a child’s gut by feeding them probiotic rich foods. Good bacteria can help to form a strong, healthy microbiome. A probiotic supplement is also an option.

The gut microbiome is established in the early years of life. It’s particularly important to support a child’s gut microbiome to thrive while they’re growing. In fact, it is believed that before the age of four or five children’s microbiome remains flexible. This is a great time to build a strong and healthy gut health in children. Beyond this age the microbiome is harder to change as it becomes well established.

Everyone’s microbiome is unique and, interestingly, diet can be responsible for up to 75% of this variation!

Elimination of Waste The gut removes waste from the body. This is important to help support liver function. So, to keep a child’s bowel movements

The gut is home to 70% of the body’s immune system. It is also the main entry point for bugs to get into the body. Therefore, if a child’s gut is not a strong barrier they will be more likely to pick up nasty bugs. This can lead to illness. Research suggests that a poor balance of bacteria in the gut during early childhood can increase risk of gut-related allergies like asthma and eczema.

Advise parents that they can help build their child’s immunity by fuelling the good bacteria in their gut. This will, in turn, keep children feeling energetic and healthy.

The Gut-Brain Axis The Gut-Brain Axis is the physical and chemical connection between the gut and brain. To clarify, it is a network of millions of nerves sending messages both ways. Chemicals called neurotransmitters, such as serotonin and GABA (which controls feelings of fear and anxiety), are sent to and from the

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The Role of Probiotics

Researchers are still learning about all the benefits of probiotics and how they work. Probiotics may help with digestion, preventing infectious diseases and even playing a role in maintaining a healthy weight.

Some studies say probiotics help children with digestive issues such as: • Constipation • Inflammatory bowel disease • Irritable bowel syndrome • Infectious diarrhea

While we often think of fibre as a singular nutrient there are actually many different types, for example:  Insoluble fibre: Wholegrain breads and cereals and the skin of fruit and vegetables help to soften bowel content, promoting regular (and comfortable) bowel movements.  Resistant starch: This is a type of fibre which is not digested as normal by the body. Resistant starch is found in wholegrain cereals, legumes and starchy vegetables like potato. It travels to the large intestine where it feeds good bacteria in the gut.

These good bacteria produce what you need for a healthy digestive system and protection against disease.  Prebiotics: These are another type of fibre which also feed the friendly bacteria in the gut. This provides another nourishing food source to the healthy bacteria in your gut. The great news is prebiotics are found in foods that are very child-friendly and delicious. Think bananas, apples and oats plus foods that are easy to sneak into meals like barley, onion or flaxseed.  Soluble fibre: These help to slow the emptying process in the stomach, which can help children to feel fuller for longer. Soluble fibre is found in fruits, vegetables, oats, barley and legumes.

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News

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Pharmacy Plays Important Role in Migraine Pathway Community pharmacies have been an important partner in a headache patient pathway, as they are often the first point of contact for people suffering from headache and migraine, and can provide invaluable advice to help with medication compliance.

This is according to Professor Orla Hardiman, National Clinical Lead in Neurology who was speaking at the launch of the new pathway, following a Sláintecare funded pilot project.

The new service for patients with headache and migraine was piloted across three Neurology centres in Galway University Hospitals, Tallaght University Hospital (TUH) and St James’s Hospital in 2020 and 2021 with funding from the Department of Health’s Sláintecare Integration Fund. The objective was to pilot a programme that joins up services across the hospital, community, and voluntary sectors.

The HSE has clinically-approved a new headache pathway for implementation across ten sites nationally. Planning has commenced in regard to funding and commencement of implementation at the remaining seven sites.

The service is led by the HSE National Clinical Lead Programme of Neurology in collaboration with the Migraine Association of Ireland, the Irish Pharmacy Union, and the

Academic Unit of Neurology at Trinity College Dublin.

The Minister for Health Stephen Donnelly said, “I am delighted to see that this excellent service is to be expanded to all neurology centres across Ireland. The purpose is self-care, and to ensure that assessment and management of headache and migraine takes place in the most appropriate setting. The multidisciplinary teams involved in this patient centred service are delivering on the Sláintecare reform objective of delivering the right care, in the right place, at the right time, by the right team.”

Professor Hardiman, National Clinical Lead in Neurology added, “800,000 people in Ireland have a neurological issue, and there are 21,000 people on a waiting list for a neurological appointment in Ireland. Between 25% and 30% of people on those waiting lists were referred because of headache or migraine.

Headache was the seventh most common reason for attendance at Emergency Departments, and the second most common reason for attendance at Medical Assessment Units.”

Professor Orla Hardiman

The teams delivering the new service include neurologists, Clinical Nurse Specialists (CNS), Psychologists and targeted administrative support. The Migraine Association of Ireland (MAI) has partnered with the project to streamline services available to patients, especially psychology support groups in the community to facilitate self-care and long-term management of headache, thus reducing the need for ongoing engagement with hospital-based services.

Professor Hardiman adds, “New patient pathways have been key to improving the patient

experience, and for a timelier, more appropriate service for patients. If the ICGP headache management guidelines are not working, GPs can refer patients to a multidisciplinary specialist headache team. The team then works out a care plan with the patient and can refer for additional supports provided by the Migraine Association of Ireland where appropriate. Pharmacies have also been an important partner in the patient pathway, as they are often the first point of contact for people suffering from headache and migraine, and can provide invaluable advice to help with medication compliance.”

New Appointment at HPRA The Health Products Regulatory Authority (HPRA) has announced the appointment of Dr Finnuala Lonsdale as Director of Human Product Authorisation and Registration. Dr Lonsdale will provide strategic and operational leadership to the Human Product Authorisation and Registration Department and will work closely with the management team to oversee the assessment of human clinical trials and registrations or variations of human medicinal products activities of the HPRA. Dr Lonsdale trained as a medical doctor in South Africa undergoing further specialist medical training in South Africa, Canada and the United Kingdom. She also holds a master’s degree in Business Administration as well as postgraduate qualifications in Clinical Pharmacology, Alliance Management and Regulatory Practice.

Dr Lonsdale has clinical experience both in the tropics and in the circumpolar regions and administrative experience as the Chief of Medical Staff for a Canadian Regional Healthcare Authority.

Since 2002 Dr Lonsdale has primarily been involved in pharmaceutical medicine, firstly as a clinical investigator and then during a 10-year period at AstraZeneca in the governance of clinical trials and in particular strategic alliances conducting clinical trials. She holds the Diploma in Pharmaceutical Medicine and is a Fellow of the Faculty of Pharmaceutical Medicine in the United Kingdom.

Her most recent position prior to joining the HPRA was with the Home Office in the United Kingdom where she was the strategy lead for a programme of regulatory reform for the Animals in Science Regulatory Unit.

Dr Finnuala Lonsdale

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Profile

Staying Well with StayWell Pharmacy Group StayWell Pharmacy, part of the Navi group, is celebrating the opening of two new outlets in Cork city and county in recent weeks. The stores – StayWell Ardfallen Pharmacy on Douglas Road in the city, and StayWell Walsh’s Pharmacy in the town of Midleton in the east of the county - are the brand’s 20th and 21st outlets.

Dr Andy Fisher, PhD, outside StayWell Ardfallen Pharmacy on Douglas Road in Cork city, where he is a pharmacist. Owner, Nigel Moloney, also has a StayWell Pharmacy premises on Washington Street and a CarePlus Pharmacy outlet in Carrigaline.

Photo: Jolene Cronin

part of a group like StayWell takes away a lot of the heavy lifting and pressures associated with running a business. Local community pharmacies are crucial to the nation’s health - we have a critical role in the sustainability of healthcare and providing our customers with access to advice and care that they may not be able to get elsewhere”.

Jerry McDonnell is Head of Business Development at StayWell Pharmacy. He says becoming part of the group makes sense for many community pharmacists.

Ireland’s newest retail pharmacy brand was established in 2018 and opened its first branch in Cavan. Outlets in Kildare, Dublin, Offaly, Meath, Limerick, Kerry, and Cork soon followed. The brand aims to inspire healthier communities by connecting customers to their local StayWell Pharmacist and Pharmacy team and is committed to giving back to the communities they serve.

Nigel Moloney has built a high profile in Cork city through his outreach work with the homeless community, and already had two outlets under Navi Group brands - a CarePlus Pharmacy in Carrigaline and a StayWell Pharmacy on Washington Street - when he decided the premises at Ardfallen Mall would be another fitting addition to the StayWell Pharmacy group.

He comments, “In a few short years, StayWell Pharmacy has established a great reputation and image, and offers proven management and work practices, access to national advertising and ongoing support. When you join

a group like this, it takes a lot of the guesswork out of your initial setup. Our latest location serves a broad mix of customers, including locals and professionals working nearby.”

Meanwhile, in Midleton, owner Marta Tomas says having the support of the StayWell Pharmacy group has made a significant difference to the daily activity of her store on the town’s Main Street: “Market demands have changed significantly because of external factors like COVID, Brexit and inflation. It’s much easier to weather those economic storms as part of the StayWell Pharmacy group, with the wrap-around support it offers,” she said.

The interior of StayWell Walsh’s Pharmacy in Midleton, County Cork. Photo: Jolene Cronin

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Marta also highlights the broad value of the community pharmacist’s role, “Our services are much more than just dispensing medicines, and the offering continues to evolve. As a businessperson, I need time to focus on the store’s day-to-day running, and the background support that the StayWell group offers frees me up to focus on the things I need to do to service my local community. Being

“Joining StayWell Pharmacy means members get to run an independent, small business but with the backup and benefits of an extensive business network.

We work closely with each new entrant, giving them access to affordable rebranding and membership costs, leading retail design, cutting-edge technology systems, national marketing and of course, the crucial group buying power. We recognise the importance of the community pharmacist role in serving all

39 parts of the locality and being part of StayWell Pharmacy frees them up to spend more time doing that, while we provide backroom support.

“Many of the people we meet around the country have wanted to refresh their look, expand their offering, or update their IT systems for a long time, but the associated costs have put these projects out of reach. We help them inject new life into a proven business and futureproof their offering through a long-lasting, affordable investment.”

Once a pharmacist or store owner decides to become a member, the StayWell Pharmacy team takes them through a sixstep process, up to the day the business launches its new look and system. From then on, the network continues to provide a full range of member services, from customer support to staff training, marketing, monthly promotions, and even social media assistance.

Owner Marta Tomas outside StayWell Walsh’s Pharmacy outlet in Midleton, County Cork.

Photo: Jolene Cronin

StayWell Pharmacy is a great example of Ireland’s franchise industry, which continues to grow from strength to strength, proof that being part of a larger, wellestablished group has proven to be a robust and resilient business model for many. 21 StayWell Pharmacies have opened around the country in less than four years, providing community pharmacy services for tens of thousands of people.

If you are interested in joining the StayWell brand or want to learn more, contact Jerry McDonnell, Head of Business Development, on 087 696 3770 or at jerrymcdonnell@navi.ie

Pictured outside StayWell Walsh’s Pharmacy in Midleton, County Cork are (l-r) Stephanie Bunce, Puri Castro, owner Marta Tomas, Lydia Power and Brooke O’Neill. Photo: Jolene Cronin

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CPD: Dermatology Continuing Professional Development

CPD 60 Second Summary First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis” implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing.

What does a dermatologist mean when they refer to “seborrheic dermatitis”?

This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.

Sufferers of eczema will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.

Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area.

Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered?

41

AUTHOR: Dr John Ashworth Dr John Ashworth is a leading Consultant Dermatologist and is registered with the General Medical Council of Great Britain and the Irish Medical Council.

Educated at St.Bedes College in Manchester and Manchester Medical School, he carried out his medical elective at Johnston Willis Memorial Hospital in Virginia, USA. At www.dermatologist.ie we offer online Consultant diagnosis/advice and prescriptions for patients

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice?

knowledge gap - will this article satisfy those needs - or will more reading be required?

2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?

3. PLAN - If I have identified a

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the

4 previous steps, log and record your findings.

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.

Management of Common Skin Conditions Provision of specialist services for dermatology is limited therefore many patients will seek High Street advice from their local pharmacy.

The bulk of dermatological problems consist of the following four situations –

1. Skin cancer 2. Acne 3. Eczema / Dermatitis 4. Psoriasis

This article is concerned with items three and four Eczema/Dermatitis First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis”

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CPD: Dermatology

implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing.

Dermatologists would hardly ever use those terms without an explanatory prefix for example SEBORRHOEIC ECZEMA or ALLERGIC CONTACT DERMATITIS thus designating a subcategory which is important in terms of management / advice The classic genetic variation is called ATOPIC DERMATITIS and is often linked to asthma, hayfever and these patients are generally “skin sensitive” - have irritations with simple products like moisturisers / sun screens / soap powders etc Many patients have overlaps of 2 types of eczema – so don’t get hung up on the “name” . Thus, many patients will have a genetic

history of the atopic conditions but will also display a seborrheic pattern of skin trouble so they are in an overlap situation SEBORRHOEIC DERMATITIS: What does a dermatologist mean when they refer to “seborrheic dermatitis”? This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.

So the eyebrows, forehead and the naso labial folds are often the dominant area – other areas include the front of the chest, between the shoulders and sometimes the armpits and groins.

Some patients seem to be suffering an allergic reaction to a naturally occurring tiny organism which lives on human skin and this is why the application

of KETOCONAZOLE can be helpful. Either in the form of a shampoo which can be scrubbed onto the skin when wet in the shower or applied in the normal way as a cream. For similar reasons DAKTACORT cream or DAKTARIN or other anti-fungal / anti-yeast creams are the mainstay of treatment This theory is also the explanation as to why this condition recurs – because you can only kill this organism off for a period of time before it naturally repopulates the skin once again ATOPIC DERMATITIS/ECZEMA: This is the classic form of the disease which is strongly genetic in origin and therefore there is often a personal or family history of the other “atopic” conditions which are asthma and hayfever.

Sufferers will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.

A very important aspect of this condition is OIL DEFICIENCY in the outer layer of the skin and therefore greasy ointments applied very regularly are a hugely important part of treatment – in fact I often say this to patients – if you were to live on a desert island with only one product that you could use for the rest of your life – it would not be a medicated steroid – it would be a greasy ointment like simple VASELINE or even natural OLIVE OIL - because long-term this would give you best benefit

43 Another important consideration is this – skin infection can spread rapidly in patients with eczema and the commonest cause of badly flaring eczema is infection – oral antibiotics such as FLUCLOXACILLIN may need to be instituted from time to time and is usually taken for 14 days at a dose of 500 mg 4 times per day ALLERGY - if the nature of the condition radically alters over a fairly short space of time, and if infection seems unlikely, then consider the possibility of an allergy to something in the environment and that would also include prescription creams as a possibility – patients with geneticbased eczema are more prone to allergy – allergy patch tests are sometimes needed The commonest allergies relate to cosmetic creams, but also prescription creams – plant pollen in the environment – cookery products contaminating the skin – nickel in jewellery and possibly in the diet but there are many other possible allergens.

Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive.

STEROID CREAMS - these are important but should be reasonably minimised for two reasons – firstly damage to the skin – secondly resistance – because in a similar manner to over treating patients with antibiotics and developing antibiotic resistance – something similar can happen with regular use of steroids therefore a rotation policy using several different products it’s tremendously important in the long run.

My own personal strategy for many patients would include the following 10 day reducing program of topical steroids.

For a temporary period of 10 days I would like to consider the following – only the third is suitable for longer term use the first two should be used exactly as directed – all applied twice per day – once the cycle is complete you should break from all prescription treatments for at least three days and use a moisturiser/skin care programme only.

If needed you can then recommence the cycle after this total period.

The treatment cycle can be shortened of course if you improve very rapidly which is possible but the critical arithmetic is to be completely away from active prescription creams for a three-day period before recommencing your cycle once again.

So the 10 day treatment is as follows: BETNOVATE: twice per day for 2 days, then; EUMOVATE: twice per day for 3 days, then; DAKTACORT: twice per day for 5 days to follow This adds up to 10 days Having emphasised these issues about Steroids it is also important to counterbalance this with the fact that some patients and also health professionals carry a steroid phobia. By this I mean they are reluctant to apply steroids even in reasonable quantities and for reasonable time periods and are thus denying adequate treatment when active treatment is required.

Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area.

TACROLIMUS and associated medications are useful in some patience and have a different action to Steroids. These treatments can irritate the skin in about 30% of patients and thus can be problematic. But certainly useful as an alternative to consider.

SUMMARY Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered?

TOP TIP 1: Most flaring eczema is NOT due to environmental changes – flaring eczema is usually due to normal skin bacteria being scratched into the skin surface and multiplying – thus, INFECTION is the commonest cause of flaring eczema. So adding an antiseptic topically or an antibiotic orally (FLUCLOXACILLIN 500 mg x4 per

day for 14 days) will often make a dramatic difference.

NEWLY DEVELOPED ECZEMA: if the problem is recent – then consider circumstances – external allergy may be of relevance – starting work as a hairdresser, nurse, food industry – any wet work / regular hand washing is a potential problem – these considerations are important.

Wet work - both domestic and occupational, can obliterated the adhesion between the top of the fingernail and the nailfold skin thus allowing contaminants underneath the skin and this can precipitate nasty finger and hand eczema – hand protection by using cotton gloves inside rubber gloves when doing any dirty or wet work can be tremendously helpful.

In sunnier months eczema can flare and many patients can be sensitive both to direct sunshine but also to airborne pollen landing on the skin – FINGER TO FACE transfer of allergens (eg in the garden; cookery products; nail varnish) is another very important cause of face and neck eczema.

In colder months eczema can also flare for different reasons –

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CPD: Dermatology

the skin tends to be less oily in winter and needs more emollient and protection from prolonged exposure to cold and wind.

TOP TIP 2: Empower yourself with further information eg www.dermatologist.ie ; www.dermnetnz.org ; www.BAD.org.uk Give your creams a star rating with your dispensed steroids so you can understand the different strengths of steroid creams eg BETNOVATE ++++ ; EUMOVATE ++; HYDROCORTISONE + ; EMOLLIENTS zero pluses – and appropriate / inappropriate body locations for the different strengths.

When I see patients on multiple steroid creams I often ask them to put the creams on my desk in strength order from top to bottom and often they have very little idea about the relative strengths.

DAKTACORT is a good +1 product for most facial eruptions and covers both SEBORRHOEIC and also ATOPIC disease.

All forms of eczema have a common abnormality, OIL DEFICIENCY in the skin (not water deficiency) - therefore the term “dry skin” is very misleading. Oily greasy products like VASELINE work well but you cannot go out wearing them more cosmetically acceptable moisturisers are often preferred.

The preference is purely personal – there is no “best” product.

CLINGFILM - if you apply a treatment to the skin and then wrap the kitchen clingfilm temporarily over the area this enhances the penetration and effectiveness of the cream or moisturiser. This is a particularly useful technique to use overnight in bed – and can make a very dramatic difference to a number of patients.

KEY QUESTIONS: Past personal and family history of eczema / asthma / hay fever – indicates a genetic disease Recent sudden onset with no past history indicates the possibility of external factors A scaly dandruff like appearance on the face, scalp or upper body indicate a likely SEBORRHOEIC DERMATITIS type problem Sudden deterioration of a previously lower level problem indicates likely infection or allergy

OVERALL STRATEGY: Try to establish a likely diagnosis by appropriate consideration of family genetics Think about external causation if possible Tackle infection if present Use plenty of oil replacement Make sure you have a grip of steroid potency in the products you use PSORIASIS Usually has a different appearance to eczema and the main characteristic differences for standard psoriasis are the fact that individual patches come to an abrupt end and quickly switch to normal skin rather than gradually fading towards normal skin which is more typical for eczema. Also, Psoriasis tends to be drier and thicker as a condition.

These distinctions are not universal and quite commonly it is difficult to differentiate between the two conditions even for experts.

DIFFERENT PATTERNS: There is a very strong genetic tendency.

There are a few different patterns of Psoriasis but the classic shows the thick plaques. Other forms can affect just the flexures only, for example the armpits and the perineum. Other patients find that the scalp is predominantly involved. Other much rarer patients find their joints become arthritic before the appearance of the rash which can take many years to manifest. In other words Psoriasis is a complex disorder of the immune system which can affect the joints as well as the skin.

BIOLOGIC THERAPY: Over the past decade the pharmaceutical industry have developed treatments broadly referred to as the “biologics”. These consist of chemicals which either bind to specific antibody sites in the immune system or interfere with the immune system cascade of chemicals many of which are called “interleukins”. Inter meaning “acting between” and leukins referring to the leukocytes – the white cells of the immune system.

However, these medications are very complicated, very expensive and tend only to be used for extreme sufferers. The majority of psoriasis sufferers have a milder disease which can usually be adequately controlled with safe external cream treatments applied in the normal way.

ROTATION POLICY: Treatment on the skin for psoriasis is usually best achieved using a rotation policy – approximately one month on each product in a triangular rotation so that the psoriasis is attacked in different ways by different molecules and this seems to be the best way to control it – below I will give you a prescription for three products that would be a good rotation policy to consider All treatments need to be applied and left on the skin for at least 30 minutes on each treatment session to allow good penetration into the skin and maximum benefit The three reasonable products I often recommend are as follows: DOVOBET EXOREX PSORIDERM Sometimes, if Psoriasis is very angry and inflammatory it is reasonable to apply a very strong steroid approach for example DERMOVATE for a temporary period of 2–4 weeks but strong steroids are not generally recommended for long-term use.

When treating psoriasis of the hairy scalp it is often difficult to get treatment into the base of the condition because of a thick surface protective scale which needs removing first. Greasy applications like COCOIS are massaged into the skin by parting the hair to expose the skin, applying the treatment then parting the hair fractionally further across the scalp and working across the entire area in this way. Then leave the treatment in position under a protective plastic shower cap for several hours, often overnight in bed – then shower out and massage with standard shampoo which will help shed a lot of the scale.

ENSTILAR and DIPROSALIC scalp liquid (as examples) are then able to be massaged in a similar way but can now penetrate into the root of the problem.

If it is not possible to control psoriasis by external treatment then oral medications can be considered and these include the following – METHOTREXATE, CYCLOSPORIN, MYCOPHENALATE and others.

Usually GPs are reluctant to initiate these treatments without supervision by specialist and repeat blood tests are needed to ensure safety.

EMOLLIENTS: these are important in Psoriasis not so much as an oil replacement therapy as in the

case of eczema – but more in the sense that the dry scaly surface thickening of typical psoriasis prevents the penetration of active treatment. Once the surface scale is softened and removed then active treatments can be more effective. Emollients also make Psoriasis feel more comfortable for the patient.

ULTRAVIOLET LIGHT: natural sunshine, sunshine of an artificial kind for example in a tanning parlour can sometimes be helpful but of course we all know these are harmful for human skin. So any recommendation to try these has to be counterbalanced by the harmful consideration and advice.

Medical ultraviolet light refers to a very specific narrow wavelength of light which is particularly helpful for skin disease and much less harmful to the skin in general. However, this kind of light exposure is a specialised option which is mainly delivered from dermatology departments are therefore can be more difficult to gain access. Many patients report great improvement on a sunny holiday.

Q/A section: ATOPIC DERMATITIS is characteristically associated with a greasy skin T/F? False – it is usually associated with an oil deficient skin and emollients are a vital part of treatment ATOPIC DERMATITIS is linked with other disease specific associations T/F? Correct – very often there is a personal or a family history of associated asthma and hayfever – there is a strong genetic link PSORIASIS has no other manifestations outside of the skin appearance T/F? False – psoriasis sometimes is associated with certain types of arthritis and the arthritis can sometimes preceed the psoriasis by many years PSORIASIS can appear at any age but is usually present from early childhood T/F? False – psoriasis very rarely presents in childhood, unlike atopic dermatitis which is characteristically common in childhood. Psoriasis appears much more commonly in adult life and sometimes is associated with a severe sore throat as a trigger factor

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Indication: Topical treatment of psoriasis vulgaris in adults. Active ingredients: 50 µg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate). Dosage and administration: Flare treatment: Apply by spraying onto affected area once daily. Recommended treatment period is 4 weeks. If it is necessary to continue or restart treatment after this period, treatment should be continued after medical review and under regular supervision. Long-term maintenance treatment: Patients who have responded at 4 weeks’ treatment using Enstilar once daily are suitable for long-term maintenance treatment. Enstilar should be applied twice weekly on two non-consecutive days to areas previously affected by psoriasis vulgaris. Between applications there should be 2-3 days without Enstilar treatment. If signs of a relapse occur, flare treatment, as described above, should be re-initiated. Maximum dose: The daily maximum dose of Enstilar should not exceed 15 g, i.e. one 60 g can should last for at least 4 days of treatment. 15 g corresponds to the amount administered from the can if the actuator is fully depressed for approximately one minute. A two-second application delivers approximately 0.5 g. As a guide, 0.5 g of foam should cover an area of skin roughly corresponding to the surface area of an adult hand. If using other calcipotriol-containing medical products in addition to Enstilar, the total dose of all calcipotriol-containing products should not exceed 15 g per day. Total body surface area treated should not exceed 30%. Safety and efficacy in patients with severe renal insufficiency or severe hepatic disorders have not been evaluated.

Safety and efficacy in children below 18 years have not been established. Shake the can for a few seconds before use. Apply by spraying, holding the can at least 3 cm from the skin, in any orientation except horizontally. Spray directly onto each affected skin area and rub in gently. If used on the scalp, spray into the palm of the hand then apply to affected scalp areas with the fingertips. See hair washing instructions in the package leaflet. Wash hands after use (unless Enstilar is used to treat the hands) to avoid accidentally spreading to other parts of the body as well as unintended drug absorption on the hands. Avoid application under occlusive dressings since systemic absorption of corticosteroids increases. It is recommended not to take a shower or bath immediately after application. Let the foam remain on the scalp and/or skin during the night or during the day.

Contraindications: Hypersensitivity to the active substances or any of the excipients. Erythrodermic and pustular psoriasis. Patients with known disorders of calcium metabolism. Viral (e.g. herpes or varicella) skin lesions, fungal or bacterial

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Enstilar should not be used in these areas. Instruct the patient in the correct use of the product to avoid application and accidental transfer to the face, mouth and eyes. Wash hands after each application to avoid accidental transfer to these areas as well as unintended drug absorption on the hands. If lesions become secondarily infected, they should be treated with antimicrobiological therapy.

However, if infection worsens, treatment with corticosteroids should be discontinued. When treating psoriasis with topical corticosteroids, there may be a risk of rebound effects when discontinuing treatment. Medical supervision should therefore continue in the post-treatment period. Long-term use of corticosteroids may increase the risk of local and systemic adverse reactions. Treatment should be discontinued in case of adverse reactions related to long-term use of corticosteroid. There is no experience with the use of Enstilar in guttate psoriasis.

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not to use Enstilar on the breast when breast-feeding. Side effects: There are no common adverse reactions based on the clinical studies. The most frequently reported adverse reactions are application site reactions. Uncommon (≥1/1,000 to <1/100): Folliculitis, hypersensitivity, hypercalcaemia, skin hypopigmentation, rebound effect, application site pruritus, application site irritation, application site pain (including application site burning). Not known frequency: Hair colour changes. Calcipotriol: Adverse reactions include application site reactions, pruritus, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, psoriasis aggravated, photosensitivity and hypersensitivity reactions, including very rare cases of angioedema and facial oedema. Systemic effects after topical use may appear very rarely causing hypercalcaemia or hypercalciuria.

Betamethasone: Local reactions can occur after topical use, especially during prolonged application, including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation and colloid milia. When treating psoriasis with topical corticosteroids, there may be a risk of generalised pustular psoriasis. Systemic reactions due to topical use of corticosteroids are rare in adults; however, they can be severe. Adrenocortical suppression, cataract, infections, impaired glycaemic control of diabetes mellitus, and increase of intra-ocular pressure can occur, especially after long-term treatment. Systemic reactions occur more frequently when applied under occlusion (plastic, skin folds), when applied onto large skin areas, and during longterm treatment. Precautions for storage: Do not store above 30°C. Extremely flammable aerosol. Pressurised container. May burst if heated. Protect from sunlight. Do not expose to temperatures exceeding 50°C. Do not pierce or burn, even after use. Do not spray on an open flame or other ignition source. Keep away from sparks/open flames. No smoking. Legal category: POM. Marketing authorisation number and holder: PA 1025/5/1. LEO Pharma A/S, Ballerup, Denmark. Last revised: March 2021.

Reporting of Suspected Adverse Reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, website: www.hpra.ie Adverse events should also be reported to Drug Safety at LEO Pharma by calling +353 1 4908924 or e-mail medical-info.ie@leo-pharma.com

References: 1. Enstilar® SPC, www.medicines.ie. Last accessed: April 2022. 2. Leonardi C et al. J Drugs Dermatol 2015;14(12):1468–1477. 3. Koo J et al. J Dermatolog Treat 2016;27(2):120–127. 4. King C and Lowson D. Poster 237 presented at the 5th Psoriasis International Network Annual Meeting, Paris, France, 5–7 July 2016. 5. Lebwohl M et al. J Am Acad Dermatol 2021;84:1269-77. 6. Menter A et al. Poster presented at the 16th Annual Las Vegas Dermatology Seminar, Las Vegas, USA 5-7 November 2015.

Further information can be found in the Summary of Product Characteristics or from: LEO Pharma, Cashel Road, Dublin 12, Ireland.

E-mail: medical-info.ie@leo-pharma.com ® Registered trademark

Date of preparation: April 2022 IE MAT-56021

New Microbiota Research Could Lift the Fog on Chemobrain Written by Dr Sarah-Jane Leigh, Government of Ireland Postdoctoral Fellow at APC Microbiome Ireland, an SFI Research Centre headquartered at University College Cork

“The mechanisms underpinning these chemobrain symptoms are poorly understood, posing a serious impediment to their clinical management” Cancer is the second-leading cause of death in Europe and imposes significant human and economic costs. Research in recent decades has primarily focused on reducing mortality and relapse rates, leading to considerable improvements to established treatment regimens as well as the advent of new therapies, specifically the development of immunotherapies and more targeted anti-cancer agents. These advancements in treatment options have dramatically improved patient care and survival for several cancers and have also exposed a number of issues around the long-term side effects of cancer therapies that impact quality of life.

What is chemobrain?

A large subset of cancer patients and survivors frequently report neuropsychiatric symptoms and impairments during and following cancer treatment, including impaired cognition, increased incidence of mood and anxiety disorders, and increased pain and fatigue which collectively resembles “brain fog” and has been termed “chemobrain”. These impairments are most frequent during and immediately following therapy, although some cancer survivors

experience these symptoms for decades after the resolution of their cancer, interfering with their well-being and return to normal life. These neuropsychiatric impairments are often difficult to quantify: while patients’ subjective reports indicate sluggish thinking and poorer cognitive performance following therapy, these are often not well captured by standard neuropsychological testing utilised in the majority of studies to date. This is most likely because standard neuropsychological tests were originally designed for diagnosis of focal lesions of the central and peripheral nervous systems, rather than diffuse damage throughout the brain.

Approaches using methods from cognitive psychology, which are designed to assess cognitive performance within healthy populations, have identified that cancer patients and survivors suffer from difficulties with concentration and attention, short-term memory and executive function.

What the Research Tells us While most research so far has shown that these neuropsychiatric symptoms and impairments are associated with traditional cytotoxic chemotherapy regimens in cancer

46 | PHARMACYNEWSIRELAND.COM

patients and survivors, there is emerging evidence that newer immunotherapies1 and targeted cancer therapies2 may have similar impacts on brain health and function. The mechanisms underpinning these chemobrain symptoms are poorly understood, posing a serious impediment to their clinical management. Similarly to cancer patients and survivors, in vivo experiments with chemotherapeutic agents induce impairments in cognition and increased anxiety-like and pain behaviours. These experiments have shown that chemotherapeutic agents increase neuroinflammation, reduce neurogenesis and neurotransmitter availability, and alter neuronal morphology throughout the central and peripheral nervous systems when administered in both healthy animals and those with cancerous tumours.

The gut microbiota, cancer and chemobrain The human gastrointestinal tract is populated by an ecosystem of bacteria and other micro-organisms, collectively known as the gut microbiota, that have co-evolved alongside humans to produce a complex symbiotic relationship. The gut microbiota supports host physiology through improved energy harvest, strengthened gut integrity and barrier function, protection from infection, immune modulation3, and brain health and function.4 A healthy gut microbiota is thought to reduce the risk of cancer development, while altered gut microbiota community as well as specific gut microbes can increase the likelihood of developing gastrointestinal cancers5 (for example, Helicobacter pylori causes stomach ulcers and increases the prevalence of stomach and small intestine cancers while Fusobacterium nucleatum promotes colorectal cancer development). Furthermore, the gut microbiota can modulate cancer therapy effectiveness through direct and indirect interactions with cancer drugs: chemotherapies can transiently shift gut microbiota composition and microbial metabolite production, and baseline

“Understanding the mechanisms at play can help find some muchneeded solutions to this problem and deliver potential interventions for these behavioural impairments” microbiota composition and exposure to antibiotics influences patient responses to immunotherapy.6 The gut microbiota also appears to be involved in cancer therapy side effects involving the gut (diarrhoea and nausea), infection risk as well as changes in the central and peripheral nervous systems. A recent systematic review assessing the role of the microbiota in side effects reported by cancer patients concluded that microbiota composition was associated with fatigue, anxiety, depression, sleep quality, cognitive impairment and peripheral neuropathy in patients undergoing chemotherapy.7 These results are in line with emerging evidence from experiments in vivo where chemotherapy-related fatigue8 and peripheral neuropathy9 are related to microbiota composition and can be modified through interventions targeting the microbiota. So far, only a few drugs and neuropsychological symptoms have been examined and several experts in the field have identified the microbiota as a potential site for intervention in chemobrain.

What is the role of drug-microbiota and brain-microbiota interactions in chemobrain?

Professors Gerard Clarke, John Cryan, and I at APC Microbiome Ireland, a Science Foundation Ireland funded research centre dedicated to the study of host-microbe interactions, are combining behavioural neuroscience and neuropharmacology approaches to address how traditional and novel cancer drugs may induce chemobrain through modulation of the gut microbiota, in collaboration with a multidisciplinary team spanning pharmacy, pharmacomicrobiomics (the study of drugmicrobiota interactions), microbiology and oncology. Our current project is grounded in the hypothesis that host-microbiota and drug-microbiota interactions underlie cancer-therapy associated behavioural impairment. Specifically, we propose that different cancer therapies will present unique drug-microbiota interactions that will modify host-microbiota interactions and subsequently behaviour.

The lived experience of cancer treatment means people often take longer than they anticipated to get back on their feet and fully engaged in life, and this is often due in part to chemobrain. Understanding the mechanisms at play can help find some much-needed solutions to this problem and deliver potential interventions for these behavioural impairments. The study of how microbiota-drug interactions alter drug benefits and side effects is a relatively new avenue of research with substantial scope to yield impactful new discoveries.

The development of microbiota-targeted therapies holds promise for the management of these troublesome side effects that cloud quality of life for cancer patient and survivor.

Twitter @SarahJane_Leigh Linkedin Sarah-Jane Leigh Twitter @Pharmabiotic Linkedin APC Microbiome Ireland Facebook Pharmabiotic Instagram microbiomeireland

References: 1. Joly F, Castel H, Tron L, Lange M, Vardy J. Potential Effect of Immunotherapy Agents on Cognitive Function in Cancer Patients.

J Natl Cancer Inst. 2020;112(2):123-127. doi:10.1093/jnci/djz168 2. Abdel-Aziz AK, Mantawy EM, Said RS, Helwa R. The tyrosine kinase inhibitor, sunitinib malate, induces cognitive impairment in vivo via dysregulating VEGFR signaling, apoptotic and autophagic machineries. Exp Neurol.

2016 Sep;283(Pt A):129-41. doi: 10.1016/j. expneurol.2016.06.004.

3. Sekirov I, Russell SL, Antunes LCM et al.

Gut Microbiota in Health and Disease.

Physiological Reviews. 2010;90(3):859-904. doi: 10.1152/physrev.00045.2009.

4. Cryan, J., Dinan, T. Mind-altering microorganisms: the impact of the gut microbiota on brain and behaviour. Nat Rev Neurosci. 2012 13, 701–712. https://doi. org/10.1038/nrn3346 5. Helmink, B.A., Khan, M.A.W., Hermann, A. et al. The microbiome, cancer, and cancer therapy. Nat Med 25, 377–388 (2019). https:// doi.org/10.1038/s41591-019-0377-7 6. Leigh SJ, Lynch CMK, Bird BRH, et al. Gut microbiota-drug interactions in cancer pharmacotherapies: implications for efficacy and adverse effects. Expert Opin Drug Metab Toxicol. 2022 Jan;18(1):5-26. doi: 10.1080/17425255.2022.2043849.

7. Song BC, Bai J. Microbiome-gut-brain axis in cancer treatment-related psychoneurological toxicities and symptoms: a systematic review. Support Care Cancer. 2021 Feb;29(2):605-617. doi: 10.1007/s00520-02005739-9.

8. Grant CV, Loman BR, Bailey MT, Pyter LM. Manipulations of the gut microbiome alter chemotherapy-induced inflammation and behavioral side effects in female mice. Brain Behav Immun. 2021 Jul;95:401-412. doi: 10.1016/j.bbi.2021.04.014.

9. Ramakrishna, C., Corleto, J., Ruegger, P.M. et al. Dominant Role of the Gut Microbiota in Chemotherapy Induced Neuropathic Pain. Sci Rep 9, 20324 (2019). https://doi. org/10.1038/s41598-019-56832-x

PHARMACYNEWSIRELAND.COM | 47

48

Elderly Care

Ageing and the Immune System Age-associated changes in a protein called KLF4 upset the normal daily fluctuations in immune system activity in mice, according to an NIA-supported study at Stanford University and the University of Pennsylvania. This loss of daily variation in the immune response may lower the body’s ability to fight infections. The findings, published in Nature Immunology, help scientists better understand the declining function of the immune system in older adults. of those adults developing and dying from an infection.

Immune responses that are disrupted, such as by the KLF4 mechanism described in this study, contribute to not only infections but other diseases associated with aging. By identifying the many pathways that control the complex responses of the immune system, researchers can provide clues that may lead to new prevention and treatment approaches for agingrelated conditions.

There are a number of ways in which community pharmacy teams can advise their elderly populations on boosting their immune systems: The research team sought to find a connection between aging and the immune system by investigating the effects of the body’s biological clocks — called circadian rhythms — on the immune response. These internal clocks, which govern our daily cycles of sleep and activity, influence the activities of the immune system.

First, the team showed that circadian rhythms are involved in the immune response in young mice, but not in older mice. In response to an infection, young mice were more likely to survive when they were infected during the day than when they were infected at night, while for older mice, survival declined no matter whether they were infected during the day or night.

The researchers then looked for the immune cells that may explain this age-related difference.

They found that circadian rhythms influenced the normal migration of immune cells into the bloodstream to fight infections in young mice, but not in older mice. The researchers also found that certain immune cells from younger mice are more effective at destroying bacteria during the day than they are at night, while the immune cells from older mice did not show any difference in activity according to the time of day.

To find an explanation for the agerelated changes, the researchers focused on a specific protein called KLF4, which is important for many diverse functions in the body, including stimulating immune cell proliferation. Because circadian rhythms influence whether KLF4 from the immune cells is active or inactive, its activity normally fluctuates over the course of the day. However, in immune cells from older mice, KLF4 levels did not change throughout the day.

In the immune cells from young mice, KLF4 controls the normal daily fluctuations of the immune cell function. In mice engineered to lack KLF4, circadian rhythms no longer controlled the immune cell activity. This lack of variation over a 24-hour period in immune cells from young mice that lacked KLF4 resembled what researchers observed previously in immune cells from older mice.

To find out whether KLF4 also plays the same role in humans, the researchers looked at medical data collected from nearly 500,000 people in the UK Biobank. When they compared the full study population to older adults with mutations in the KLF4 gene, they confirmed the connection between KLF4 and the aging-related decline in immune function: The loss of KLF4 function increased the likelihood

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Eat a nutrient-dense diet Eating a balanced, nutrientrich diet is an important way to boost the immune system. This includes eating plenty of fruits and vegetables, which contain nutrients and antioxidants to promote good health.

Many different vitamins and minerals play a role in maintaining the immune system. The best way for people to meet their needs is to eat a variety of foods.

Specific nutrients that play a role in immune health include: • B vitamins. B vitamins are found in dairy products, grains, meats, eggs, and beans.

Vitamin B12 deficiency is common in older adults.

• Vitamin C. Vitamin C is found in many fruits and vegetables, especially red and orange types and citrus fruits. Most people are able to get enough from food and usually a supplement is not needed.

• Selenium. Selenium is an antioxidant that is found in small amounts in many foods. Sources include nuts, meats, and grains.

• Zinc. Zinc is a mineral is found in oysters, cheese, beans, lentils, and beef. Most people are able to get enough from their diet but in special cases, a supplement may be recommended.

There is some evidence that a Mediterranean-style diet can support good immune function. A Mediterranean diet can also play a role in helping to prevent and manage chronic diseases.

Manage stress Chronic stress can have many negative effects on the body, including lowering the immune response. When under stress, the body increases the production of a hormone called cortisol.

Cortisol helps the body deal with stressful situations. It also limits certain bodily functions that aren’t essential in a fight-orflight situation. This includes the immune system.

It’s difficult to live a life that is completely free of stress, so learning how to manage stress when it arises may be the most helpful option.

Get plenty of sleep Quality sleep becomes more important with age. Getting enough sleep can improve brain function, concentration, and memory.

Conversely, sleep deprivation can cause a multitude of issues, like reducing the effectivenessTrusted Source of the immune system.

Spend time outdoors Being outside has so many benefits for health. Many people find that time in nature helps to reduce their stress. Another bonus of outdoor time is vitamin D from moderate sun exposure.

Vitamin D helps strengthen the immune system. When your vitamin D levels are adequate, they may help prevent inflammation and some autoimmune diseases.

A 2017 reviewTrusted Source suggests vitamin D may also help prevent certain infections. When more than 11,000 people were analyzed, researchers found that those who supplemented vitamin D had fewer respiratory infections.

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50

Elderly Care: Vaccinations

Vaccinations in Older Adults As vaccination of the population against SARS-CoV-2 infection began, it was critically important that lessons from previous vaccination programmes among older adults were used to inform current efforts.

To assist this, researchers at The Irish Longitudinal Study on Ageing (TILDA), at Trinity College Dublin, rapidly produced a report that provides key information on influenza (flu) vaccine uptake and health behaviours which govern vaccine efficacy, while addressing important considerations and opportunities for government and the HSE ahead of the Covid-19 vaccine rollout for older adults.

The report analyses data from TILDA participants between 2016 and 2019, outlining the prevalence of flu vaccination in this cohort and levels of physical activity among those who received the flu vaccine, and provides a review of the scientific evidence showing the positive effects of prolonged physical activity on vaccine efficacy. The report also provides key information on news sources accessed by TILDA participants during the Covid-19 pandemic and the levels of trust in these sources among those surveyed.

It shows that 65% of TILDA participants accessed information via national radio channels, 43% accessed information via national newspapers, and very few (6-7%) older adults accessed public health information through government websites. This is an important consideration when communicating messaging on the vaccine.

the long-term protection often required for full immunity to a virus.

Research shows that exercise can help to boost antibody responses in older adults. TILDA’s report outlines how prolonged, regular aerobic or moderate exercise in the weeks and months prior to vaccination can help to improve antibody responses post vaccination in older adults.

Key Findings: • 59% of adults aged over 60 had an annual flu vaccination between 2016 and 2019.

• More older persons received the vaccine: 40% aged 60-69 compared with 76% aged 70 and older.

• Of those living with others, 49% are least lonely, 30% sometimes and 21% often lonely.

Considerations for efficacy of vaccines in older adults

• The report provides evidence on the positive effect of prolonged physical activity on boosting antibody responses following vaccinations in older adults.

This is important information given that adults are less likely to mount robust antibody responses following vaccination; 44% of adults aged over 60 in Ireland do less than the recommended level of physical activity for cardiovascular health and for enhanced immunity and vaccination responsiveness.

Vaccine efficacy in older adults can be a challenge due to the effects of ageing on the immune system. As people age, the ability to produce robust antibody responses following vaccination declines, with older adults less likely to generate

• It is recommended that adults aged 60 and older should consistently incorporate some form of aerobic exercise such as a brisk walk at least 2 – 3 times per week in the weeks and months prior to vaccination.

• Public health campaigns should specifically target groups that are less likely to meet minimum recommended physical activity levels: that is, women; adults aged 75+; individuals with a primary level of education or none; and those who live in urban areas.

• It is important that information on a vaccine for the COVID-19 virus is communicated via trusted news sources where adults aged over 60 might access information on a vaccine.

Covid-19 Vaccines Coronavirus (Covid-19) is a respiratory disease that causes symptoms such as fever, cough, and shortness of breath. It can lead to serious illness and death. Studies show that Covid-19 vaccines are effective at keeping people from getting Covid-19. People over 65 are at the highest risk of serious illness from COVID-19 if they have not been vaccinated.

A booster dose is recommended to extend the protection of COVID-19 vaccines. It is not yet known how long immunity will last after getting a booster. Trials are currently underway to learn more about this.

Flu Vaccines Everyone aged 6 months and older should get an annual flu vaccine, but the protection from a flu vaccine can lessen with time, especially in older adults. However older adults are less likely to become seriously ill or hospitalized because of the flu if they get the vaccine. Flu vaccines are especially important for those with a chronic health condition such as heart disease or diabetes.

Older adults should be advised to get their vaccine ideally by the end of October each year so they are protected when the flu season starts. It takes at least two weeks for the vaccine to be effective. However, if they have not received their flu vaccine by the end of October, it’s not too late as flu season typically peaks in December or January.

Those over 65 in Ireland will be offered the adjuvanted Quadrivalent Influenza Vaccine (aQIV). It’s also known by the brand name Fluad Tetra. This is a 1 dose vaccine.

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Tetanus, diphtheria, and pertussis (whooping cough) vaccines Tetanus, diphtheria, and pertussis are serious diseases that can lead to death.

• Tetanus (sometimes called lockjaw) is caused by bacteria found in soil, dust, and manure.

It enters the body through cuts in the skin.

• Diphtheria, also caused by bacteria, is a serious illness that can affect the tonsils, throat, nose, or skin. It can spread from person to person.

• Pertussis, also known as whooping cough, is caused by bacteria. It is a serious illness that causes uncontrollable, violent coughing fits that make it hard to breathe. It can spread from person to person.

Getting vaccinated is the best way to prevent tetanus, diphtheria, and pertussis. Most people get vaccinated as children, but will need booster shots as they get older to stay best protected against these diseases.

Shingles Vaccine Shingles is caused by the same virus as chickenpox. For those who have had chickenpox, the virus is still in their body. The virus could become active again and cause shingles.

Shingles affects the nerves.

Common symptoms include burning, shooting pain, tingling, and/or itching, as well as a rash with fluid-filled blisters. Even when the rash disappears, the pain can remain. This is called post-herpetic neuralgia, or PHN. Of the 95% of adults who’ve had chickenpox, around a quarter will go on to develop shingles – and it’s more likely to happen as they get older. It can be reactivated when the immune system weakens due to increasing age, stress, or certain conditions and treatments e.g. cancer or HIV. The shingles vaccine is safe and it may keep you from getting shingles and PHN. Healthy adults age 50 and older should get vaccinated with the shingles vaccine. There are two shingles vaccines currently available in Ireland, one is a live vaccine called Zostavax (given as one dose) and the other is a recombinant vaccine called Shingrix (given as a two dose).

YOUR PATIENTS AGED 50 YEARS OF AGE OR OLDER ARE AT INCREASED RISK OF DEVELOPING SHINGLES.1 YOU CAN PREVENT IT.2,3 SHINGRIX demonstrated >90% efficacy against shingles in all age groups aged 50 years of age or older, based on pooled data from two large, phase 3 randomised control trials.2,3

SHINGRIX IS NOW AVAILABLE For more information on SHINGRIX, please scan the QR code.

Shingrix powder and suspension for injection in vials (Please refer to SmPC before prescribing) Composition: After reconstitution, one dose (0.5 mL) contains: Varicella Zoster Virus glycoprotein E antigen1,2 50 micrograms. (1 adjuvanted with AS01B containing: plant extract Quillaja saponaria Molina, fraction 21 (QS-21) 50 micrograms, 3-O-desacyl-4’-monophosphoryl lipid A (MPL) from Salmonella minnesota 50 micrograms, 2 glycoprotein E (gE) produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology). Therapeutic indications: Prevention of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in adults 50 years of age or older and in adults 18 years of age or older at increased risk of HZ. The use of this vaccine should be in accordance with official recommendations. Posology and method of administration: For intramuscular injection only, preferably in the deltoid muscle. Primary Vaccination: Initial dose of 0.5 ml followed by a second 0.5 ml dose 2 months later. For flexibility the 2nd dose can be administered between 2 and 6 months after the first dose. For subjects who are or might become immunodeficient or immunosuppressed and whom would benefit from a shorter vaccination schedule, the 2nd dose can be given 1 to 2 months after the initial dose. Booster doses: need not established. Contraindications: Hypersensitivity to the active substances or any of the excipients. Special warnings and precautions for use: The name and the batch number of the administered product should be clearly recorded. Appropriate medical treatment and supervision should be readily available in case of an anaphylactic event. Administration of Shingrix should be postponed in subjects suffering from an acute severe febrile illness. However, the presence of a minor infection, such as cold, should not result in deferral. A protective immune response may not be elicited in all vaccinees. Never administer intravascularly or intradermally; subcutaneous administration not recommended as it may lead to an increase in transient local reactions. Caution in individuals with thrombocytopenia or any coagulation disorder since bleeding may occur following intramuscular administration. Syncope can occur following, or before any vaccination as a psychogenic response. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints. There are no data to support replacing a dose of Shingrix with another HZ vaccine. There are limited data to support the use of Shingrix in individuals with a history of HZ and in frail individuals including those with multiple comorbidities. The benefits and risks of HZ vaccination should be weighed on an individual basis. Interactions: Shingrix can be given concomitantly with unadjuvanted inactivated seasonal influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPV23) or reduced antigen diphtheriatetanusacellular pertussis vaccine (dTpa). The vaccines should be administered at different injection sites. Fertility, pregnancy and lactation: There were no effects on male or female fertility in animal studies. It is preferable to avoid the use of Shingrix during pregnancy. The effect on breast-fed infants of administration of Shingrix to their mothers has not been studied.

It is unknown whether Shingrix is excreted in human milk. Effects on ability to drive and use machines: Shingrix may have a minor influence on the ability to drive and use machines in the 2-3 days following vaccination. Undesirable effects: Very common (≥1/10): Headache, GIT symptoms, myalgia, injection site reactions, fatigue, chills, fever. Common (≥1/100 to <1/10): injection site pruritus, malaise. Uncommon (≥1/1000 to <1/100): lymphadenopathy, arthralgia. Rare (≥1/1000 to <1/100): Hypersensitivity reactions. Legal Category: POM A. Marketing Authorisation Number: EU/1/18/1272/001. Marketing Authorisation Holder: GlaxoSmithKline Biologicals S.A., Rue de l’institut 89, B-1330 Rixensart, Belgium. Further information is available from GlaxoSmithKline (Ireland) Ltd. 12 Riverwalk, Citywest Business Campus, Dublin 24. Telephone: 01-4955000. Code: PI-7757. Date of preparation: March 2021.

Adverse events should be reported directly to the Health Products Regulatory Authority (HPRA) on their website: www.hpra.ie. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

References : 1. Gauthier et al. Epidemiology and costs of herpes zoster and postherpetic neuralgia in the United Kingdom. Epidemiol infecti. 2009 137 38-47. 2. Lal H et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015; 372(22):2087-96. 3. Cunningham AL et al.

Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016; 375(11):1019-32.

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.

Trade marks are owned by or licensed to the GSK group of companies ©2022 GSK group of companies or its licensor.

PM-IE-SGX-JRNA-220001 | Date of Preparation: March 2022

52

Elderly Care: Dementia

Challenging assumptions on the economic costs of Dementia Health Economists Global Brain Health Institute (GBHI) Faculty Dominic Trépel and Atlantic Fellow for Equity in Brain Health Sanjib Saha share findings from recent research examining the health care costs of dementia.

Dominic Trépel

should take a life-course view in reducing the risk of dementia and support the growing idea that policymakers should allocate resources to reduce dementia risk factors, in line with highlevel recommendations from the Lancet Commission on Dementia Prevention, Intervention and Care.”

What is driving dementia health care costs?

Health care costs of dementia before, during and after diagnosis Increasingly severe cognitive, behavioural, or motor symptoms due to the dysfunction and death of the brain’s nerve cells are the hallmarks of the diseases that cause dementia. There is no cure and, therefore, patients with Alzheimer’s disease, vascular dementia, or other dementias have a growing need for care as the disease progresses.

With populations around the world ageing, the number of people experiencing dementia is increasing and so the associated global costs following diagnosis is assumed to be tending towards $2 trillion, thus creating major societal challenges and economic pressure to provide high quality care.

In this respect, researchers at the Global Brain Health Institute (GBHI) at Trinity College, undertook a new study in collaboration with the Health Economics Unit of Lund University in Sweden, which has revealed previously unknown aspects of how health care costs develop over the course of the disease. Curiously, health care costs were significantly higher as early as 10 years before dementia diagnosis. And, while care costs increased, and indeed doubled, at diagnosis, this new research challenges existing assumptions

about the economic implications of dementia as a few years after diagnosis, costs drop to the same, or even lower, levels than in those without dementia. This raises real equity concerns for people living with dementia. For example, do people with dementia receive the health care they need as things get more difficult, or have our systems developed a tendency to displace the burden of care on others?

This register-based study, published in the journal Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, examines the full population of people living with dementia in Region Skåne in southern Sweden. These 21,184 people were first identified as having a dementia diagnosis between 2010 and 2016. The research insights were made possible as individuals registered in Sweden’s national dementia registry can be linked to routinely collected healthcare data such as from primary healthcare, inpatient, and outpatient care. These data enabled the research team to examine individuals living with dementia over a 17-year period, including the year of diagnosis, 10 years before, and 6 years after diagnosis.

Dr Dominic Trepél, Assistant Professor of Health Economics at the School of Medicine at Trinity and the Global Brain Health Institute (Trinity and UCSF), said, “Our results support the brain health hypothesis that policy

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The team is now undertaking further research, using stateof-the-art statistics methods, to explore what is driving the excess health care costs before diagnosis and why the marginal cost is lower in the subsequent years after diagnosis. For example, is the drop in health expenditure after diagnosis due to the initiation of treatments and social care provided by the municipalities, which substitutes for the need for health care? And if so, are costs being appropriately displaced onto social care, or onto families?

And, could the initial increases in cost at diagnosis be related to difficulty in getting a definitive dementia diagnosis?

In conclusion, the findings suggest that people living with dementia have significantly higher costs compared to their counterparts long before the official diagnosis of dementia.

To improve quality of life and to reduce the associated economic burden experienced by people living with dementia and their carers, this work mandates that future policies on brain health must: (1) be fit for purpose, and; (2) support timely identification of dementia, or indeed earlier changes in brain health.

The study was conducted at the Health Economics Unit, Department of Clinical Sciences, Malmö, Lund University, based on collaborative funding from Region Skåne and seven municipalities (Burlöv, Båstad, Lomma, Simrishamn, Vellinge, Eslöv and Örkelljunga municipalities), in collaboration with the Global Brain Health Institute and the Clinical Memory Research Unit at Lund University.

Key Facts About Dementia • There are 64,000 people with dementia in Ireland and the number of people with the condition will more than double in the next 25 years to over 150,000 by 2045.* • Dementia is an umbrella term used to describe a range of conditions which cause changes and damage to the brain.

• Dementia is progressive.

There is currently no cure.

Dementia is not simply a health issue but a social issue that requires a community response.

• The majority of people with dementia (63%) live at home in the community. Over 180,000 people in Ireland are currently or have been carers for a family member or partner with dementia with many more providing support and care in other ways.

• There are 11,000 new cases of dementia in Ireland each year. That’s at least 30 people every day and anyone can get dementia – even people in their 30s/40s/50s.** • 1 in 10 people diagnosed with dementia in Ireland are under 65.

• The overall cost of dementia care in Ireland is just over ¤1.69 billion per annum; 48% of this is attributable to family care; 43% is accounted for by residential care; formal health and social care services contribute only 9% to the total cost.

Figures referenced to Cahill, S. & Pierce, M. (2013) The Prevalence of Dementia in Ireland *Figure referenced from Alzheimer Europe (2020) Dementia in Europe Yearbook 2019 ‘Estimating the prevalence of dementia in Europe’ **Figure referenced from Pierce, T., O’Shea, E. and Carney P. (2018) Estimates of the prevalence, incidence and severity of dementia in Ireland.

FAST RELIEF OF ALLERGIES

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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 film-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 film-coated tablets, scored on one side. Can be divided into equal halves. Clear, colourless liquid with banana flavour.

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 insufficiency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insufficiency (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 insufficiency (creatinine clearance CrCl 30-49 ml/min): 5 mg once daily. Severe renal insufficiency (creatinine clearance ≤30 ml/min): 5 mg once every 2 days. In paediatric patients suffering 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 effect 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 Effects: Cetirizine at the recommended dosage has minor adverse effects 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 difficulty, 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 Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie) or by emailing Rowex pv@rowa-pharma.ie

Date of preparation: (04-22) CCF: 24955

Supply status: Supply through pharmacies only.

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.

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.

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.

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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.

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Footcare

‘Let’s talk foot care with patients’ 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.

Written by Rebecca Conway – BSc (Hons) Podiatrist, Dundrum Podiatry Clinic

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?

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.

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

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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.

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News

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. Dr Suzanne McCarthy, Dr Aoife Fleming, Ms Aoife Delaney, Ms Deirdre Lynch and Dr Kirstyn James

in the area of medication safety, to improve patient outcomes.

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

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.

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.

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

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

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Deirdre Somers, Chair, Cancer Trials Ireland, and Prof Ray McDermott, consultant medical oncologist, and Cancer Trials Ireland Clinical Leadership

¤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.

Ireland’s No. 1 Provider of Ostomy Products & Services Customer Care Over 20,000 calls handled annually from our customer care team.

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Complimentary wipes and bags For Pharmacists to offer their patients.

Expanding Range We continue to expand our range as Ireland’s leading stockist for Ostomy & Urology products.

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News

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.

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.

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.

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

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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.”

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Advertorial

Obesity is a Complex Chronic Disease Dr Conor Woods is a Consultant Endocrinologist in Naas General and Tallaght University Hospitals 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

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

(>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

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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

63 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).

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).

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

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Medication Service

Discharge Medication (TTO) Service: Bridging the Gap 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.

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.

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.

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.

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

Written by Patrick Foley, Head of Pharmacy, Blackrock Health at The Hermitage Clinic

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

Figure 1 Pharmacist and Medicines Management Pharmacy Technician dispensing TTO's

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65 Pa tie

nt

Figure 2 Patient Information Leaflet Describing TTO Service

ut

PHARMACY DEPARTMENT

Discharge Medication Service

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.

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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.

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

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Medication Service Figure 3 Pharmacists work closely with their medical colleagues on the ward. Here Clodagh Dolan, Senior Pharmacist, clinically screens a TTO Prescription

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

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

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

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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

Awards The Irish Pharmacy

2023

Save the Date Saturday, 27th May, 2023

The Clayton Hotel, Burlington Road, Dublin

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Medication Service

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

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Trade Fair

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

Tina Buckley Sales Director UK and Ireland, Zoe Spillane, Key Account Manager East and Shirley Hornibrook Key Account Manager South

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Andra Rooney, Area Manager and Rhys Phillips, Revive Active

Caroline Deady, BPerfect and Deirdre Richardson, Voduz

Kare Cosmetics

Belle Brush Stand

DON’T LET PAIN HOLD YOU BACK

For more detail and for any training requirements please contact your Perrigo Pharmacy Business Manager ALAN HARNETT

RUTH GRANT

CHARLIE RICKARD

ANNE MARIE O’NEILL

BRENDAN O’KEEFFE

PAUL FLYNN

OLLIE HIGGINS

Nth Leinster

Midlands

Greater Dublin

South Leinster

Cork and Kerry

Waterford/Tipperary/ Limerick/Clare

West

086-8189846

086-4679113

086-6011643

086-1749626

086-8189843

086-1427717

087-9533161

ESSENTIAL INFORMATION *To verify contact verify@perrigo.com Solpa-Extra 500mg/65mg Soluble Tablets contain paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and children over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Children 12-15 years: 1 tablet disolved in water every 4-6 hours. Max 4 tablets a day. Not suitable for children under 12 years. Contraindications: Hypersensitivity to the ingredients. Precautions: Particular caution needed under certain circumstances, such as renal or hepatic impairment, chronic alcoholism and malnutrition or dehydration. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Patients should be advised not to take other paracetamol containing products concurrently. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions.

Unknown: nervousness, dizziness. Further information is available in the SmPC. PA 1186/017/001. P. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

Date of preparation: July 2020. Legal Class P – Pharmacy only.

IRE/SOL1/2022/02

72

Trade Fair

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

Aoife Nic Chuirc Key Account Manager for Uniphar Link Up Consumer and Aine Devlin Uniphar Brand & Trade Marketing Manager

Jennifer Lyons and Aoife O’Melia from the Tan Organic stand

Allegro Nivea Gift Train Display

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United Drug Consumer Team

Calpol® Infant & Calpol® SixPlus

Ireland’s No.1 pain & fever reliever* From fever to blocked noses, Calpol® has got you covered

Paracetamol

Lets Kids be Kids MAH: Johnson & Johnson (Ireland) Ltd. Airton Road, Tallaght, Dublin 24. Products not subject to medical prescription.

Supply through non-pharmacy outlets and pharmacies. Full prescribing information available upon request. *IQVIA MAT Units April 2022 (For Calpol® Infant and Calpol® SixPlus medicinal products).

Calpol® Vapour Plug & Nightlight is an electrical device and non-medicine. ® Calpol Saline Nasal Spray, Calpol® Saline Nasal Drops and Calpol® Blocked Nose Spray are medical devices for congestion relief.

IE-CAR-2200054

Topic Team Training Pain in Children

In our series designed to help pharmacists train their OTC teams, we cover a range of healthcare topics that are important for patient consultations and product recommendations at the OTC counter. Thanks to the team at totalhealth and Haven Pharmacies for this month’s topic: Pain in Children.

What is a ‘child’?

For the purpose of this article, a child refers to anyone aged 12 or under. An infant is a child from birth to the end of the first year. While the ingredients of pain relief products for children are similar to those for adults, children react to medicines in very different ways. It is therefore crucial that medicines suitable for children are recommended and that clear dosage instructions are communicated according to the age of the child. Gather all necessary information by following WWHAM protocol at all times.

communicate, always aim to identify the source of the pain, e.g., tooth, knee, ear. Non-verbal indications that a child is in pain may include: • Changes in crying pattern or behaviour – prolonged or more intense • Squeezing eyes shut or grimacing

chewable tablet and suppository form.

Again, dosage guidelines and products vary for children aged from 3 months, those aged 6 and over, and those aged 7 and over.

Ibuprofen should be used with caution in children with asthma.

• Holding or rubbing a particular part of the body

Types of Pain in Children

Concurrent use of paracetamol and ibuprofen may be suitable for more severe pain. It is helpful to remember the importance of clear explanation of dosages to parents, who may be experiencing stress or upset due to their child’s pain. Try to explain directions as if explaining to a family member, making sure they understand the instructions thoroughly.

• Irritability or acting out.

Pain in children should always be treated. If it is not, it can cause anxiety or emotional distress.

Some of the most common types of pain that we will be asked about in the pharmacy are:

Other products and advice for pain relief

It may also be difficult to ascertain the severity of pain, even if the source is clear.

The Wong-Baker Face Pain Scale is a helpful tool in discovering how much pain the child is experiencing, using smiley faces to help the child point to how bad they are feeling.

Depending on the type of pain, there are additional medicated and homeopathic products which may relieve symptoms, including colic drops, teething gels, and teething granules.

• Teething • Colic • Dental • Growing/Joint Pain • Injury • Cuts and Scrapes • Sunburn • Sore Throat • Earache • Headache • Stomach-ache • Post-Immunisation Pain.

Assessing Pain in Children Every child will experience pain differently and assessment of pain may be difficult, especially in infants and children who have difficulty describing pain. Where children can

• Visible signs (flushed cheeks, red gums, dribbling, bruising, swelling) • Withdrawal or lack of usual responsiveness

OTC Pain Relief for Children Products containing paracetamol or ibuprofen are the only pain-killers suitable to recommend for children’s pain in the pharmacy. They are both effective and generally safe, and available in different forms for children.

Paracetamol is suitable for babies and children from 2 months of age and who weigh at least 4kg. Use in children under that weight or age, or who are premature, must be under doctor supervision. Paracetamol is available in suppository, liquid and meltable tablet form.

There are different dosage guidelines and products for children aged from 2 months and for those aged 6 years and older. Parents should be reminded of the importance of reducing the risk of paracetamol by ensuring only one paracetamol-containing product is used at any time.

Ibuprofen is suitable for use in children aged 3 months and older. It is available in liquid,

Additional relief may be gained from cooling teething rings, applying cold compress to painful body parts, applying heat or giving a warm bath, and best of all, ensuring that children in pain are comforted and reassured.

Referral to Pharmacist Using WWHAM questions, refer to the pharmacist if the child: • Is under 2 months or under 4kg • Has a head injury • Is in severe distress • Is experiencing persistent pain with no known cause • Has unexplained swelling, bruising, or bleeding • Has lost their appetite or is losing weight • Has persistent vomiting • Has had no relief from OTC pain products.

Consider:

Key Points:

Actions:

Reflect on the following in assessing your own knowledge and your team’s training:

Ensure your team understands and is confident explaining the following:

Your action plan for Children’s Pain should include the following:

 Is your knowledge up to date on children’s pain and treatments?  Do you know what patients should be referred to a GP?  Does the team follow WWHAM protocol at all times?  Are all staff confident and comfortable explaining the varying instructions and dosages for all children’s pain products?  Are all staff aware of age limits on aspirin use in children?  Are product instructions explained in easyto-understand language?

74 | PHARMACYNEWSIRELAND.COM

 The various types of pain that may be experienced by children  The products available and the dosages and ages for each one  The additional products that may further relieve symptoms  The warnings and precautions associated with all products  The additional advice that should be given for non-drug relief of pain  WWHAM protocol and which patients must be referred to the pharmacist  All patient conversations are conducted with discretion, sensitivity, and appropriate tone.

 Your own knowledge is up to date, on types of pain, treatments, and GP referral  You are up to date with post-immunisation guidelines on pain-relief products  The appropriate training has been provided to all team members, and assessed, for example through observation or role play  You have the appropriate range of products available  WWHAM Protocol forms the basis of all interactions at the OTC counter  Update your CPD record.

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

76

ICO Conference

ICO Annual Conference – Latest Developments in Eye Care The Irish College of Ophthalmologists Annual Conference 2022 took place from Monday 16th to Wednesday 18th May 2022 at the Kilkenny Convention Centre, Lyrath Estate. Over 200 ophthalmologists in practice and training gathered for the three-day meeting to hear the latest clinical and scientific updates and developments in the specialty from national and international eye experts.

Symposia topics included a clinical session on Ocular Surface Disease; a service delivery session on ‘Planning for the Future’ examining Medical Retina and Telemedicine/Virtual Review, IOP Clinics and Glaucoma Diagnostic Hubs; whilst a separate symposium focused on the Integrated Eye Care Team highlighted the model of eye care implementation at national, regional and community level.

A separate clinical session on Recent Clinical Trials in Glaucoma, Myopia and Retina also featured on the programme.

It was a great honour and privilege for the ICO to welcome Professor Stanley Chang, K.K. Tse and Ku Teh Ying Professor of Ophthalmology, Columbia University, New York to present this year’s Annual Mooney Lecture. A specialist in vitreoretinal disorders and surgery, Prof Chang has pioneered many of the surgical techniques currently used in this field.

Parallel workshop sessions on Ocular Movement and OCTA, in addition to the paper and poster sessions (ICO Honorary Medals and prize presentations) and the SOE Young Ophthalmologist Lecture 2022 were among the other highlights of this year’s reunion conference, following a two year break for the conference due to Covid restrictions.

Professor Stanley Chang, K.K. Tse and Ku Teh Ying Professor of Ophthalmology, Columbia University Department of Ophthalmology, Annual Mooney Lecturer 2022 with Professor David Keegan, Clinical Professor of Ophthalmology and Retina (University College Dublin) and Consultant Ophthalmic Surgeon, Mater Misericordiae University Hospital, Dublin.

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Mr Tim Fulcher, President, Irish College of Ophthalmologists with keynote speakers from the 'Delivering Integrated Care in Ireland' symposium which took place on the opening day of the OCO Annual Conference 2022 L-R Dr Margarat Morgan, Consultant Medical Ophthalmologist, Royal Victoria Eye and Ear Hospital, Professor William Power, Clinical Lead for Ophthalmology and Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Dublin; Ms Chriosa O’Connor, Optometrist, Mater Misericordiae University Hospital, Dublin and Professor David Keegan, UCD Clinical Professor of Ophthalmology and Retina, UCD School of Medicine, University College Dublin. National Clinical Lead for Diabetic Retinopathy Screening.

Addressing delegates, ICO President, Mr Tim Fulcher said it was wonderful to return to an in person meeting for members in 2022 following a difficult two years throughout Covid.

“Our Annual Conference has always been an extremely valuable educational meeting for the specialty and important collegiate occasion for our members. It is crucial to return to in person engagement forums to discuss the latest developments and learnings amongst colleagues, difficult and unusual cases and of course all we have learnt about our specialty and service delivery management as a result of the pandemic.

“Despite the challenges of the past two years, much progress has taken place in the specialty of ophthalmology with investment into the new Integrated Eye Care Teams at community and hospital level, and the establishment of dedicated cataract theatres. There is much more to be done to address the waiting lists in ophthalmology and our focus, alongside the work of the National Clinical Programme led

by Prof William Power, remains on delivering a service equipped to manage the areas of greatest patient demand.

“We are very fortunate to once again be welcoming leading experts from home and overseas to the ICO Annual Conference, who will impart their exceptional knowledge to

the benefit of all in attendance and our health service over the three-day meeting.”

Annual Mooney Lecture 2022 ‘Improving the Outcomes of Surgery for Retinal Detachment’ Professor David Keegan formally introduced Professor Chang, noting the incredible contribution Professor Chang has made to the speciality throughout his career, retina in particular and his status as a pioneer of several revolutionary surgical approaches to treat complicated forms of retinal detachment which have led to improved outcomes for patients worldwide.

Professor Chang’s subject for the 2022 Mooney Lecture discussed the four different methods of treating retinal detachment – pneumatic retinopexy (injection of a gas bubble, with positioning, and laser), scleral buckling alone, vitrectomy, and vitrectomy and scleral buckling.

The characteristics of the retinal detachment, such as size and number of tears or extent, cannot be determined by the surgeon, but the selection of the procedure and the adjuncts used in the surgical management are critical to achieving a successful outcome.

Evidence -based data on the outcomes of the different methods of the treatment for retinal detachment were discussed and surgical techniques that enhance the outcomes.

77 Professor Chang highlighted the exciting future developments for improving the anatomic and visual outcomes in retinal detachment surgery.

TALK OVERVIEWS Professor David Keegan

Planning for the Future

Clinical Professor of Ophthalmology and Retina (University College Dublin)

Ms Dawn Sim, Medical Director in Product Development Ophthalmology, Genentech Roche, Honorary Consultant Ophthalmologist,, Moorfields Eye Hospital, UK, Associate Professor, Institute of Ophthalmology, University College London gave her talk ‘The Idiosyncrasies of Telemedicine in Ophthalmology’ virtually at the Planning for the Future Symposium.

Ms Dawn Sim opened the ‘Planning for the Future’ symposium (Wednesday, 18th May) with her (virtual) talk on the topic ‘The idiosyncrasies of Telemedicine in Ophthalmology’. Ms Sims obtained her PhD from the UCL Institute of Ophthalmology for her work on endothelial progenitor stem cells and has published extensively on diabetic retinopathy, age-related macular degeneration, and retinal vein occlusions.

Her presentation at the ICO Conference discussed new technologies in retinal imaging, digital health, and the field of teleophthalmology. Dawn is working with device-agnostic platforms to facilitate the acceleration of new technology and artificial intelligence software into clinical practice.

Ms Aoife Doyle, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin highlighted the work of the Lean Team at Ireland East Hospital Group and of the ophthalmology team at RVEEH with CHO6 and CHO7 in her talk ‘Transitioning Stable Glaucoma Care to the Community’.

Having closely followed developments in glaucoma care in the UK in recent years, Ms Aoife Doyle set up a virtual glaucoma clinic

Consultant Ophthalmic Surgeon (Mater University and Mater Private Hospitals) Talk: Establishment of a Novel Governance Structure to Transform, Integrate and Deploy Regional Eye Care - the virtual Accountable Care Organisation (vACO)

Ms Dawn Sim, Medical Director in Product Development Ophthalmology, Genentech Roche

at RVEEH in 2018. A key component of this was the early adoption of an electronic record (Medisight) for patient management.

During the Covid-19 pandemic Ms Doyle worked together with the Lean Team at Ireland East Hospital Group and Professor Colm O’Brien to set up a Drive-Through IOP clinic at the City West Facility that saw over 650 patients from RVEEH and MMUH between August 2020 – July 2021.

She participated in a Lean Healthcare initiative on glaucoma in 2020-2021 and after further training was awarded a Bronze qualification for work on delivery of virtual care, improving visual field capacity and establishing and managing the RVEEH side of the City West Initiative.

With her team, Ms Doyle has recently extended that model to the CHO7 area together with

Professor David Keegan said, "We have established, over the last year, a novel governance structure to manage integrated eye care in the North East thus opening a path to tackling one of the longest wait lists, by specialty, in the region. Ophthalmology also has one of the highest waitlists in the country with nearly 50000 patients waiting for an outpatient appointment and > 8000 waiting for surgery. In the North East alone we estimate 14000 patients are awaiting an outpatient appointment with over 3000 patients waiting for surgery, most of whom for cataract surgery. Eye care is delivered by 6 distinct healthcare organisations who have all committed to working together to achieve our goals. Our clear focus is on reducing avoidable vision impairment and blindness by reorganising our service delivery via a transformation plan and unique voluntary governance structure.

“As a means to tackle this, we have instituted the collaborative governance structure called the Virtual Accountable Care Organisation (vACO) to integrate, transform and deploy eye care services in the North East. We are near completion of the first year of the development of this pathway and already we are seeing impact on our wait lists.”

Dr Margaret Morgan Consultant Medical Ophthalmologist, Royal Victoria Eye and Ear Hospital, Dublin and CHO7 Talk: Eye Care in the non-Acute Setting Dr Margaret Morgan provided an update on the CHO7 Adult Ophthalmology Service one year on from the establishment of the team and unit. Dr Margaret Morgan discussed how the service came about, the set-up process, progress made to date and the future direction.

Mr Jonathan Clarke, Consultant Ophthalmologist, Moorfields Eye Hospital, London, Ms Evelyn O'Neill, Consultant Ophthalmologist, Mater Misericordiae University Hospital, Dublin, Mr Tim Fulcher, (Chair), ICO President and Consultant Ophthalmic Surgeon, Mater Misericordiae University Hospital, Dublin, and Ms Aoife Doyle, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital and St James's Hospital, Dublin

Dr. Margaret Morgan, Consultant Medical Ophthalmologist (Royal Victoria Eye and Ear Hospital and CHO7) with staff training commenced to introduce a similar clinic in CHO6. This is helping to more efficiently deliver care to people with glaucoma in the community and closer to home. Ms Doyle said it will also help to improve capacity for the hospital eye services to see the more complex and surgical patients and reduce waiting times, improving outcomes in glaucoma care through the collaboration of the hospital and community eye care services.

In his talk, panelist guest speaker Mr Jonathan Clarke, Moorfields Eye Hospital, London, discussed the set up and safe assessment of diagnostic (virtual) clinic pathways

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ICO Conference Professor Conor Murphy of the Royal Victoria Eye and Ear Hospital and RCSI presented on complex inflammatory disorders of the anterior segment that lead to progressive and often sight threatening and painful conjunctival fibrosis. The principles of the diagnosis and management in both the acute and chronic phases of mucous membrane pemphigoid and Stevens Johnson syndrome were described. The key message was that early recognition and appropriate immunosuppressive and supportive therapies lead to a far better prognosis and quality of life in the long term for affected patients.

The final lecture was given (virtually) by former Associate Professor at Harvard Medical School and Chairman of TFOS Mr David Sullivan PhD. Mr Sullivan discussed the influence of an individuals sex (male or female) and steroid hormones on dry eye disease.

Professor Conor Murphy, Professor of Ophthalmology, Royal College of Surgeons in Ireland, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Mr Samer Hamada, Clinical Lead and Consultant Ophthalmic Surgeon, Queen Victoria Hospital NHS Foundation Trust, UK, Ms Nikolina Budimlija, Ocular Surface Specialist, Institute of Eye Surgery, Waterford and Mr Tom Flynn, Consultant Ophthalmic Surgeon, Bon Secours Hospital, Cork.

A consultant in the glaucoma service at Moorfields Eye Hospital since 2009, Mr Clarke is Clinical Trials Lead for the glaucoma service with a responsibility for delivering clinical trials for new pharmaceutical treatments. He is also Joint Director of the Moorfields North Division, involved in testing and setting up new models of care including virtual clinics for glaucoma and medical retina patients.

Ms Evelyn O’Neill, Consultant Ophthalmologist, Mater Misericordiae University Hospital, Dublin provided an overview of the changes that were made at the Mater Eye Emergency Department during the pandemic in her talk highlighting the transitioning of care and lessons learned during COVID. Ocular Surface Disease Symposium Keynote speakers at the ICO Annual Conference 2022 (16th-18th May Kilkenny Convention Centre, Lyrath Estate Hotel) Ocular Surface Disease Symposium were;

Mr David Sullivan, Chairman, Board of Directors, Tear Film & Ocular Surface Society (TFOS), Boston, US

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Professor Conor Murphy, Professor of Ophthalmology, Royal College of Surgeons in Ireland, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Mr Samer Hamada, Clinical Lead and Consultant Ophthalmic Surgeon, Queen Victoria Hospital NHS Foundation Trust, UK, Ms Nikolina Budimlija, Ocular Surface Specialist, Institute of Eye Surgery, Waterford and Mr Tom Flynn, Consultant Ophthalmic Surgeon, Bon Secours Hospital, Cork Mr David Sullivan, Chairman, Board of Directors, Tear Film & Ocular Surface Society (TFOS), Boston, US and former Associate Professor, Department of Ophthalmology, Harvard Medical School gave a virtual presentation ‘Ménage à Trois: Sex, Sex Steroids and Dry Eye Disease’ at the Ocular Surface Disease Symposium, Mr Tom Flynn, Bon Secours Hospital Cork opened the Ocular Surface Disease symposium on day 2 (Tuesday, 17th May) of the ICO Annual Conference with his talk ‘Allergic eye disease: myths, mysteries and modern medicine’ . Mr Flynn discussed how allergic eye disease is a broad umbrella term for a variety of ocular surface conditions each with specific and different presentation and prognosis. He outlined the presentation and treatment of seasonal allergic conjunctivitis and atopic keratoconjunctivitis, with emphasis on management of steroid-dependent disease.

New biologic treatments for atopic dermatitis were also discussed.

Guest panelist, Mr Samer Hamada from Queen Victoria Hospital London continued the same topic in children in his talk entitled ‘Paediatric Ocular Surface Disease: JOMO (joy of missing out!) to FOMO and also talked about specific ocular surface problems in peadiatric population.

Mr Sullivan said, “One of the most compelling epidemiologic features of dry eye disease (DED) is that it occurs predominantly in females. That such a sex-related difference exists in the prevalence of an eye disease is not a surprise, as the influence of sex on the eye has been known since the time of Hippocrates.

In the late 1800s there was widespread belief among European physicians that ocular health was dramatically influenced by sex, and that males were by no means as prone to diseases of the eye from sexual causes as females.

Since that time, many sex-related differences in the eye have been attributed to the effects of sex steroids (e.g. androgens and estrogens).”

Mr David Sullivan discussed how researchers at the Tear Film & Ocular Surface Society (TFOS) believe that recognition of these sexrelated differences and the determination of their underlying basis (e.g. sex steroid action) are extremely important. He explained such understanding may be translated into new insights into the physiological control of ocular tissues, as well as the generation of novel therapeutic strategies to treat DED. Miss Yvonne Delaney, Dean of Postgraduate Education, Irish College of Ophthalmologists is pictured during her talk to delegates at the ICO Annual Conference on the significant milestones and recent developments of the ICO National Training Programmes, and in particular the dedicated Medical Ophthalmology specialty training programme which was launched in 2017 in response to demand for specialists in the area.

Miss Yvonne Delaney, Dean of Postgraduate Education, Irish College of Ophthalmologists is pictured during her talk to delegates

79 TALK OVERVIEWS: Professor Billy Power Clinical Lead for Ophthalmology and Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Dublin Talk: The National Clinical Programme for Ophthalmology: Supporting the Delivery of Integrated Care Professor Power provided an overview and historical context of the Clinical Programme for Ophthalmology and Model of Care, focusing on the implementation of the integrated eye care team and dedicated cataract clinics. He also discussed the new clinical pathways for cataract, medical retina and paediatrics, the benefits and the potential challenges going forward.

Ms Chriosa O Connor Optometrist, Mater Misericordiae University Hospital, Dublin Talk: The Role of an Optometrist in a Multidisciplinary team Pictured (l-r) at the 'Recent Clinical Trials' session at the Irish College of Ophthalmologists Annual Conference were chair Ms Janice Brady, Consultant Ophthalmologist, University Hospital Waterford, Prof Ian Flitcroft, Consultant Ophthalmologist, Children’s Health Ireland (CHI) Temple Street and Mater Misericordiae University Hospital, Dublin (myopia focus) and Prof Tunde Peto Professor of Clinical Ophthalmology, Queen’s University, Belfast (medical retina)

ICO Dean of Postgraduate Education, Miss Yvonne Delaney, hosted a session at the ICO Conference to update members on the significant progress and development of the ICO National Training Programmes over recent years. In particular, Miss Delaney discussed the advancement of the dedicated Medical Ophthalmology specialty training programme, launched in 2017.

The standalone programme was developed in response to the demand for ophthalmic specialists to treat patients in the areas of greatest eyecare demand, namely medical retina, glaucoma amd paediatric ophthalmology, coupled with an increasing ageing demographic and the huge expansion of new medical treatments for sight threatening conditions.

Optometry is a new profession to join the HSE Ophthalmology Multidisciplinary (Integrated Eye Care) team in Ireland.

Chriosa O’Connor gave an overview of what roles optometrists are currently involved in since joining, including paediatrics and adult roles and transformation teams. Also what roles they could do in the future, with training and support.

This has led to a big shift in how we practice and deliver medical ophthalmology and the reconfigured national training programme has been designed to address workforce and service demands, with the curriculum mapped to the National Clinical Programme for Ophthalmology Model of Care.

Professor Anthony King, Consultant Ophthalmologist, Nottingham University Hospital, NHS and Honorary Professor of Clinical Ophthalmology at the University of Nottingham, UK gave a virtual presentation at the session on ‘The Treatment of Advanced Glaucoma Study - Outcomes at 24 months’.

Ms McElnea delivered the European Society of Ophthalmology (SOE) Lecture 2022 on the topic “Oculoplastics and Orbit Today” at the ICO Annual Conference which took place from 16-18th May in the Kilkenny Convention Centre, Lyrath Estate Hotel.

Ms McElnea presented and reviewed a number of emergent ophthalmic plastics and orbit related cases of interest to trainees, general ophthalmologists and sub-specialists alike, and the safe and appropriate management of these conditions all of which have important systemic associations.

Ms Elizabeth McElnea (centre), Consultant Ophthalmologist, University Hospital Galway with Miss Yvonne Delaney, Dean of Postgraduate Education, ICO and Prof Colm O'Brien, Consultant Ophthalmic Surgeon, Mater Misericordiae and Chair of the ICO Scientific Committee.

Ms McElnea completed fellowship training in oculoplastic, orbit and lacrimal disease at the Royal Victorian Eye and Ear Hospital in Melbourne, Victoria and in cornea and anterior segment disease at Royal Perth Hospital in Perth, Western Australia before returning to Ireland and her current post at University Hospital Galway.

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‘THE ART OF MS – SYMPTOMS UNDER THE SPOTLIGHT’ EXHIBITION ‘The Art of MS – Symptoms Under the Spotlight’ is an art exhibition created by MS Ireland in partnership with Novartis Ireland and opened recently featuring 12 original works of art created by people living with MS in Ireland.

The exhibition has been organised to raise awareness of MS and the wide-ranging symptoms of the disease to mark World MS Day 2022.

The 12 works of art on display were shortlisted by a panel of judges and chosen for their ability to impactfully depict the many symptoms of MS, many of which are invisible and unknown to the general public such as fatigue, vision impairment, depression and difficulties with memory and thinking[i]. The exhibition will feature paintings, digital illustrations, freestanding sculptures and creative video content all of which aim to help the viewer better understand what it is like to live with MS day to day.

Méabh Hennelly is a featured artist who lives with MS, aged 25.

Her piece, entitled ‘Secret Central

Pictured at the launch of The Art of MS – Symptoms Under the Spotlight are Ava Battles Chief Executive MS Ireland and Audrey Derveloy, General Manager, Novartis Ireland. Picture: Andres Poveda

System’ is a 3D printed sculpture which is intact from the front and exposes the brain and spinal cord from the back, representing the hidden nature of MS. Ava Battles, Chief Executive of MS Ireland said “One of the big challenges for people living with MS is trying to articulate their symptoms to others when so much of their disease is invisible.

Without understanding, empathy is limited as people do not realise how debilitating the disease can be on all aspects of the person’s life. The beauty of our exhibition opening today is that people have been able to show through art what they find hard to articulate in words. I would encourage everyone to visit The Art of MS – Symptoms Under the Spotlight exhibition and show your support for the 9,000 people in Ireland living with this disease.”

Audrey Derveloy, General Manager and Country President, Novartis Ireland speaking about the opening of The Art of MS – Symptoms Under the Spotlight said, “At Novartis Ireland we are committed to supporting the community of people living with MS in Ireland as they navigate both the management of their disease as well as day to day life living with the broad ranging symptoms. We hope that The Art of MS – Symptoms Under the Spotlight will help the wider community to better understand and proactively manage their disease and I would like to personally thank all the artists

who have exhibited their work to mark World MS Day.” The Art of MS – Symptoms under the Spotlight is accessible to the public from Thursday 26 May to Wednesday 1 June 2022 from 9am-5pm and is located at the main foyer of Trinity Biomedical Sciences Institute, 152 - 160 Pearse St, Dublin 2.

Find more information about MS and to view the profiles of the artists who will feature at the exhibition at www.MS-Society.ie SANOFI GRANTS REGENERON WORLDWIDE EXCLUSIVE LICENSE RIGHTS TO LIBTAYO® (CEMIPLIMAB) Sanofi restructures its immunooncology collaboration with Regeneron Pharmaceuticals, Inc. Under the amended and restated license and collaboration agreement, Regeneron will obtain worldwide exclusive license rights to Libtayo. The Sanofi and Regeneron global immuno-oncology license and collaboration agreement was originally executed in 2015.

Prior to today, the companies had split Libtayo’s worldwide operating profits equally and co-commercialized Libtayo in the U.S., with Sanofi solely responsible for commercialization in the rest of the world.

Bill Sibold, Executive Vice President of Specialty Care & President of North America, Sanofi said, “Our diverse oncology portfolio doubled between 2019 and 2022 and now includes twelve compounds in clinical trials, each with a unique mechanism of action. Our early steps with Libtayo in immunooncology provided a strong foundation for our revitalized oncology efforts. Now, we are focused on leveraging our internal capabilities and advancing a new generation of oncology medicines.

We continue to maintain a strong partnership with Regeneron in immunology, and will work closely with them on the seamless transition of Libtayo to ensure there is no impact for patients.”

Under the terms of the amended and restated immuno-oncology license and collaboration agreement, Sanofi will transfer the rights to develop, commercialize, and manufacture Libtayo entirely to Regeneron, on a worldwide basis, over the course of a defined transition period (to start upon receipt of any required governmental clearances worldwide). In exchange, Sanofi will receive an upfront payment of $900 million, and an 11% royalty on worldwide net sales of Libtayo.

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Sanofi will also be entitled to a $100 million regulatory milestone payment upon the first approval by either the FDA or European Commission of Libtayo in combination with chemotherapy for first-line treatment of certain patients with NSCLC, as well as sales-related milestone payments of up to $100 million in total over the next two years. The transaction is subject to clearance under competition law and is expected to close in the third quarter of 2022.

Regeneron will also accelerate reimbursement of the development balance associated with Regeneron and Sanofi’s separate Antibody Collaboration.

Regeneron will increase from 10% to 20% the share of its profits that are paid to Sanofi to reimburse Sanofi-funded development expenses, until Regeneron’s share of the total cumulative development costs incurred under the collaboration has been reached.

Sanofi continues to build its considerable expertise in oncology and has increased research and development capabilities, focusing on difficult to treat cancers including breast, blood, and lung. We are committed to translating scientific discoveries into potential new treatments and addressing critical gaps in cancer care.

UNAIDS RESPONDS TO VIIV’S ANNOUNCEMENT ON THE LICENSING OF LONG-ACTING CABOTEGRAVIR HIV medicine manufacturer Viiv has announced that it is “actively negotiating” a voluntary license with the Medicines Patent Pool on long-acting Cabotegravir.

The World Health Organization will soon issue updated global guidelines on the appropriate application of new long-acting HIV medicines.

Responding to the announcement made by Viiv, UNAIDS Deputy Executive Director a.i. Matt Kavanagh said, “Last year there were 1.5 million new HIV infections, which shows the urgency of global access to new tools to overcome this pandemic. A successful global HIV response depends on the sharing of technologies.

We are encouraged by ViiV’s announcement of negotiations with the Medicines Patent Pool, which has followed engagement

by UN partners, financing agencies, civil society, and others. The announcement is an important sign of progress toward affordable global access to this technology for the HIV response;

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it now needs to be followed by rapid action, in order to translate promises into medicines.

“To have transformative impact as a tool for HIV prevention on the scale needed, it is vital that a license for this long-acting antiretroviral come quickly, with open non-exclusive terms for use and production across the world’s low- and middleincome countries. The licensing agreement should also be accompanied by an effective transfer of a technology package, to facilitate quality-assured manufacturers around the world to produce the medicines as soon as possible. There is an urgent need for large-scale production to get underway in Africa, Asia, Latin America and beyond, as soon as possible, to minimize the further wait for affordable products where they are most needed.

“Because generic manufacturing will take time to get running, even once a license is agreed, it is also key that ViiV name an interim price that is affordable for low- and middle-income countries.

“Those who need new HIV prevention tools most are too often those who get access last — but this need not happen.

“We can, as promised, end AIDS as a public health crisis by 2030 – if leaders act boldly to address the inequalities which have driven it. Hoarding life-saving science hurts everyone; it perpetuates pandemics. Sharing life-saving science benefits everyone.”

RCSI LAUNCHES TRANSFORMATIONAL DEVELOPMENT AT 118 ST STEPHEN’S GREEN The end of May marked the official launch of construction at 118 St Stephen’s Green, the next phase of RCSI’s campus development in Dublin city centre.

The ¤95m expansion project, also known as Project Connect, will enrich the student experience at RCSI and provide vital infrastructure for pioneering health sciences research and innovation, as well as creating a space for local community engagement.

A key design element of 118 St Stephen’s Green is its physical link to RCSI’s presence at 26 York Street, significantly opening up RCSI’s education space for the estimated 3,000 students and staff who visit the campus daily for study, work and extracurricular activities.

The development will be home to the new RCSI School of Population Health, the RCSI Graduate School of Healthcare Management, and

Minister for Further and Higher Education, Research, Innovation and Science, Mr Simon Harris TD pictured at the new phase of RCSI’s campus development

a 50sqm virtual reality surgical training space for the National Surgical Training Centre.

methodologies and expanding research potential in the field of medicine and health sciences.

It will allow for the introduction of new concepts such as learning communities and provide includes small group teaching spaces and flexible flat floor teaching spaces.

“As the attraction and retention of world-class talent becomes increasingly competitive on a global level, Ireland needs to be a location of choice for the best and the brightest in order to realise our ambition to become an Innovation Leader. Investments such as this will help us achieve our goals.”

Another key purpose of the project is to enhance RCSI’s research and innovation activities, providing up to three floors of state-ofthe-art laboratory, write-up and support facilities for existing and new research programmes and initiatives.

The development will renew RCSI’s historic connection St Stephen’s Green by becoming the new “front door” of the campus. It will include a new civic engagement space for public events and exhibitions, aligning with RCSI’s goal of enabling people to live long and healthy lives.

The launch was attended by Minister for Further and Higher Education, Research, Innovation and Science, Mr Simon Harris TD, who unveiled hoarding that will be the centrepiece for the project until its scheduled completion in 2025.

Minister Harris said: “This stateof-the-art facility, which will come to being in 2025, will be a centre of excellence, providing innovative teaching and learning

RCSI President Professor P. Ronan O’Connell welcomed the launch, commenting: “Since 1810, RCSI has influenced the landscape of St Stephen’s Green. This new development at 118 demonstrates our dedication to unlocking opportunity for truly exceptional healthcare professionals who have the passion and commitment to make a lifelong difference to patient care.”

FDA ACCEPTS DUPIXENT® (DUPILUMAB) FOR PRIORITY REVIEW IN ADULTS WITH PRURIGO NODULARIS The U.S. Food and Drug Administration (FDA) has accepted for priority review the supplemental Biologics License Application (sBLA) for Dupixent® (dupilumab) to treat adults with prurigo nodularis, a chronic inflammatory skin disease that causes extreme itch and skin lesions. The target

action date for the FDA decision is September 30, 2022.

The sBLA is supported by data from two pivotal Phase 3 trials evaluating the efficacy and safety of Dupixent in patients 18 years and older with uncontrolled prurigo nodularis (PRIME2 and PRIME).

Both trials met the primary and key secondary endpoints, showing Dupixent significantly improved disease signs and symptoms compared to placebo, including reduction in itch and skin lesions.

The safety results from these trials were generally consistent with the known safety profile of Dupixent in atopic dermatitis. The adverse event more commonly observed with Dupixent was conjunctivitis.

The FDA grants priority review to therapies that have the potential to provide significant improvements in the treatment, diagnosis or prevention of serious conditions.

Additional regulatory filings outside of the US are also planned in 2022.

The potential use of Dupixent in prurigo nodularis is currently under clinical development, and the safety and efficacy have not been fully evaluated by any regulatory authority.

About Prurigo Nodularis People with prurigo nodularis experience intense, persistent itch, with thick skin lesions (called

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Clinical Profiles

nodules) that can cover most of the body. Prurigo nodularis is often described as painful with burning, stinging and tingling of the skin.

The impact of uncontrolled prurigo nodularis on quality of life is one of the highest among inflammatory skin diseases due to the extreme itch and is comparable to other debilitating chronic diseases that can negatively affect mental health, activities of daily living and social interactions. High-potency topical steroids are commonly prescribed but are associated with safety risks if used long term. There are approximately 75,000 people in the U.S. who are unable to control their disease with systemic therapy and are most in need of a treatment option.

About Dupixent Dupixent is a fully human monoclonal antibody that inhibits the signaling of the interleukin-4 (IL-4) and interleukin-13 (IL13) pathways and is not an immunosuppressant. The Dupixent development program has shown significant clinical benefit and a decrease in type 2 inflammation in Phase 3 trials, establishing that IL-4 and IL-13 are key and central drivers of the type 2 inflammation that plays a major role in multiple related and often co-morbid diseases.

These diseases include approved indications for Dupixent such as asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyposis and eosinophilic esophagitis, as well as investigational diseases such as prurigo nodularis.

Dupixent is approved for use in certain patients with atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyposis and eosinophilic esophagitis in different age populations in a number of countries around the world. Dupixent is currently approved across these indications in the U.S. and for one or more of these indications in the European Union, Japan and more than 60 countries. More than 400,000 patients have been treated with Dupixent globally.

are probably the only hospital anywhere carrying out this procedure as a day case. Certainly we are the only hospital in the world carrying out the procedure, which is called renal artery denervation, using a product manufactured by Medtronic here in Galway.

“We are using renal artery denervation to help patients with high uncontrolled blood pressure or hypertension which is a major risk factor for stroke, heart attack, vascular disease and chronic kidney disease.

“Approximately 35% of the adult population in Ireland have hypertension and around one third of these patients are taking medication but their blood pressure is still uncontrolled. If we are able to control blood pressure we are able to reduce the risk of debilitating side effects. Even a small reduction in blood pressure can lead to a significant reduction of the risk of stroke or heart attack.

“We have participated in a number of clinical trials for renal artery denervation here in GUH that have shown reduction in blood pressure.

Based on these results, renal artery denervation is now being carried out as a day case procedure. This has huge benefits for the patients in terms of reduced disruption to their lives, recovery at home and we are not dependent on the availability of beds for an overnight stay which can be a challenge with the current demands on inpatient care.

“At the moment we are carrying out one or two of these procedures every month to help patients control their blood pressure.

Consultant Cardiologist Professor Faisal Sharif who has introduced a day case procedure to address uncontrolled blood pressure at Galway University Hospitals, in the Cath Lab at the hospital

INNOVATIVE NEW PROCEDURE AT GALWAY UNIVERSITY HOSPITAL Galway University Hospitals (GUH) is the first hospital in the country to introduce a new minimally invasive day case procedure to reduce blood pressure in patients. This means that patients arrive in the hospital in the morning, have the procedure and are able to return home the same day.

Professor Faisal Sharif, Consultant Cardiologist at GUH said, “We

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Patients can contact our team directly to enquire about the procedure by calling Eileen Coen on 086 1455568. We then ask patients to wear a blood pressure monitor for 24 hours and we do other checks to make sure that they are suitable for the procedure.

“The feedback from our patients who have had renal artery denervation has been incredibly positive with all benefitting from the procedure with improved blood pressure and better future health prospects.”

HSE LAUNCHES COMPETENCY FRAMEWORK The HSE Antimicrobial Resistance and Infection Control team (AMRIC) has launched the Competency Framework for Infection Prevention and Control Practitioners in Ireland.

This important framework was developed to support health care professionals pursuing specialist careers in infection prevention and control (IPC). It helps staff in identifying and gaining the specific competencies they will require as an IPC practitioner.

Dr Eimear Brannigan, HSE Clinical Lead, Antimicrobial Resistance Infection Control (AMRIC) commented, “Effective infection prevention and control (IPC) is central to providing clean, safe and high quality health and social care for people who use those services. It also protects those who deliver the services and the wider community. All healthcare services must have basic IPC capacity within their core staff complement, and must also have access to higher-level expertise to support decision-making when necessary. This new document has been developed by the AMRIC nursing team to support health care professionals pursuing specialist careers in IPC. It will help in identifying and gaining the specific knowledge and skills they will require as IPC practitioners.”

Rachel Kenna, Chief Nursing Officer, Department of Health says, “I am delighted to support the launch of this new Competency Framework for Infection Prevention and Control Practitioners in Ireland. This is the first such framework on IPC for Ireland and it is an important step forward in advancing IPC practice. It will also assist with maintaining and improving expertise in IPC among health staff and promoting a high-quality and consistent approach to IPC practices. This Framework is significant for the delivery of Ireland’s second One Health National Action on Antimicrobial Resistance 20212025, iNAP2, by helping to prevent and control the spread of infection and demonstrates Ireland’s commitment to best practice in this area. Importantly, it builds on the learning and experience from the COVID-19 pandemic response, a time when IPC was so important for safe environments for patients receiving care and the staff that delivered such care. I would like to congratulate the HSE National AMRIC Team for their leadership in developing and making available this valuable resource for healthcare professionals and service providers.”

The framework aims to support managers, in growing and developing a skilled infection prevention and control workforce by: • providing standardised core competencies required for IPC practitioners in Ireland • assist in curriculum design of post graduate training courses for IPC in Ireland • support healthcare organisations in growing and developing skilled and educated IPC workforce • support self-assessment of competence by the IPC practitioner • assist and complement staff appraisal and professional development plan processes.

This document will continue to support the growth and development of a skilled infection prevention and control workforce in Ireland.

MAYOR UNVEILS PROFESSOR GERRY O’SULLIVAN MEMORIAL STATUE On National Cancer Survivors Day, Sunday June 5, a life-sized statue was revealed by a West Cork community to honour the late Professor Gerry O’Sullivan, a pioneer in the field of cancer research, and founder of Cork Cancer Research Centre and

83 the national charity Breakthrough Cancer Research.

The statue was officially unveiled in the Professor Gerry O’Sullivan Memorial Park, Caheragh, by the Mayor of the County of Cork, Cllr.

Gillian Coughlan and Professor of Sullivan’s widow Breda and family.

The keynote speaker at the event was one of the world’s most influential scientists, leading immunologist, author and broadcast personality, Professor Luke O’Neill. Professor O’Neill is a regular contributor to discussions on science and research on TV and radio in Ireland and around the world. Like many said of Professor O’Sullivan, he has an infectious enthusiasm and belief in the power of science to help us live better lives, so those attending can expect to be inspired.

Professor O’Sullivan was a highly acclaimed surgeon, scientist and cancer researcher. His worldrenowned clinical expertise was matched by his belief in the power of research to mould a better future for people with cancer.

Chair of the committee Micheál Kirby, said, “Professor O’Sullivan died at the young age of 65 from cancer, a disease he had spent his whole career saving others from. We are so incredibly proud of his achievements and the man he became and want to encourage young people in our community to follow in his footsteps. Nothing is impossible when you have passion, determination and a kind heart. Gerry never forgot his roots in West Cork and we will always remember him.”

Professor O’Sullivan’s work continues with Breakthrough Cancer Research, an Irish medical cancer research charity that he founded on the unshakeable Professor Gerry O’Sullivan

belief in Cork and in Ireland that we can make more survivors of cancer and we will do that through research. Breakthrough invest in world-class research in Ireland to impact the quality of life for cancer patients and to save lives. They are particularly focused on improving outcomes for cancers which are poorly served by current treatment options and have helped take 9 new treatments from the lab into clinical trial.

The statue unveiling is an event open to the public from 1.30pm4pm on Sunday 5th June. In addition to the commemoration ceremony, there will be dancing performances from the local national school, music with the St Fachtna’s Silver Band, facepainting and food trucks.

CANCER VACCINE BIOTECH CIMCURE RAISES ¤5 MILLION in seed round investment led by Positron Ventures CimCure, a biotech spin-off of Amsterdam UMC, focusing on the development of a novel vaccinebased cancer immunotherapy through its Immune-Boost (iBoost) technology, has announced that it has raised little over ¤5 million in a financing Seed Round led by Dutch VC Positron Ventures. The round was supported by several investors with deep industry knowledge, including the investment vehicle of Tom Würdinger, professor at Amsterdam UMC. With the proceeds of this Seed Round CimCure will further advance the vaccine up until phase 1-2 clinical studies in humans. Dutch vaccine CDMO Intravacc will be CimCure’s partner for the development and production of the lead compound.

The vaccine-based immunotherapy developed by the team of Prof.

Dr Griffioen at the Amsterdam UMC and licensed to CimCure, has shown high effectiveness and safety, both in murine animal models and in an efficacy study in client-owned dogs with spontaneous bladder cancer.

Late May, some of the research results which underlie CimCure’s innovation were published in Nature Communications (Van Beijnum et al, 2022).

CimCure was founded in 2016 as a spin-off of Amsterdam UMC supported by Amsterdam UMC’s TTO Innovation Exchange Amsterdam and is led by Prof. dr.

Arjan Griffioen, CSO, and Diederik Engbersen, CEO. Both have extensive experience in the biotech industry and started CimCure to commercialise a smart, effective and safe treatment strategy against all types of solid tumors at all stages, and can be combined

with conventional and state-of-theart anti-cancer strategies.

Joseph Peeraer, founding partner of Positron said, “We feel privileged to be able to invest in this promising iBoost technology and vaccine-based cancer immunotherapy, which might become a real game changer in the fight against cancer.

This investment in CimCure exemplifies our thesis to invest at an early stage in outstanding scientists who would like to bring a potentially groundbreaking and impactful innovation to market. Professor Griffioen’s invention may lead to a much less demanding, cheaper and more effective cancer treatment.”

About CimCure’s vaccine-based immunotherapy CimCure develops cancer vaccines through its proprietary ImmuneBoost (iBoost) technology of targeted conjugate vaccines. The company has identified specific targets in the tumor vasculature.

Eradication of tumor blood vessels and inhibition of their growth will lead to inhibition of cancer growth.

This is an attractive approach for treatment of cancer. However, past and current angiostatic drugs are known for rapid induction of drug resistance and loss of effectiveness, due to intervention in tumor-produced growth factors or their receptors. CimCure’s approach directly targets the tumor blood vessels, which efficiently attenuates tumor growth directly and does not induce resistance. An additional advantage of targeting blood vessels is that the barrier function of the tumor vasculature for leukocytes can be overcome (Huinen et al, Nature Reviews Clinical Oncology, 2021).

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DARZALEX® (DARATUMUMAB) APPROVED FOR REIMBURSEMENT IN IRELAND IN COMBINATION WITH BORTEZOMIB, THALIDOMIDE AND DEXAMETHASONE (VTD) FOR PATIENTS WITH NEWLY DIAGNOSED MULTIPLE MYELOMA WHO ARE TRANSPLANT ELIGIBLE Janssen, the Pharmaceutical Companies of Johnson & Johnson, has announced Darzalex® (daratumumab) in combination with bortezomib, thalidomide and dexamethasone (VTd) has been granted reimbursement in Ireland for the treatment of patients with newly diagnosed multiple myeloma who are eligible for autologous stem cell transplant (ASCT).

The announcement follows EC approval of daratumumab based on results from Part one of the Phase 3 CASSIOPEIA (MMY3006) study, published in The Lancet5 in

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June 2019 and presented at the 2019 American Society of Clinical Oncology (ASCO) Meeting.

Professor Philip Murphy, Consultant Haematologist, Beaumont Hospital said: “For Irish patients newly diagnosed with multiple myeloma, the importance of early intervention with effective first-line treatments to maximise response cannot be emphasised enough. Improvements in the standard of care to provide patients with valuable extra time are vital. Data from the CASSIOPEIA study demonstrates that the addition of daratumumab in combination with VTd can lead to deep remissions and prolong PFS.” Dr Thorsten Giesecke, General Manager, Commercial Business, Janssen Sciences Ireland UC, said: “Janssen is committed to providing access for patients to daratumumab in earlier disease stages of multiple myeloma, a type of blood cancer that can have a devastating impact on the lives of those affected. Every year in Ireland about 350 people are diagnosed with this condition, and today’s reimbursement provides those who are newly diagnosed and transplant eligible, with a long-awaited additional frontline therapy.”6 The Phase 3 CASSIOPEIA trial is a two-part study. Results from this first part of the trial showed that after consolidation, the stringent complete response (sCR) rate was significantly higher in the daratumumab-VTd arm (29 percent) compared to VTd alone (20 percent) (Odds Ratio [OR] = 1.60; 95 percent confidence interval [CI], 1.21-2.12; P<0.0010).2 At a median follow-up of 18.8 months, PFS was significantly improved in the daratumumabVTd group compared to VTd alone (Hazard Ratio [HR] = 0.47; 95 percent CI, 0.33-0.67; P<0.0001), and the median PFS was not reached in either arm.2 The addition of daratumumab to VTd resulted in an 18-month PFS rate of 93 percent compared to 85 percent for VTd alone.2 The most common (≥10%) Grade 3/4 treatment-emergent adverse events (TEAEs) for daratumumabVTd and VTd, respectively, were neutropenia (28 percent vs. 15 percent), lymphopenia (17 percent vs. 10 percent), stomatitis (13 percent vs. 16 percent) and thrombocytopenia (11 percent vs.

7 percent).2 In the daratumumabVTd combination arm, infusionrelated reactions occurred in 35 percent of patients.2

PHARMACYNEWSIRELAND.COM

MORE PATIENTS CAN DO IT WITH THEIR PHONES1

Digital health tools that work together for seamless diabetes management

Healthcare providers have secure, online access to glucose insights2

Caregivers can remotely monitor their loved ones4 People with diabetes can conveniently check their glucose using their phone1,3

For more information visit www.FreeStyleDiabetes.ie Images are for illustrative purposes only. Not actual patient or data.

1. The FreeStyle LibreLink app is only compatible with certain mobile devices and operating systems. Please check the website for more information about device compatibility before using the app. Use of FreeStyle LibreLink requires registration with LibreView. 2. The LibreView website is only compatible with certain operating systems and browsers. Please check www.LibreView.com for additional information. 3. The FreeStyle LibreLink app and the FreeStyle Libre reader have similar but not identical features. Finger pricks are required if readings do not match symptoms or expectations. The FreeStyle Libre sensor communicates with the FreeStyle Libre reader that started it or the FreeStyle LibreLink app that started it. A sensor started by the FreeStyle Libre reader will also communicate with the FreeStyle LibreLink app. 4. The LibreLinkUp app is only compatible with certain mobile device and operating systems. Please check www.LibreLinkUp.com for more information about device compatibility before using the app. Use of LibreLinkUp and FreeStyle LibreLink requires registration with LibreView. The LibreLinkUp mobile app is not intended to be a primary glucose monitor: home users must consult their primary device(s) and consult a healthcare professional before making any medical interpretation and therapy adjustments from the information provided by the app. © 2021 Abbott. FreeStyle, Libre, and related brand marks are marks of Abbott. ADC-37632 v1.0 04/21.