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June 2020 Volume 12  Issue 6 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS:

While we must stay apart

Minister acknowledges efforts of profession Page 6

PROFILE: Pharmacy Placement during a Pandemic Page 10

PERSPECTIVES:

We stand together supporting you

An Italian Pharmacist reflects and advises Page 12

REPORT: Impact of Covid on Industry Landscape Report Page 18

CPD: Managing People with Intellectual Disabilities Page 37

FEATURE: Focus on Eye Health Page 43

EDUCATIONAL: Smoking Cessation Page 52


THERE IS NO STRENGTH WITHOUT UNITY “Ni neart go cur le chéile” Standing together with our Pharmacy Frontline Heroes. At these crucial times let’s all: • Demonstrate compassion • Choose knowledge over fear • Protect the vulnerable • Lead with empathy www.theapharma.ie

TP20014


3

Contents

Foreword

Page 4: Pharmacists emerge as most trusted professionals

As Irish Pharmacy News was going to press, a Programme for Government was published; a document that has been welcomed by community pharmacy. Irish Pharmacy Union Secretary General Darragh O’Loughlin said, “Pharmacists want to do more for their patients, and we hope these talks will focus on adding to the range of healthcare services provided in Ireland’s 1,900 pharmacies. This has the potential to deliver significant benefits to patients and to the system as a whole, and to free up GP and A&E time for more complex cases.

Page 5: Video Pharmacy first for Meaghers Page 7: Is a new Pharmacy Contract on the horizon?

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“The inclusion of pharmacies in commitments to expand primary and community care, making the vast majority of healthcare services available in the home or close to home, rather than in our hospitals, is very positive. We look forward to working with the new Minister for Health and their officials to develop this programme focused on improved health outcomes and implementing it across the country.”

Page 10: Pharmacy students hit the frontline Page 18: Covid-19 impact report and landscape outlook Page 34: Corporate Profile with TheaPamex General Manager Page 54: Financial and Business planning Continuing Professional Development PUBLISHER: IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

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Light

after Lockdown

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ADVERTISING DIRECTOR Debbie Graham: 00353 (87) 288 2371 debbie@ipn.ie ADVERTISING EXECUTIVE Amy Evans: amy@ipn.ie CONTRIBUTORS Rachel Dungan Bernadette Flood DESIGN DIRECTOR Ian Stoddart Design

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@Irish_PharmNews

IrishPharmacyNews

01

Turn to page 7 to read more. The leading news in this issue is our exclusive May 11-page report on the impact of Covid-19 to the pharmaceutical industry. Just last month, the Irish government announced its roadmap for lifting restrictions March 1 May imposed by the lockdown in the wake of Covid-19. Ireland has set Gradually, businesses have been opening up, socialisation out a roadmap of five stages for is starting to re-emerge.

27

27 March Everyone told to The future of course will look very stay at home

easing lockdown.

TaoiseachHow Leo different. Varadkar calling it businesses and professionals engage with each other will a “journey to a explore new models of e-technology and e-commerce. new normal”

March

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com EDITOR Kelly Jo Eastwood: 00353 (87)737 6308 kelly-jo@ipn.ie

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However the Irish Pharmaceutical Healthcare Association (IPHA), which represents the international research-based biopharmaceutical industry has said that whilst the report is ‘welcomed’ it leaves unresolved the funding crisis for new medicines.

The pharmaceutical industry and the pharmacy profession

24 March welcomed theclosed. emergence from lockdown and now All have non-essential shops it is time to navigate this new world. There is much to Schools, colleges, childcare hadbe closed 12thabout March and afterthis report reflects the efforts and positive St Patrick’s Dayof parades dedication many of Ireland’s leading OTC and cancelled March pharma9thcompanies.

29 Feb

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Turn to page 18 to read the full report. 29 February Ireland’s first case of This issue is also packed with educational clinical features Covid-19 was confirmed and news, including our contributed CPD on People with

Intellectual Disabilities on page 37 and a Finance CPD by Irish Pharmacy IRISH News is regular contributor Rachel Dungan on page 54. PHARMACY circulated to all NEWS independent, multiple Pharmacists and academics I hope you enjoy this issue. Stay safe. in Ireland. All rights reserved by Irish Pharmacy News. All material published in Irish Pharmacy News is copyright and no part been highly responsive. OTC relationships and communications of this magazine may be reproduced, and pharma organisations have were key in Ireland. How will this How organisations and brands stored in a retrieval system or transmitted rallied to enable the supply of key look in a landscape dominated by CPD: PWID DURING COVID P37 across borders, manage social distancing? in any form without written permission. have behaved during Covid-19 will medicines workforce safety, and handle IPN Communications Ltd. has taken every The FEATURE: EYE CARE MANAGEMENT disruptive effects of P43 evolving government restrictions. care in compiling the to ensure bemagazine remembered. coronavirus placed enormous All while beginning to prepare for that it is correct at the time of going to strain on the global supply of new vaccines and therapeutics. FEATURE: ALLERGIES P48 press, however the publishers assume medical products, increasing the welcomed the emergence from Just last month, the They have also rallied in helping risk of shortages. As consumers no responsibility forIrish any effects from EDUCATIONAL: SKIN P57 governmentorannounced to support those at the frontline, went into a shopping frenzy, lockdown and now it is time to omissions errors. its

What impact has Covid-19 had on the industry and what will the future look like? Regulars

roadmap for lifting restrictions imposed by lockdown in the wake of Covid-19. Gradually, businesses have been opening up, socialisation is starting to re-emerge.

navigate this new world.

How organisations and brands have behaved during Covid-19 will be remembered.

at which community pharmacists have been prominent.

With these initiatives established, companies can begin taking stock of what lies ahead. Given

pharmacy shelves were stripped of household staples ranging from paracetamol and ibuprofen to nasal congestion sprays and throat lozenges.


4

News

Who do we Trust? Pharmacists The latest Veracity Index 2020 has been revealed by Ipsos MRBI showcasing who the public trust most and, unsurprisingly but reassuringly, local pharmacists came in second at 96%. Healthcare professionals continue to lead the way, with Gardaí, government ministers & other politicians seeing strong increases. Local pharmacists came second only to Nurses. However, in the midst of COVID-19, it seems we trust each other a little less.

ePortfolio Review 2019/20 Outcomes from the 2019/20 ePortfolio Review The aim of ePortfolio Review is to allow pharmacists to demonstrate their ongoing engagement with Continued Professional Development (CPD), in line with the legislative requirements. The 2019/20 ePortfolio Review process finished in late April. In total 1352 pharmacist were included in this year’s review.

2020/21 ePortfolio Review Pharmacists who are three or more years qualified can expect to be selected for ePortfolio Review once in every five year period. The PSI will notify pharmacists selected for the 2020/21 ePortfolio Review in July 2020. Return to Practice The Irish Institute of Pharmacy, in collaboration with the Pharmaceutical Society of Ireland, have developed a Return to Practice Resource for the purpose of providing support to pharmacists returning to the register under Section 77 of the Pharmacy Act 2007, as amended.

No Shortage of Medicines The Health Products Regulatory Authority (HPRA) has confirmed there is no shortage of critical care medicines in Ireland, despite ongoing problems in other European countries arising from the Covid-19 pandemic. The Authority is working with a number of organisations, including manufacturers and wholesalers, to prevent shortages. “Currently, there is no shortage of ICU medicines in Ireland impacting on patient treatment and care. Sufficient supplies of anaesthetics and sedatives, antibiotics, muscle relaxers and emergency drugs are in place and available to hospitals,” said a HPRA spokesperson. “With regard to the potential future shortage of any specific medicine, this is managed through the existing medicine shortages framework to prevent the shortage from occurring where feasible or, where it does occur, to manage the impact in terms of identifying alternative treatments.

“In the case of medicines used most often in Ireland, there are typically multiple forms and brands available from a range of sources. In the event that there are some supply issues for individual medicines, it is expected that alternative brands will be available to ensure continuity of treatment. Therefore, Ireland is unlikely to face general medicines supply issues now or in the near future as a result of any Covid-19-related issues.” The European Medicines Agency (EMA) is working with organisations to ensure medicines shortages are kept to a minimum during the pandemic. An i-SPOC (industry single point of contact) system, the fast-track monitoring system for

PHARMACYNEWSIRELAND.COM

crucial medicines used in the context of Covid-19, has been set up by the EMA. “The data collected so far through the system indicates that current or anticipated shortages of some of these medicines are mainly driven by the unexpected surge in demand and by changes in prescribing behaviours”, according to a statement from the agency. “EMA will keep updating the steering group on a regular basis as more data are gathered through the i-SPOC system in order for the steering group to discuss possible options for resolution of the reported shortages.”

The resource is mapped to the Core Competency Framework for pharmacists has six sections which cover the following: • Professional Practice • Personal Skills • Organisation and Management Skills • Safe and Rational Use of Medicines • Supply of Medicines • Public Health This resource contains information which is intended to be helpful to all pharmacists, but is particularly relevant to pharmacists working in a Community Pharmacy setting. It is an evolving resource, with information being added which is intended to be helpful to practitioners as the situation evolves. You can find the resource in the “All Courses” section of the IIOP website.


News Boots launch Safe Space Boots Ireland have this month launched a ‘Safe Space’ initiative in partnership with Safe Ireland. Women who are experiencing domestic violence can go into their local Boots and access a ‘Safe Space’ in a pharmacy consultation room. In this confidential space they can contact one of the 39 frontline specialist domestic abuse services across the country and access free, confidential support and advice.

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First for Meagher's Video Pharmacist Dublin based pharmacy Meagher's has launched an innovative new service that will allow customers to speak directly to one of the onsite pharmacists via video call - thereby allowing customers to have a face-to-face consultation from the comfort of their own home.

Safe Ireland is the national policy and services hub for 39 frontline domestic abuse services throughout the country. According to An Garda Siochána, which has prioritised domestic and sexual violence through Covid-19 with Operation Faoisimh, domestic violence reports have increased by up to 30 percent in some areas. Safe Ireland frontline services provide a range of supports to approximately 12,500 women and 3,000 children across Ireland. In addition, there are on average 50,000 calls to helplines around the country each year. The national freephone helpline accounts for approximately 19,000 calls, with the remaining 34,000 calls being made to local helpline services. Bernadette Lavery, Managing Director of Boots Ireland comments, “Now, more than ever, people need safety and security in their lives, and we are very proud that our eightyeight stores are seen as a place where people can turn to for help during this time. “We hope that by making our consultation rooms ‘Safe Spaces’, people will be able to find the support they need during this difficult time in their lives. This initiative is something our pharmacy and store teams feel very passionate about and I would like to praise them for the amazing job they are doing, at a time when they too are under immense pressure.” Safe Ireland Co-CEO Mary McDermott said victims of domestic abuse are being forced to chose between the threat of infection and the threat of abuse. Speaking on RTÉ's Morning Ireland, Ms McDermott said the national helpline has seen an increase in calls since the Covid-19 restrictions were imposed, while there have been more presentations at refuges by single women, pregnant women, and women with children.

Oonagh O’Hagan, Meagher's, Managing Director

The first service of its kind, the consultations are carried out through secure video link to ensure confidentiality and privacy. Calls can be carried out via mobile, tablet or PC and, in line with new legislation, customers can

also have their doctor send an electronic copy of their prescription directly to Meagher's via the HSE's secure email system Healthmail. This means that customers or their carers can have any queries or concerns around their medicines answered without the need to leave their houses and go instore - a particularly helpful service for more vulnerable customers

who may be trying to limit their interactions with other people. Managing Director Oonagh O’Hagan says, “As a pharmacy group, we pride ourselves on constantly innovating to enhance our patient care. What began as just a seed of thought has resulted in Meagher's becoming the first pharmacy group in Ireland to launch a video pharmacist service.”

Staunton’s Chocolate Gesture Staunton’s Pharmacy in Mayo is giving out special chocolate subscriptions to spread good will during the coronavirus pandemic. The pharmacy team are giving customers a club milk bar after visits to the local chemist along with a kind message. Written on the bars is: “Community spirit will beat this virus. Social distancing, hand washing and keeping in touch with friends helps us to stay healthy.

“A little chat and a cuppa helps also! Relax and have a little break.” Welcoming their retail neighbours back earlier this week the owners posted on Facebook saying: "As we slowly reopen our doors to our beautiful country the team here at Stauntons Pharmacy wish to welcome our neighbouring businesses back.

PHARMACYNEWSIRELAND.COM


6

News

Joanne re-appointed PSI Council President At the online meeting of the PSI Council on 18 June 2020, the Council re-elected Joanne Kissane as President and Michael Lyons as Vice-President of the PSI. The appointments are effective immediately. Joanne Kissane, PSI President

The President and Vice-President are office holders as designated under the Pharmacy Act 2007. They are elected for a one-year term and may hold office for up to two years. Both Joanne and Michael will serve a second term in these roles at the pharmacy regulator.

Joanne Kissane has served on the PSI Council since 2015. She is a graduate of the School of Pharmacy, Trinity College Dublin and has worked as a community pharmacist, then superintendent pharmacist for seven years, for the Lloyds Pharmacy group. She is currently the Director and National Coordinator for APPEL (Affiliation for Pharmacy Practice Experiential Learning) which manages the experiential learning placements of the integrated pharmacy programmes of the three Schools of Pharmacy in Ireland. She holds a Masters in Quality and Safety in Healthcare Management from the Royal College of Surgeons in Ireland. Michael Lyons has been a PSI Council member since 2017. Michael is a dual-qualified pharmacist and barrister. He received a Master of Pharmacy degree from the University of Kent in 2011 and began his pharmacy career as a support pharmacist

in Cork and Dublin. Michael was called to the Irish Bar in 2016 after attaining a Barrister-at-Law degree at the Honorable Society of Kings Inns, Dublin. Alongside his brother, Michael owns and operates Lyons Family Pharmacy in Fermoy, Co. Cork where he is the superintendent pharmacist. Separately, Michael also provides expert scientific reports for legal cases and has appeared before the Central Criminal court providing independent expert evidence. The President and Vice-President will continue, with the Council, to oversee the ongoing work of the PSI, including supporting national response efforts during the Covid-19 public health emergency, aimed to ensure that the necessary support and engagement is in place with pharmacists and pharmacies for continued safe and effective pharmacy care and services to the public. The Council is currently overseeing the final year of its Corporate Strategy 2018-2020, and in the process of developing its future strategy objectives, remaining focused on assuring public trust in pharmacy through effective regulation.

Minister acknowledges Pharmacy Irish Pharmacy Union Secretary General Darragh O’Loughlin recently shared with the profession, a letter of acknowledgement on the dedicated work being carried out by Ireland’s community pharmacists. “Got this message from Minister for Health Simon Harris today, acknowledging the pivotal role of community pharmacists in responding to the health needs of the public in very pressurised circumstances during the current #Covid19 crisis,” he stated. “Thanks to all the fantastic pharmacists out there who continue to represent the profession so proudly and serve their communities so well.”

Medicines Shortages June The Health Products Regulatory Authority has been notified of a shortage of the following products: • Diabrezide 80mg Tablet – PA0925/001/001 • Flixotide 0.5mg/2ml Nebules – PA1077/044/016 • Flucloxacillin 2000mg Powder for Solution for Injection/ Infusion – PA1862/003/004 • Neurontin 300mg Capsule – PA0822/015/002 • Neurontin 600mg Capsule – PA0822/015/004 • Neurontin 800mg Capsule – PA0822/015/005 • Oprymea 0.088mg Tablet – EU/1/08/469/001-005 • Zinnat 250mg Tablet – PA1077/015/003 The following shortage has been resolved and supply has resumed to the Irish market: • Accupro 20mg Tablet – PA0822/007/003 • Ciproxin 500mg Tablet – PA1410/028/003 • Propofol-Lipura 2% 20mg/ ml Emulsion for Injection or Infusion – PA0736/018/003 • Propoven 2% Emulsion for Injection or Infusion – PA2059/017/003 • Zomig 2.5mg Tablet – PA2242/004/001 Please see the shortages section of the HPRA website for further information at www.hpra.ie Medical Devices and PPE In response to the rise in new economic operators producing medical devices and PPE, the European Commission has published guidance on the placing (and making available) of these products on the EU market. As noted in this document, extraordinary circumstances have led to a rapid increase in the need, and demand, for specific devices and equipment. This has resulted in the involvement of economic operators (such as importers, distributors and manufacturers) who were not previously involved in the supply of these products. The document is available to download from the website of the European Commission. It may be useful to new economic operators in these areas. The HPRA is the competent authority for medical devices. However, queries pertaining to PPE should be directed to the Health and Safety Authority.

PHARMACYNEWSIRELAND.COM


News

7

Hopes for new Pharmacy Contract The Irish Pharmacy Union (IPU) has welcomed the commitments towards expanding the role of community pharmacies contained within the draft Programme for Government – Our Future, published this month. However, it leaves unresolved the funding crisis for new medicines, according to the Irish Pharmaceutical Healthcare Association (IPHA), which represents the international research-based biopharmaceutical industry. New Pharmacy Contract The IPU has said that they hope talks on a new pharmacy contract can commence immediately and be concluded within this calendar year. Commenting on the Programme for Government, IPU Secretary General Darragh O’Loughlin said, “Over the past few months, throughout the COVID-19 crisis, community pharmacies have played a pivotal role in responding to the health needs of people in communities across the country. With 78 million visits per year, pharmacies are the most accessed part of our healthcare system. Despite this, we have long been both undervalued and underutilised by successive governments. “We welcome the commitment to commence talks with pharmacists on a new contract and enhancement of our role in the delivery of healthcare in the community. Pharmacists want to do more for their patients, and we hope these talks will focus on adding to the range of healthcare services provided in Ireland’s 1,900 pharmacies. This has the potential to deliver significant benefits to patients and to the system as a whole, and to free up GP and A&E time for more complex cases. “The inclusion of pharmacies in commitments to expand primary and community care, making the vast majority of healthcare services available in the home or close to home, rather than in our hospitals, is very positive. We look forward to working with the new Minister for Health and their officials to develop this programme focused on improved health outcomes and implementing it across the country.” Mr O’Loughlin warned that pharmacists are growing wary of false promises and delayed

Oliver O’Connor, CEO of IPHA

"With the current Agreement on pricing and supply of medicines set to expire, we are working on a co-funding model in which both industry and the State would agree to jointly fund new medicines. That’s the fairest way to ensure patients get timely access to the best medicines" action. “After a decade of decline in payments for delivering services on behalf of the State, pharmacy businesses and their staff are under unsustainable pressure. Previous promises of talks on additional services and resources have consistently failed to materialise. The time for empty talk has gone; now we need action. We hope to meet with the new Minister for Health, once appointed, in the first few days of their time in office and agree a defined timeline to make good on these commitments before the year is out.” He concluded by stating, “Pharmacists are ready, willing, and waiting to do more for their patients. We look forward to working with the new Government to make it a reality.” Deliberate Decisions For almost a year, there has been a deliberate decision from Government to provide no new funding to the HSE for new medicines, says IPHA. “The HSE has asked and was refused. This has created a backlog of at least 18 new medicines still unavailable for patients, despite having met Irish clinical effectiveness and value for money tests.

“The funding of new medicines is in crisis,” said Oliver O’Connor, CEO of IPHA. “The new Programme for Government is totally silent on funding new medicines. Without a change in direction from Government, the HSE is still effectively prohibited from paying for new medicines for patients. The result is that patients in Ireland are among the last in western Europe to access new innovative treatments. That means doctors are unable to prescribe the newest and best medicines for patients with serious illnesses like cancer, stroke and heart disease. This Programme for Government leaves patients and doctors still waiting,” he added. IPHA has said it is ready and willing to co-fund new medicines in the October Budget. “In its first Budget, the new Government must put new funding for new medicines on the table. That can be the basis for a new Agreement - a joint funding model recognising that both industry and the State share a responsibility to give patients the same treatment options as their peers in western Europe. “With the current Agreement on pricing and supply of medicines set to expire, we are working on a co-funding model in which both industry and the State would agree to jointly fund new

medicines. That’s the fairest way to ensure patients get timely access to the best medicines,” said Mr O’Connor. IPHA said it would study closely the mandate of the “National Medicines Agency”. “The National Centre for Pharmacoeconomics already professionally evaluates new medicines and the HSE implements a Medicines Management Programme. But without new Government funding, the experience is that medicines simply back up inside the HSE. The same thing will happen in the National Medicines Agency if funding is not provided. Patients will still wait for treatment options that are available elsewhere in Europe.” IPHA also said the Government should recognise the potential of the biopharmaceutical industry, whose footprint in Ireland creates some 45,000 jobs, to enable “reform and renewal” in society. It also welcomed the planned rollout of the flu vaccine to more people without charge and urged the promotion of childhood vaccinations. Next month’s issue will carry a more in-depth look at the Programme for Government.

PHARMACYNEWSIRELAND.COM


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


Pharmacy staff

Day-to-day operating costs Day-to-day operating costs have also dramatically have also dramatically increased for pharmacies. increased pharmacies. There wasfor a significant cost There wasinapharmacy significantstaff cost increase increase in pharmacy costs primarily due tostaff the costs primarily the introduction ofdue splittoshifts, introduction of split shifts, longer working hours and longer workingfor hours and the necessity increased the necessity for increased cover in the dispensary. The cover in thecosts dispensary. The additional are averaging additional costs are€2,300 averaging a not insignificant per apharmacy not insignificant €2,300 per month andper are pharmacy perin month are much higher some and cases. Duehigher to business pressures much in some cases. one into five (19%) pharmacies Due business pressures reported to let staff go one in fivehaving (19%) pharmacies with a further confirming reported having38% to let staff go that athey may38% haveconfirming no option with further but to do may so over the that they have nofollowing option three The indications Additional costs but to months. doday-to-day so over the following are that it is mainly front of three months. The indications pharmacy who haveof been it isstaff mainly front 74%are of that pharmacies experienced temporarily laid-off. pharmacy staff who have been additional cleaning costs and 15% sawtemporarily an increaselaid-off. in security costs.

What has been the impact of the current public health emergency on your pharmacy staff costs health emergency on your pharmacy staff costs (excluding delivery staff costs)? (excluding delivery staff costs)? News 9 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0%

56% 56%

Impact of Covid on Pharmacy Business

31% 31% to The IPU COVID-19 Pharmacy Business Survey was undertaken in the week beginning 20 April 2020 13% establish the impact of COVID-19 on pharmacy businesses and to get an estimate 13%of the costs already Increased Decreased Remained the same incurred, and the potential future costs when the public emergency measures Decreased are eased. There 190 Increased Remainedwere the same responses to the survey, representing 430 pharmacies. Last month's issue of Irish Pharmacy News revealed the startling statistics on the impact the global pandemic that Covid-19 has brought upon community pharmacy business. Ireland’s 1,900 community pharmacies are struggling to cope with soaring costs and falling revenues. New research released by the Irish Pharmacy Union reveals the extent of the severe cost increases being borne by pharmacies providing front line care during the crisis. Physical distancing/PPE The IPU COVID-19 Business Survey revealed that most pharmacies had been hit by significant extra costs to enable them to remain open and to provide safe care. The costs associated with physical distancing and PPE are among the most significant, with over two thirds (68%) installing new counter screens to protect patients and staff, and significant costs highlighted for the implementation of other measures, including signage introduced by 82% of pharmacies, floor markings (74%) and security pods (28%). Over half of pharmacies (56%) had introduced a barrier system within the pharmacy premises. The average cost of implementing these measures was ¤1,500 per pharmacy. Pharmacy staff Day-to-day operating costs have also dramatically increased for pharmacies. There was a significant cost increase in pharmacy staff costs primarily due to the introduction of split shifts, longer working hours and the necessity for increased cover in the dispensary. The additional costs are averaging a not insignificant ¤2,300 per pharmacy per month and are much higher in some cases. Due to business pressures one in five (19%) pharmacies reported having to let staff go with a further 38% confirming that they may have no option but to do so over the following three months. The indications are that it is mainly front of pharmacy staff who have been temporarily laid-off.

94%Additional of pharmacies reported that Additional they were offering day-to-day costs a delivery service. Of these,costs 59% have their day-to-day 74% of pharmacies experienced own staff delivering medicines, additional cleaningexperienced costs and 74% of pharmacies 12%15% are saw employing additional an increase in security additional cleaning costs and staff costs. and 29% are using voluntary 94% pharmacies 15% saw anof increase in security organisations/volunteers. These reported they were costs. 94%that of pharmacies additional costs are costing offering a delivery service. Of reported that they were these, 59% have their own staff pharmacies average ¤2,800 offering aon delivery service. Of delivering medicines, 12%with are per month. Taken these, 59% havetogether their own staff employing additional staff delivering medicines, 12% are the increase in staff costs, the and 29% are using voluntary employing staff survey revealsadditional that pharmacies organisations/volunteers. These and 29% are using voluntary are shouldering additional monthly additional costs are costing organisations/volunteers. costs of ¤5,000, equating toThese almost pharmacies on average €2,800 additional costs are costing ¤10 pharmacies million per Taken monthtogether across per month. on average €2,800 with the increase in staff the sector. 75% of respondents per month. Taken together costs, the survey reveals that envisage an increase costs with the increase inin staff pharmacies arepharmacy shouldering in preparing for costs, the their survey reveals that additional monthly costs of pharmacies are shouldering when the public health emergency €5,000, equating to almost additional monthly costs of€10 is over, withper an average cost of millionequating month across the €5,000, to almost €10 ¤4,100 per 75% pharmacy anticipated. sector. of respondents million per month across the envisage anofincrease in costs sector. 75% respondents Turnover/sales in preparing their pharmacy retail has envisage anbusiness increase inreduced costs for when theof public health because the restrictions in preparing their pharmacy introduced during the The increase iniscosts comes emergency over, with ancurrent for when thehealth public health with public emergency, average cost of €4,100 perin at a emergency time when sales isretail over,confirming with an respondents pharmacy anticipated. pharmacies have average of dropped €4,100 per an cost average reduction dramatically due to the movement of 36% in sales. pharmacy anticipated.

On the dispensary side of restrictions imposed by the Turnover/sales business, not surprisingly, COVID-19the response. Almost (56%) over half of respondents The increase in costs comes 9 outTurnover/sales of 10 pharmacies reported that their(86%) dispensary at a time when retail sales pharmacy increased reported that their front shop The increase inbusiness costs of comes in pharmacies have dropped significantly at thesales start of a time when retail retailat business has reduced dramatically due to the the pandemic, but a decrease in pharmacies have dropped because of the restrictions movement restrictions was noticed subsequently dramatically due tocurrent the fallintroduced during reflecting a the dramatic imposed by the COVID-19 movement restrictions off in GP visits. response. Almost 9One outin often 10 public health emergency, with imposed byreported the COVID-19 (12%) increase in pharmacies (86%) an reported respondents confirming an dispensary sales, with response. Almost 9 out of14% 10 that reduction their front of shop average ofreported 36%Itinshould reporting a decrease. pharmacies (86%) be noted that survey sales. Ontheir the dispensary sidewas of that front ofthe shop undertaken in the last week the business, not surprisingly, over of April, and consequently IPUREVIEW JUNE 2020 half of respondents (56%) reported there is anecdotal evidence that IPUREVIEW their to dispensary suggest that,pharmacy at the time JUNE 2020 writing, thesignificantly dispensary business of increased business is more reflective of at the start of the pandemic, normal trade (if we can use but a decrease wasinnoticed such a term the current circumstances), subsequently reflectingin acomparison dramatic to the first few weeks of the falloff in GP visits.

If the current public health emergency measures If theinhas current health What beenpublic the impact of emergency the current measures stay place, how long do you think you can publichealth emergency on your pharmacy staff stay in place, how long do you think you can support your current employee numbers? costs (excluding delivery staff costs)? support your current employee numbers? 35% 30% 35% 25% 30% 15% 25% 10% 15% 5% 10% 0% 5%

33% 33%

26% 26%

19% 19%

12% 12%

3% 3%

8% 8%

0%

Has your front of shop retail pharamacy business been If theyour current public health emergency measures Has front of shop retail pharamacy business bee impacted by the health stay in place, howcurrent long dopublic you think you emergency? can impacted by current the current publicnumbers? health emergency? support your employee 100%

100% 90%

86% Have you had to undertake any of the following measures 80% 70% 86% to ensure adequate cash flow within your business? 70% 60% 90% 80%

50% 60%

50%

40% 50%

40% 30% 40%

46%

42%

20% 30% 30% 10%

20% 20%

26%

6% 6%

8% 19% 8%

0% 10%

10%

0%

5%

0%

creditors

Please indicate how your dispensary pharmacy Please indicate how your dispensary pharmacy business has been impacted by the current business public health emergency has been impacted by the current public health emergency 100% 80%

public health emergency.

Cashflow/credit limits A quarter of pharmacies (26%) reported having had to restructure their loans to ensure adequate cashflow within their business, with a further 19% increasing their overdraft facility. 42% have had to defer payment to their creditors. Similarly, a quarter of pharmacies have reached their credit limit with medicine wholesalers, impacting their ability to purchase further supplies. Worryingly, 30% of respondents indicated that they had difficulty in ordering key medicines for patients due to reaching their credit limit.

60%

56% 40% 20% 0%

12%

14%

17%

Increased

Decreased

Stayed the same

form of social distancing measures and introduced PPE equipment for the safety of staff and members of the public, at a considerable cost. When these are added

With costs increasing and income reducing it is no surprise that a substantial number of pharmacies have had to resort to alternative funding to maintain cashflow,

Increased significantly at the start but a decrease noticed since stricter quarantine measures in place

unsustainable cost to many. The easing of lockdown restrictions should continue over the next number of weeks. While this may require some further modifications

PHARMACYNEWSIRELAND.COM


10

Students

Pharmacy Placement during a Pandemic COVID19 has seen pharmacists and other pharmacy professionals on the frontline adapting to unprecedented changes in the past few months. But they’re not the only ones facing new challenges and experiences – final year pharmacy students have been a key part of many pharmacy teams around the country as they complete their experiential learning placements and prepare to join the profession. We hear from Melissa Duggan (final year pharmacy student in RCSI) and Ellen Gilmartin (final year pharmacy student in Trinity College Dublin) on what placement during a pandemic is like. Melissa Duggan, final year pharmacy student in RCSI

On the 6th of January 2020, I started my first day of my 8 month APPEL Pharmacy placement working in a community pharmacy in Cork City. The last four years have really been building up to this moment, so I was both excited and nervous to the year ahead. Now I am half way into my placement and I still find it hard to believe how much things have completely changed since I have started. A new routine has developed that involves gowning up with gloves, face masks and plastic aprons as soon as we enter the pharmacy, as well as disinfecting all the work benches, computers, and cash machines before the doors open to the customers. We are only allowing a maximum of three people into the pharmacy at a time, making sure everybody adheres to the social distancing rules by placing markers on the floor of where people should stand. We have a tent erected outside the door for people to take shelter while they wait for their prescriptions on rainy days. We also erected a plastic shield at the counter to protect ourselves. At the beginning of the lockdown

in Ireland the community pharmacy was a very busy and stressful environment. There was a huge demand for hand sanitisers, masks and gloves, resulting in a shortage of supply during the first few weeks. Our patients began to worry that they would not be able to collect their medication which led them to ordering their prescriptions early and for a few months at a time. The wholesalers found it very difficult to keep up with the demand of ordering medicines across Ireland which resulted in very few orders being delivered on time or even at all. There were many medicine shortages which meant we had to ring other pharmacies to source some medicines for our patients. Despite it being so chaotic, our patients were very understanding with some bringing us sweets and chocolates to brighten up our day. These treats were a welcomed boost that we all needed to keep the team morale going. This sense of community spirit has really lifted me up over the last few weeks. Thankfully that period has finished and things are beginning to settle down to some extent. There has been new pharmacy legislation introduced by the Irish government which has eased the pressure for pharmacists and doctors. Prescriptions are now valid for 9 months, which makes it easier for those who cannot attend their doctor. Email prescription via Healthmail are now valid, and this is one of the main ways we get our prescriptions now instead of hardcopy prescriptions. A lot of things have changed for me over the past two months. It is hard not being able to meet up with your friends and family at the

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weekend, or go out for dinner or go to the cinema. Currently we are only allowed out within a 2km radius. I play Gaelic football at a county level and we used to train four to five times a week before the lockdown happened so it is difficult to motivate yourself to keep the training up by yourself. I would never have imagined any of this to happen while I was on placement, but even though it has been challenging and stressful at times, I am learning a lot and developing as a person and pharmacist. The support I have gotten from my friends, family, the community and RCSI has helped me immensely throughout this challenging time. Looking forward to our pre-reg over the past few years, I don’t think I, nor any of my fellow classmates imagined a final year placement quite like this. Rush hour traffic has disappeared and instead, we walk to work on deserted streets, often alone. It’s a reminder that we are among the country’s few ‘essential workers’ and that we have an important role to play in the COVID-19 crisis. The norm has gone out the window and instead we’re having to adapt and find new ways of practising our Core Competency Framework competencies. Everything we thought we knew, changed overnight. E-prescribing

is now the norm, with most scripts coming through Healthmail. There are no longer patients in the shop to counsel. We mainly counsel patients over the phone now. Similarly, our classmates in hospital placement settings have had to think of novel ways to counsel patients in order to minimise patient contact on the wards, including written counselling sheets for the patient to take home. We chat about how this will all soon be over, however, it’s likely that these phone calls may be the only way we communicate with our patients over the next few months and our pre-reg training may be over by the time things return to normal. We may not get the chance to see or chat with some of our elderly patients in the pharmacy again but social distancing is the sad reality that is necessary to keep all our patients safe. As students, we had to grow into our roles fast and take on more responsibility as pharmacies became inundated with panicked requests for hand sanitiser, face masks and multiple months’ supply of medications. Patients have been frustrated and worried about the pandemic and it’s been difficult to put minds at ease. They often don’t understand the medicine supply chain and why

"As students, we had to grow into our roles fast and take on more responsibility as pharmacies became inundated with panicked requests for hand sanitiser, face masks and multiple months’ supply of medications"


11 Ellen Gilmartin, final year pharmacy student in Trinity College Dublin

and pharmacy colleagues, the last few weeks would have been extremely difficult. We will be forever indebted to them for their incredible knowledge and support throughout our final placement. Nothing could have prepared us for the worldwide pandemic that has emerged over the last few months, but we have managed to rise to the challenge. In fact, some students are thriving in the challenging work environment. We’ve learnt some valuable lessons that will no doubt stand to us when we qualify at the end of this year. it’s not appropriate to supply them with several months of their prescription medicines at once. We’ve been working longer hours, extra days and delivering medicines to the most vulnerable after work. We’ve learned pretty quickly just how important the role of the pharmacist is and how entire communities rely on us. It’s rewarding to know that our work matters and that we too are on the frontline, contributing to the national effort in the fight against Coronavirus. We’ve lost some of our patients, a stark reminder of the threat that COVID-19 presents. Some students have family members who have received a COVID-19 diagnosis or family members at home with underlying illnesses, and they continue to put themselves at risk in order to put their patients first. Others have had to self-isolate while continuing to write a thesis and keep up with academic modules online. We’ve been juggling it all but ultimately it is preparing us and equipping us with the necessary skills we will need when we qualify as pharmacists. After a day’s work on placement, our evenings consist of zoom meetings with our college groups planning and executing our research projects. We’ve settled into our ‘new norm’ and it’s nearly hard to remember what life was like pre-COVID-19. Although we have remained on placement in what can only be described as a scary time, our School of Pharmacy has supported us and reminded us just how crucial the role of the final year pharmacy students is. Without the amazing support of our Senior Preceptors

As pharmacy students, patientcentred care remains our number one priority. Many of us have gone above and beyond and put our patients’ needs ahead of our own and we will be better pharmacists for it. I’m very proud of all my fellow classmates who have stepped up to the plate and accepted the challenge that COVID-19 has presented. I look forward to standing alongside them and qualifying as pharmacists in December when we can look back and realise how far we’ve come.

"Some students have family members who have received a COVID-19 diagnosis or family members at home with underlying illnesses, and they continue to put themselves at risk in order to put their patients first" PHARMACYNEWSIRELAND.COM


12

News

Lessons from Italy Italian Pharmacist Carlotta Castagneris has been working as a Pharmacist near Turin, one of the hardest hit areas of Italy during the Covid-19 pandemic. Pharmacist Carlotta with her Pharmacy team

Carlotta Castagneris, Pharmacist, Turin

Here Carlotta Castagneris speaks to Irish Pharmacy News about what impact the experience has had on her and her pharmacy and shares lessons learned as they move into the reopening phase just ahead of Ireland. Carlotta has been a pharmacist for almost 7 years, having began working in her family’s rural pharmacy in 2014. Two years later she took on the role of Director of the pharmacy and now has three more businesses, all of them rural. “Our pharmacies are all based near Turin, in the north of Italy, in small towns. We have a strong loyal customer base. The original pharmacy where I started my profession has been in our family since 1957,” she explains. Reflecting on the situation as the Covid-19 pandemic approached, she says, “We really didn’t know what to expect but since the very beginning, that is since patient one, at the end of February, we began to work with gloves and masks. “We also received numerous calls from customers asking, ‘don’t you think it’s too much? Surely it’s just a flu, you are scaring people.’ But to us, safety was the most important thing. Looking back at how the situation evolved, we were right.

“During lockdown our pharmacies had to face many challenges. I remember we couldn’t find any hand sanitizer and we started the galenic production. Then customers wanted Vitamin C to help boost their immune system, and we had the same problem trying to source products, because companies ran out. “When the government started to talk about the wearing of masks to avoid the contagion, in turn we found it incredibly difficult to source them. The market for these was rampant, prices were ridiculously high, and there were issues around certifications. This was really a very stressful time.

needed were oximeters and frontal thermometers. “I can’t say we had a big spike in OTC, but we had very high requests for paracetamol 500. “Furthermore, we encountered issues while trying to find oxygen cylinders; it was extremely worrying not to be able to source them during an epidemic spread. “Luckily Piedmont was not facing the same situation of those near Milan where cylinders couldn't be located at all. In these areas the contagion had hit hard and many of my pharmacy colleagues experienced severe shortages.”

“The day we received the surgical masks, we had a queue of almost 500 meters in front of our pharmacy. It was incredible. I remember looking to my colleagues and we couldn’t believe what was occurring in front of us.

Much like her Irish counterparts, Carlotta has installed plexiglass in every counter of the pharmacy, and employed footsteps lines where customers stop to avoid coming under the security distance.

“After almost 3 months I can say the situation is getting better with masks but it’s pretty hard with gloves. As we talk now I am hoping we will receive them shortly, but after over a month of attempts to source them I am not hugely confident.

Carlotta and her team are currently in Phase 2 of reopening.

“Other items that were very hard to find and that people

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We are now out of lockdown, but clearly nothing in our lives is the same as before. The same can be said of our work environment as we are still working under various security protocols. I see people trying to return to their normal lives.

“With regards to our approach, I can say that I wouldn’t change anything, the protocols we decided to put in place by ourselves since the very beginning have permitted us to feel safe and I think it was an important part not only for our health and for clients health, but also to be always ready to listen to them, to help them while they couldn’t go to a doctor. “I am proud of how we worked, it was hard but we were able to perform to the best of our ability. “I think we are going to see and feel the effects economically of Covid for some time. I also believe we have to be a reference point for the community, during the lockdown Italian pharmacy covered also the lack of the healthcare system, we don’t have to lose our social importance. “I think we need to be ready to follow our customer needs, such as exams they can do in our pharmacies without going to hospital where they fear contagion, to be near them in many ways. “We are building an even stronger relationship with our customers, I think this is the key to keep working in a good direction.”


A personalised service your patients can really smile about Ostomy For more information please contact: Free Phone 1800 540 540 I OstomySource@uniphar.ie I www.uniphar.ie


14

News

Five Year Strategic Plan on Asthma Pharmacists can be instrumental in providing patients with valuable resources to educate them about pharmacologic agents for treating and managing asthma. Asthma Society CEO, Sarah O'Connor

well-being and, without proper treatment, can – and at times does – prove fatal.” Since the coronavirus outbreak, the Asthma Society considers its work to be more critical than ever.

Pharmacists can educate patients about the proper use of inhalation devices, especially newly diagnosed patients who may be overwhelmed with diagnosis and treatment plans. As more treatment options and patient resources become available for controlling asthma, a collaborative effort between health care professionals and patients, coupled with patient education and stressing the importance of patient adherence, is fundamental for effectively controlling asthma.

clear to Sarah that every action taken in the organisation was ultimately an integral step to, not just improving the lives of people with asthma, but saving their lives. The new strategic plan for the organisation brings together its health promotion, education, advocacy, awareness and fundraising functions to deliver the best services possible for asthma patients.

The Asthma Society of Ireland has recently launched Stopping Asthma Deaths in Ireland, the organisation’s new 2020-2025 Strategic Plan, which commits to bringing an end to asthma deaths by 2030. 380,000 people currently have asthma in Ireland. At least one person with asthma dies every week in Ireland due to the disease, with an estimated 90% of these deaths believed to be preventable.

Sarah says, “The core focus of our work until 2030 will be eradicating asthma deaths. While we do know that the vast majority of asthma deaths are preventable in Ireland, there is not sufficient data to precisely identify what is causing them. This leaves healthcare planners uninformed and patients at unnecessarily high risk. It is critical that the Minister for Health commits to conducting a comprehensive investigation into asthma deaths and to publishing a plan to drastically reduce asthma deaths in Ireland.

As the organisation embarks on its fifth decade, the Asthma Society’s new five-year strategic plan is intentionally ambitious. CEO Sarah O’Connor joined the organisation in February 2018 and has set about making the Asthma Society a force for change in the Irish healthcare landscape. It quickly became

“We know that asthma can be mistakenly considered – including by some patients and medical professionals – a harmless condition experienced in early childhood. Although asthma can be easily managed for many people living with the disease, it can severely impede patients’ physical, mental and financial

“The Asthma Society’s work has become more important than ever in recent weeks, given that a reported 10% of those needing intensive care due to coronavirus have asthma as an underlying illness and a further 22% having another chronic respiratory illness. “In March and April alone, we fielded 2,251 support calls and queries (up from 293 in the same period in 2019); 1,031 appointments were made with our specialist Asthma and COPD Adviceline nurses (up from 489 in the same period in 2019) and 12,810 Asthma Action Plans a crucial element of effective asthma self-management - were downloaded from our website (up from 356 in the same period in 2019). Our website visitors have increased 611% to 470,000 over March/April 2020 (up from 66,619 in 2019). We have redeployed five staff, recruited four additional staff members and doubled our nurse hours to field the surge in calls from concerned patients and their carers. “We also launched our new Beating Breathlessness service during Asthma Awareness Week in May for people with asthma and COPD. This service allows patients with asthma or COPD to message a respiratory specialist nurse to get support, advice and information about their condition. We could not be prouder of the work we are undertaking to help vulnerable patients during the pandemic; we are seeing its impact every day. We are keeping patients safe and well at home.”

Life Long Learning in Pharmacy 2021 Due to the global impact that Covid-19 has had on travel restrictions and mass gatherings the 13th International Life Long Learning in Pharmacy Conference has been postponed until the 27th to 30th of June 2021. A provisional programme will be available to view on the Irish Institute of Pharmacy website in the coming weeks and the organising committee hope to reopen submissions for later this year. “We hope for it to be an excellent opportunity to reconnect with friends and colleagues after such challenging and unprecedented times and we look forward to welcoming you all to Dublin in 2021,” they say.

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Blood Pressure Research Research completed in NUI Galway has shown that lowering blood pressure by taking blood pressure medications reduces the risk of developing dementia and cognitive impairment by 7%. Fourteen randomised controlled trials (96,158 participants) were included in this systematic review and meta-analysis. Blood pressure lowering with antihypertensive medications reduced the risk of developing dementia or cognitive impairment by 7%, and cognitive decline also by 7% over a four-year period. “When you consider how common dementia is in the population (50 million people worldwide), effective treatment and control of hypertension would have a major impact on preventing dementia. Our findings emphasize the need for more effective screening, prevention, and treatment of hypertension, which remains suboptimal in Ireland”, explains Dr Conor Judge, joint first author and Wellcome Trust Health Research Board Irish Clinical Academic Training (ICAT) fellow. This study aimed to gather all the evidence from previous trials of blood pressure lowering medications and estimate how much the risk of dementia can be reduced by taking blood pressure lowering medications in people who are diagnosed with high blood pressure. Blood pressure lowering reduces the risk of stroke and heart disease. Prevention of dementia can now be added to the benefits of treating hypertension. Dr Michelle Canavan, Consultant Geriatrician at Galway University Hospital, and senior author of the paper, commented: “Prevention of dementia is a major health priority. We know from previous research that a major concern of older people is developing dementia. The message from this study is simple: Get your blood pressure checked. If it is high, it can be readily treated with lifestyle changes and medications. We would hope that our study will heighten awareness of the importance of controlling blood pressure to maintain “brain” health, combined with a healthy lifestyle.”


Genuair -has it ‘clicked’ yet? ®

The ONLY prefilled inhaler with visual and audible feedback for confirmed dose delivery 1-4

Genuair - a simple to use inhaler for patients with COPD 4

LAMA + LABA

LAMA Abbreviated Prescribing Information Eklira® Genuair® 322 micrograms inhalation powder. Please consult the Summary of Product Characteristics (SPC) for the full prescribing information. Presentation: Inhalation powder in a white inhaler with an integral dose indicator and a green dosage button. Each delivered dose contains 375 µg aclidinium bromide equivalent to 322 µg of aclidinium. Also, contains lactose. Use: Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage: For inhalation use. Recommended dose is one inhalation of 322 micrograms aclidinium twice daily. Patients should be instructed on how to administer the product correctly as the Genuair inhaler may work differently from inhalers used previously. It is important to instruct the patients to read the Instructions for Use in the pack. No dose adjustments are required for elderly patients, or those with renal or hepatic impairment. No relevant use in children and adolescents. Contraindications: Hypersensitivity to aclidinium bromide or to any of the excipients. Warnings and Precautions: Stop use if paradoxical bronchospasm occurs and consider other treatments. Do not use for the relief of acute episodes of bronchospasm. Use with caution in patients with myocardial infarction in the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, or hospitalisation within the previous 12 months for heart failure functional classes III and IV. Dry mouth, observed with anticholinergic treatment, may be associated with dental caries in the long term. Use with caution in patients with symptomatic prostatic hyperplasia or bladder-neck obstruction or with narrow-angle glaucoma. Do not use in patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Interactions: Do not administer with other anticholinergic-containing medicinal products. No other interactions expected. Please consult the SPC for more details. Fertility, pregnancy and lactation: No data on use in pregnancy. Risk to newborns/infants cannot be excluded. Consider risk-benefit before using during lactation. Unlikely to affect fertility at the recommended dose. Side-effects: Common (1-10%): Sinusitis, nasopharyngitis, headache, cough, diarrhoea, nausea. Uncommon (0.1- 1%): Dizziness, blurred vision, tachycardia, palpitations, dysphonia, dry mouth, stomatitis, rash, pruritus, urinary retention. Rare (0.01-0.1%): hypersensitivity. Not known: angioedema, anaphylactic reaction. Pack sizes: Carton containing 1 inhaler with 60 unit doses. Legal category: POM Marketing Authorisation Number: EU/1/12/778/002 Marketing Authorisation holder: AstraZeneca AB, SE151 85 Södertälje, Sweden. Marketed by: A. Menarini Pharmaceuticals Ireland Ltd., Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin A96 T924. Further information is available on request to A. Menarini Pharmaceuticals Ireland Ltd. or may be found in the SPC. Last updated: May 2018

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 to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www.hpra.ie, e-mail: medsafety@ hpra.ie. Adverse events should also be reported to A. Menarini Pharmaceuticals Ireland Ltd. Phone no: 01 284 6744. Date of item: October 2019. IR-BRI-17-2019

References:

1. MIMS Ireland October 2019 2. Eklira Genuair Summary of Product Characteristics, last updated February 2018 3. Brimica Summary of Product Characteristics, last updated August 2019 4. Magnussen, H et al. COPD. 2019 Apr;16(2):196-205

Abbreviated Prescribing Information Brimica® Genuair® 340 micrograms/12 micrograms inhalation powder. Please consult the Summary of Product Characteristics (SPC) for the full prescribing information. Presentation: Inhalation powder in a white inhaler with an integral dose indicator and an orange dosage button. Each delivered dose contains 396 µg aclidinium bromide (equivalent to 340 µg of aclidinium) and 11.8 micrograms of formoterol fumarate dihydrate. Also, contains lactose. Use: Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage: For inhalation use. Recommended dose is one inhalation of 340 µg/12 µg twice daily. Patients should be instructed on how to administer the product correctly as the Genuair inhaler may work differently from inhalers used previously. It is important to instruct the patients to read the Instructions for Use in the pack. No dose adjustments are required for elderly patients, or those with renal or hepatic impairment. No relevant use in children and adolescents. Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings and Precautions: Do not use in asthma. Stop use if paradoxical bronchospasm occurs and consider other treatments. Do not use for the relief of acute episodes of bronchospasm. Use with caution in patients with myocardial infarction in the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, or hospitalisation within the previous 12 months for heart failure functional classes III and IV. Discontinue if increases in pulse rate, blood pressure or changes in ECG occur. Use with caution in patients with a history of or known prolongation of the QTc interval or treated with products affecting the QTc interval. Use with caution in patients with severe cardiovascular disorders, convulsive disorders, thyrotoxicosis and phaeochromocytoma. Hypokalaemia may occur, is usually transient and supplementation not needed. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment. Use with caution in patients with symptomatic prostatic hyperplasia, urinary retention or with narrow-angle glaucoma. Dry mouth, observed with anticholinergic treatment, may be associated with dental caries in the long term. Do not use in patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Interactions: Do not administer with other anticholinergic and/or long-acting β2-adrenergic agonist containing medicinal products. Caution in use with methylxanthine derivatives, steroids, non-potassium-sparing diuretics, β-adrenergic blockers or medicinal products known to prolong the QTc interval. Please consult the SPC for more details. Fertility, pregnancy and lactation: No data on use in pregnancy. Consider risk-benefit before using during lactation. Unlikely to affect fertility at the recommended dose. Sideeffects: Common (1-10%): Nasopharyngitis, urinary tract infection, sinusitis tooth abscess, insomnia, anxiety, headache, dizziness, tremor, cough, diarrhoea, nausea, dry mouth, myalgia, muscle spasms, peripheral oedema, increased blood creatine phosphokinase. Uncommon (0.1- 1%): Hypokalaemia, hyperglycaemia, agitation, dysgeusia, blurred vision, tachycardia, electrocardiogram QTc prolonged, palpitations, angina pectoris, dysphonia, throat irritation, stomatitis, rash, pruritus, urinary retention, increased blood pressure. Rare (0.01-0.1%): Hypersensitivity, bronchospasm, including paradoxical. Not known: anaphylactic reaction, angioedema. Pack sizes: Carton containing 1 inhaler with 60 unit doses. Legal category: POM Marketing Authorisation Number: EU/1/14/963/001 Marketing Authorisation holder: AstraZeneca AB, SE-151 85 Södertälje, Sweden. Marketed by: A. Menarini Pharmaceuticals Ireland Ltd., Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin A96 T924. Further information is available on request to A. Menarini Pharmaceuticals Ireland Ltd. or may be found in the SPC. Last updated: October 2019 This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@ hpra.ie. Adverse events should also be reported to A. Menarini Pharmaceuticals Ireland Ltd. Phone no: 01 284 6744.


16

News

Patients can take Ibuprofen, say officials A new and updated position by local, European and indeed global health experts, has confirmed that patients can take paracetamol or ibuprofen when self-medicating for symptoms of COVID-19, such as fever and headache. review of NSAIDs in patients with Covid-19. “At present there is no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs,” the study concluded. Key considerations when recommending ibuprofen • You should continue to consider a patient’s individual risk factors, including any history of cardiovascular and GI illness or known renal impairment • Your patients should use the lowest effective dose of ibuprofen for the shortest duration necessary to control symptoms This comes following reports raising questions about whether NSAIDs could worsen coronavirus disease, which a number of organisations have stated is not the case. Community pharmacists will welcome the advice, as it reassures those using medicines such as ibuprofen and paracetamol and help stop the spread of misinformation. The position has been confirmed across the Health Service Executive (HSE), Health Products Regulatory Authority (HPRA) and the European Medicines Agency (EMA). The HSE advised anyone with Covid-19 to 'continue to take any medication they were already taking, unless told not to by a healthcare professional. This includes anti-inflammatories (NSAID) such as ibuprofen, naproxen or diclofenac.' In response to information about anti-inflammatory medication and Covid-19 circulating in media and on social media, Dr Colm Henry, Chief Clinical Officer of the HSE advised, “It is okay to take paracetemol and an anti-inflammatory like ibuprofen at the same time. There is no evidence to stop any medication at this time.”

Scientific Evidence

Medicines Safety

Alongside the World Health Organisation (WHO), US Food & Drug Administration (FDA), the EMA and various other health authorities have issued statements acknowledging an absence of conclusive scientific evidence on this topic.

Safety remains a priority. Ibuprofen is a well-established medicine with a good safety profile that has been used as a self-care fever and pain reducer for more than 30 years.

“There is currently no scientific evidence establishing a link between ibuprofen and worsening of COVID 19. EMA is monitoring the situation closely and will review any new information that becomes available on this issue in the context of the pandemic,” stated an EMA spokesperson. The EMA recommends that, in the treatment of COVID-19 infection, patients and healthcare professionals should consider ‘all available treatment options including paracetamol and NSAIDs.’ In line with EU national treatment guidelines, patients and healthcare professionals can continue using NSAIDs (like ibuprofen) as per the approved product information. The EMA further adds that “there is currently no reason for patients taking ibuprofen to interrupt their treatment. This is particularly important for patients taking ibuprofen or other NSAID medicines for chronic diseases”.

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A statement from HPRA confirms, “In relation to prescription medicines, patients should not stop taking these on foot of media reports, which may be unsubstantiated, and should instead seek the advice of their doctor should they have concerns. The advice of pharmacists should be followed regarding use of over the counter medicines.” In April, the World Health Organisation carried out a

• Patients who have been prescribed NSAIDs as a treatment for a long-term condition, such as arthritis, should be advised to keep taking these medicines as normal • Adult patients who take low-dose 75 mg aspirin regularly for prevention of heart attacks or for vascular disease are urged to continue to do so • You, your patients and carers should report any suspected side effects from a medicine. Please refer to the Patient Information Leaflet or Summary of Product Characteristics for further detail on reporting of side effects’.


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18

COVID - Industry

Light

after Lockdown

01 27

May

March

27 March Everyone told to stay at home

24

March

1 May Ireland has set out a roadmap of five stages for easing lockdown. Taoiseach Leo Varadkar calling it a “journey to a new normal”

24 March All non-essential shops closed. Schools, colleges, childcare had closed 12th March after St Patrick’s Day parades cancelled 9th March

29 Feb

29 February Ireland’s first case of Covid-19 was confirmed

What impact has Covid-19 had on the industry and what will the future look like? How organisations and brands have behaved during Covid-19 will be remembered. Just last month, the Irish government announced its roadmap for lifting restrictions imposed by lockdown in the wake of Covid-19. Gradually, businesses have been opening up, socialisation is starting to re-emerge.

welcomed the emergence from lockdown and now it is time to navigate this new world. How organisations and brands have behaved during Covid-19 will be remembered.

The roadmap provided a degree of certainty that, whilst the global pandemic continues to abate, a new normal will be borne. The future will look very different.

In this exclusive report, Irish Pharmacy News speaks to market and industry leaders, Ireland’s two leading wholesalers and the pharmacy profession, to gauge their thoughts and opinions.

The pharmaceutical industry and pharmacy profession have

During the Covid-19 pandemic, many across the industry have

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been highly responsive. OTC and pharma organisations have rallied to enable the supply of key medicines across borders, manage workforce safety, and handle evolving government restrictions. All while beginning to prepare for new vaccines and therapeutics. They have also rallied in helping to support those at the frontline, at which community pharmacists have been prominent. With these initiatives established, companies can begin taking stock of what lies ahead. Given the shifts that have taken place seemingly overnight in response to the immediate crisis, many are also turning their attention to recovery and the path to the next normal. This will likely bring about fundamental changes. Face-to-face established

relationships and communications were key in Ireland. How will this look in a landscape dominated by social distancing? The disruptive effects of coronavirus placed enormous strain on the global supply of medical products, increasing the risk of shortages. As consumers went into a shopping frenzy, pharmacy shelves were stripped of household staples ranging from paracetamol and ibuprofen to nasal congestion sprays and throat lozenges. But after initial supply logistics subsided, adoptions of a new normal were fast-paced. A new meaning to the word ‘teamwork’ really came into play as internally, companies worked together to rapidly employ new working strategies.


19 Tanya O'Toole, Head of Sanofi Consumer Healthcare Ireland business was very seriously impacted owing to a lack of customer footfall and serious restrictions of customer access to pharmacy shops,” he says. “We increased our stock of all relevant products. Throughout this time, all of our pharmacy sales representatives have worked tirelessly to keep up and maintain contact with customers, keeping them abreast at all times of our stock and supply levels. In addition, we developed e-calling and e-information detailing of our products.”

“Our utmost priority is to ensure the safety of our employees around the world. Our crisis committee has continued to constantly assess the evolution of the pandemic and take appropriate measures, in full compliance with the guidelines offered by governments and health authorities" “

T

here’s been huge levels of collaboration between local, regional and global Sanofi teams and with our suppliers throughout the world, to ensure that patients and consumers maintain access to the OTC products they need, when they need them,” says Tanya O’Toole, Head of Consumer Healthcare Ireland with Sanofi. “You need to build a clear picture of the changing market needs through closely working with all stakeholders (customers, regulators, distributers, government, HSE, etc…) Given the diversity of our sourcing so far we’ve managed to avoid supply disruptions. “Our utmost priority is to ensure the safety of our employees around the world. Our crisis committee has continued to constantly assess the evolution of the pandemic

Clonmel’s distribution and support staff continue to operate as normal from their distribution centre with an altered working environment.​

“We managed to ensure there were no restrictions on orders, with all dispatched within 3-5 days at the height of the crisis. I am immensely proud of what the team achieved. Alan continues, “We have spent the last two years planning for Brexit, directing supply from the UK to Europe. Fortunately, we had much of this in place pre Covid-19 so I feel we are in a strong position with no stock issues comparatively with some of our competitors. This combined with co-operation from the brand owners puts us in a good position. “Several of our products are in huge demand; such as Nelsons Rescue Remedy, A.Vogel Herbal Remedies, Optibac and Sambucol, as these are well

and take appropriate measures, in full compliance with the guidelines offered by governments and health authorities. Our pharmacy sales team are calling pharmacists by telephone instead of in person. We’ve been able to deliver company and product news successfully this way, and the recent launch of Pharmaton Advance Fizz is a good example of that.” Pulling Together Martin Gallagher is Director of Marketing & Business Development with Clonmel Healthcare. He reflects that whilst March and April saw a huge spike in demand for first line Covid-19 medications, such as paracetamol and ibuprofen, the industry was in a strong position to respond, with little or no shortages. “Pharmacy only medicines

Alan Martin, General Manager, Wholefoods

lan Martin is General Manager with Wholefoods. Their workforce commenced working from home in early March, having first ensured the team were established with clear lines of communication. “Wholefoods began as a family-owned business in 1983, and whilst now under PLC ownership we still have a very strong 'family' ethos; the team has really pulled together during this time,” he reflects. “We had the reported spike in demand and sales encountered elsewhere," Alan adds. "With no immunisation, many consumers turned to looking for alternative ways to protect their health and wellbeing.

known natural remedies for stress, cold and flu and can help support the immune system; a key factor to consider when protecting your health against viruses such as coronavirus.” Graham Anthony retained a focus for looking towards the positive. “As with all changes we looked to see opportunities and positive changes we could make both short and long term which will benefit our company, our team and the pharmacies and accounts we supply,” says Tina Buckley, Sales Director. “With immediate effect we allowed pharmacies order smaller quantities of the key products which are recommended by consultants and doctors, Bariederm and Xemose range in Uriage with no delivery charges.”

Martin Gallagher, Director of Marketing & Business Development, Clonmel

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20

COVID - Industry Jeffrey Walsh, Head of Sales, Retail Division, Pinewood

KRKA Ireland adds, “APIs coming from China and India have been an issue and will continue for some time. Luckily for KRKA we manufacture in Europe and we have a very stable supply of raw material and finished product, but we are making up for the shortages of other companies to have continuity of supply.” Varying Impacts

P

inewood Healthcare witnessed a varied impact on their business. Jeffrey Walsh, Head of Sales, Retail Division adds, “We have examples of growth in some ethical lines and this was very evident in March and April, however we are also now beginning to witness a decrease in demand for our OTC range of products as a result of the restrictive measures adopted in order to combat Covid-19. “Pharmacists have managed and maintained these measures highly effectively and have done a wonderful job in making sure patients receive their medication during this process. Supply chain issues have mainly evolved around transportation rather than securing supply but we have seen very significant prices increases for certain raw material and finished goods. We are also deploying more working capital in order to hold more stock and this is impacting on the normal business practices.” Pinewood have adopted a cautious approach in relation to procurement and secured supplies beyond their usual stock holding patterns. “Some products will be adversely affected towards the latter half of the year due to constraints in API or finished good production, particularly where products are being sourced from India and China. We are working very hard to avoid any out of stock situations for our patients and indeed in Pinewood we have moved a lot of our products to European based suppliers,” Jeffrey adds. Since March there has been a decline in market demand which in turn has led to less strain on the supply chain. Keith Sheridan, Sales & Marketing Manager with

Unprecedented Demand

K

ate Fleming Director of Fleming Medical says that they are continuing to receive unprecedented demand for infection control products and therefore the team have been working tirelessly to meet this, supplying PPE to both the community and hospital pharmacy sectors. It is clear, she says, that the sale of PPE products, along with thermometry and pulse oximetry will continue to dominate in drawing footfall into pharmacy, helping to develop and grow these categories. She says, “We are in the business of making sure that our customers are equipped to fight Covid-19 by supplying products which conform to EU safety standards. We take the responsibility of providing these necessary products to pharmacies, healthcare facilities and first-line responders very seriously.

Will O'Brien,Country Manager RB

Country Manager with RB, Will O’Brien reflects that the pandemic brought a sharp shock to the working environment of so many. “Overnight we felt this huge impact internally. The positive surprise however was how quickly we adapted within RB. Our IT structure and commerciality were extremely robust and so we coped very well. It was quite challenging for our Field Sales who could no longer visit pharmacy and carry out face-to-face engagement but again, we adapted and now have embedded telesales relationships in order to still meet the needs of our pharmacy customers. “Our sales reached huge proportions at the beginning and of course, like so many others, we encountered supply issues. The wholesalers were also under severe pressure.”

As Fleming Medical have worked in partnership with their suppliers for many years, they are in a strong position to supply in the event of shortages.

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When Covid-19 began to impact Ireland, and indeed the world, the team quickly revised their business thinking. Virginia Medical have built strong values in customer care and customer base forecasts. Jason Clarke, Managing Director tells us, “We ensured continuity of service by ensuring our relationships across key suppliers were safeguarded. Our virtual sales team have been invaluable and a huge asset in delivering daily demonstrations, training and product support. “Maintaining support of community pharmacies, particularly when dealing with the nursing home sector, is vital; this is when a product is at its best. As we are a small company, strong customer relationships and consolidation are critical to our existence and growth.”

“Our Logistics and Quality team are working closely with our manufacturing partners to secure continuity of supply of compliant product. Worldwide demand has disrupted the supply chain for PPE with many new entrants to the market, we only purchase from trusted certified suppliers to ensure continued confidence in the MEDICARE brand.” Kate adds, “Interestingly, we have witnessed an increase in sales of sport supports and footcare as consumers are clearly adapting to new lockdown rules and regulations and so are exercising outdoors more.”

Virginia Medical Supplies are renowned for their innovative thinking in sourcing solutions for improving medication compliance and adherence as well as reducing wastage. With the health and wellbeing of patients, and saving time for pharmacists in dispensing medicines in mind, they developed the Nu-Life Monitored Dosage System (MDS) and MAMA, (Medication Administration Mobile Application).

Jason Clarke, Managing Director Virgina Medical

Sales have really dominated with the company's salt based Air Purifier, Salin©Plus, a noninvasive natural salt therapy. This is a fantastic product for those who suffer from debilitating respiratory issues such as asthma, sinusitis and COPD for example and offers a huge marked improvement in quality of life.”


21 Reviving the Industry is Key Revive Active is an Irish super supplement brand with its own dedicated manufacturing plant in Mullingar, Co. Westmeath. The company aspires to formulating products that enrich people’s lives using the best quality ingredients, sourced from premium suppliers located around the world.

Keith McLernon, Managing Director, Mclernon Computers Vital Work of Pharmacy

E

verything has changed since March, reflects Keith McLernon, Managing Director of McLernon Computers. “The way in which community pharmacy looks after their patients and manages their business has been totally turned on its head since mid-March. “Contractors and their staff have been under incredible stress – not just trying to keep themselves and their families safe and healthy, but also dealing with exponential increases in dispensing volumes with reduced numbers of staff, questions whether to furlough long-standing members of their pharmacy team and a retail environment which has fallen off a cliff. “Perhaps the only good thing that has come from this global pandemic has been the rightful recognition of the huge amount of work done by community pharmacies, most of which is unremunerated. Indeed, just recently Ipsos MRBI published their ‘who do we trust the most in 2020?’ survey with local pharmacists second only to nurses in the list of professions that people trust to tell them the truth. This public recognition needs to be reflected within Government, and adequate and fair methods of remuneration achieved. “As many IPN readers will know, the team at McLernons hasn’t stopped supporting our customers since the onset of lock down. Our engineers are still making calls, our trainers and sales teams are still working with customers to ensure that they are getting the optimal benefits from their McLernons systems and our Customer Services team have been

continuing to answer your calls and help with your queries, albeit mostly from secure connections in their own homes. “And our team of developers are refining our existing software and designing new programmes to help our customers in these difficult times. Patient downloads of our Medi Marshal patient app, which can be branded for individual pharmacies with additional services and online retail opportunities, has been increasing exponentially as it allows for a two-way, trusted communication between pharmacy and patient. “It also allows them to re-order repeat prescriptions, send photos or scans of current prescriptions and receive updates on when their medication is available for collection. Demand for VMS

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here are steps which consumers can take to help support their natural defences, which Sinead Mitchell, Commercial Manager with Pharma Nord Ireland knows well. With both its production facilities and company headquarters located in Denmark, Pharma Nord has a large operational field. Ireland Team members changed their way of working from midMarch. Reps and Educational trainers worked from home servicing pharmacies on the phone and the web-store was able to continue sending out products.

Daithí O’Connor, Founder and MD of Revive Active says, “When Irish media first reported on the outbreak of Covid-19 in early January 2020, Revive Active had the foresight and capability to stockpile ingredients as a preventative measure, to ensure that manufacturing and delivery to Daithí O’Connor, Managing our retailers and consumers would Director, Revive Active not be impacted if the virus spread to Europe. When this was done, we had no idea of the magnitude of what was going to be facing us in Ireland in a few short months. This stock piling ensured our supply chain was not affected and this was achievable due to the strong relationships we had built with our suppliers over the last number of years. “When Covid-19 arrived in Ireland, due to the nature of our products we did experience an increase in demand across the entire range but in particular our products that support the immune system; Revive Active, Zest Active, Teen Revive and Junior Revive. “As a result of the stockpiling we carried out in early January our manufacturing plant was capable of meeting the increased demand and we immediately took steps to ensure that the welfare of our staff is maintained and that all government advice and measures were followed, while still maintaining a suitable service level to our customers. “Staff who can work from home have done so since mid-March, which was approx. 70% of the workforce. Technology has provided the tools to continue the level of service to our retailers throughout this unusual time and we are finding ways to work smarter. We have continued to invest in marketing, running a national advertising campaign for the month of May which included TV, Radio, Digital and Print Media, our customer service team have continued to provide the same high standards of service and our sales team are supporting our retailers daily. “There will be a seismic shift in the way people think about health and this will include consideration of supplementing their diet but also talking to their local pharmacist to get expert advice and to treat ailments before letting them develop. In the short-term retailers who have a strong online presence will benefit but as the country opens face-to-face interaction with the local pharmacist will become as important. “Our retailers are key to our business in Ireland and Revive Active will continue to advertise nationally to keep the brand in focus, driving consumers to our retail partners and keeping the brand at the forefront of consumers’ minds. We are in this together.”

“The demand for vitamin, mineral and supplement products was huge, and did cause some stock issues,” Sinead says. “However the factory in Denmark was hugely efficient at increasing production and getting this sent to us in a time when all of Europe were asking for immune boosting supplements.

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22

COVID - Industry “The positivity and

Tackling the Challenges

support of everyone

Managing Director of Ocean Healthcare, Graham Stafford is tackling Covid-19 and the challenges it brings head-on.

and willingness to

Having established the company some 17 years ago and surviving the recession of 2008, Ocean Healthcare's strong heritage in sales has meant they were more than ready when lockdown came into force.

work in a new way, has been phenomenal.”

Ocean Healthcare is a dynamic privately owned business. Established in 2003, they offer sales, marketing and distribution solutions to healthcare brand owners. Graham believes the industry needs to focus on its re-emergence. “All of our sales team remain on board, working remotely,” he says. “We have been keeping in close contact with our customers, calling, emailing and increasing our digital output. “We offer total distribution to the pharmacy and grocery channel in Ireland. Our team has established long standing relationships with key players in the retail trade. We supply over 2000 pharmacies throughout the north and south of Ireland either directly or indirectly via wholesale. We call directly on 70% of pharmacies in Ireland. We also supply all of the major grocery multiples. “The team have increased their support to pharmacy, training and educating them on our portfolio and offering total brand management in order to best help them drive traffic to their own online platform presence. “I have a great belief in strong brands and we hold an excellent portfolio so I will be continuing to invest in these and advertising them. “Community pharmacy has experienced a particularly difficult 12 weeks, with social distancing in place and the measures they have to had to implement to counteract this. It is important they open back up; not just pharmacies but the retail sector as a whole. “Pharmacy is the central part of any community for offering health and wellbeing advice. They are play a crucial role and so for the industry, for the profession and for the general population, access must be available once more.”

Sinead Mitchell, Commercial Manager, Pharma Nord, Ireland

“As the demand increased, so too did our web store sales, ensuring appropriate PPE was utilised at all times, we still managed to run this operation from Ballycoolin. The positivity and support of everyone and willingness to work in a new way, has been phenomenal.” Pharma Nord in Ireland currently have 4 sales field representatives working from home and are focusing on training over the phone. “We are also carrying out phone webinars for pharmacies although I find the personal touch of one-to-one communication is most effective for relationshipbuilding,” Sinead adds. Paul Hatton is the National Field Sales Controller with Perrigo Ireland. With the Covid-19 pandemic confirmed in Ireland from early March Paul, and his team, have been working through a 10-week training program which was designed with two goals in mind;

Paul Hatton, National Field Sales Controller, Perrigo Ireland

To help keep the Sales Team engaged and motivated and To provide an opportunity for growth through competency based training programs designed to meet a defined need.

Graham Stafford, Managing Director of Ocean Healthcare

“Our existing relationships with customers are very strong” he says. “We have been speaking with our customers throughout the lockdown and have conducted our own in-house research to form a base of thinking as to what our customers want and need from us in order to support them now and into the future.” He also referred to some of the

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interactions they have been having with customers. “We’ve had great success engaging our customers in E-Training around certain brand and category areas – the main focus has been on our newly launched Nytol, in the sleep category, and of course our Allergy range of Beconase and Becodefence considering the season that’s in it. “It’s important for us to listen to our customers and understand their needs as this helps us react to what pharmacies need moving forward. The future is a little


23 unknown but we’re a resilient bunch and we’re well capable of adapting to new ways of working for the foreseeable future. “We hope to better reconnect with all of our customers over the coming months in whatever way possible and we want to ensure that our customers, and consumers, continue to have access to our full range of products in the Irish Market.” Boom of the Self Care Market

O

ver the last few years, an increase in self-care interventions has been shifting the way health care is perceived, understood and accessed, and adding to the many medicines, diagnostics, and technologies available for people to use themselves. As consumers are adopting a more proactive approach to managing their own health, Ambermed saw an increase in sales for the first quarter of this year. Director Jon Hayes tell us, "It was in fact the best we have seen in our business history. Sales have continued to grow through sales via our website also." On the current pandemic siutuation, Jon reflects, “I myself had many a sleepless night worrying about the Covid-19 situation, and the surrounding contamination issues, such as packaging-to-individual. I was working in our warehouse cleaning boxes myself, often putting in 15hour days, so that I had the peace of mind to know our stock was safe to be dispatched.”

consumer landscape will change, if the sellers adopt a realistic approach, I’m convinced that the buyers will respond positively. We have to seek out the opportunities and this quote from my business hero the late, great Lee Lacocca comes to mind: “We are continually faced by great opportunities brilliantly disguised as insoluble problems.” “Without doubt we need to have open minds and not only be prepared for change but embrace it. I’ve no reason to believe that the world is about to end, so my view is to make sure your products and service are second to none, and make your customers happy, whoever those customer may be. “Customer focus is crucial to your success, that way we’ll thrive and not just survive. No doubt Covid-19 has given us all time to consider where we are in life and no matter how good we think we are, there’s always room for improvement and now is the time to do just that. So up your game folks, let’s not stagnate in the negativity and remember, even diamonds have to be polished now and again!

A new normal is now starting to emerge but with it brings new challenges. Returning to browsing in pharmacy will be a challenge if Ireland is dominated by COVID-19 in 12 months time,” Tanya O’Toole of Sanofi believes. “We will need to find new ways to help support customers, patients and shoppers. One area of OTC healthcare that may present an opportunity for further development is eCommerce, as there are a lot of Irish pharmacies with websites.

“I’ve no doubt the future will be different. However, I’m an optimist by nature and we’ll all have to change to some degree. While the

“We have all lived through the fake news and false information across all platforms. Consumers are now much more aware of its propensity, particularly with regards to the healthcare profession.

“The Impact of COVID is still uncertain. More than ever companies in Ireland like Sanofi will need to learn from other

“I believe facts and figures and expertise will once again come back to the fore. Pharmacists are central sources of trust and I believe the role of the pharmacist will, in the future, be around much more value added products and advice. “Ireland is behind the curve when it comes to e-business and script fulfilment and this is where we now must step up to the plate.”

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Pinewoods Jeffrey Walsh says it’s time to be proactive. “In terms of the pharmaceutical landscape I suspect a new normal will progress to facilitate additional footfall back into the pharmacies, if within the next 6 months this is perhaps still restrictive in nature, companies will need to be very proactive and engage multiple strategies especially relating to new products launches and ensuring continuity of supply. Reaching your target audience will require using several platforms.

Tina Buckley, Sales Director, Graham Anthony Distribution

I

“I believe we are seeing a significant move towards food supplements and personal health and hygiene. This will continue to grow.”

“Within Pamex Limited we have very dedicated sales teams covering different sectors. Covid-19 gave us all an opportunity to increase our knowledge regarding products and indeed to further our education about what our customers want from Pamex, and how we can meet those needs.

Will O’Brien of RB adds that they are being led by what their pharmacies want. “There is no sense to outlining our future approach, if it’s not something that works for, or supports, pharmacy. There is scope to look at how things have been done before with a view to how we should be working now.

raham Anthony’s Tina Buckley says, “With all companies trying to retain their workforces, save costs to offset the loss of turnover, and looking to build and invest in their business they may need supplier support. Communication is so important. Meeting the buyers in pharmacies and going through new launches, special offers and training the teams will always be key for Graham Anthony Distribution.”

"This market sector is definitely increasing, bringing further footfall into community pharmacy. More and more consumers are aware of their own health and the huge benefits of self-care and in protecting your immune system.

Managing Director of Pamex Ltd, Tom Murphy is an optimist at heart.

countries, other industries and most important of all we will need to listen to customers, patients and consumers to understand what the future of the OTC business could look like to meet their needs.”

Future Landscapes

"If the Irish economy can resume operations as quickly as possible, I believe the future is extremely promising for community pharmacy" Pamex Managing Director, Tom Murphy

also think it is very important that we work very closely with our customers to see how we can assist them along with all relevant stakeholders over this period of time. Costs will certainly rise as a result of Covid-19 but opportunities will exist to increase demand for products in general. “I think planning for additional resources will be crucial particularly associated with above and below the line advertising for O.T.C products. Examining alternative platforms and expanding the distribution network would be a pre-requisite in order to get your product viewed by a wider audience. I think adopting plans that fulfil the need of your local pharmacist as well as the large chains is very important and increasingly looking for new trends and vying to be first to market is a must.

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24

COVID - Industry

Visualising the Reality V360° - formerly known as Visualise - provide a range of marketing and media services for brands and retailers, working predominantly across the pharmacy and grocery sectors. “Like all marketing agencies, the last few months have been challenging for us” reflects Eoghan Phelan, Managing Director.

“From Pinewood’s perspective we will increase our research and development capacity to develop additional in-house products. These products could possibly be line extensions for existing products or completely new developments. We have a dedicated research team who will be working on these new products for both the domestic market and export market over the next few years.”

“The closure of all non-essential businesses forced many consumers to transform how they live their daily lives, as well as their purchasing behaviours. This unprecedented situation resulted in many marketing plans being shelved for a variety of economic, logistical, and moral reasons.” Eoghan believes the change is coming as we emerge from lockdown. "Post Covid-19, customers will value engaging purchasing experiences and the challenge for pharmacy retailers, and for brands, is to anticipate and meet these needs. As the initial fear among consumers has now subsided somewhat and we all seek to navigate the post Covid-19 landscape, it is important to continue to communicate to consumers. “Yes, the message may need to be adapted and the channels and formats selected to best engage your target audience may change but it is still imperative to connect with people, and as they continue to adapt their shopping and consumption behaviours they are actively looking for solutions, so let them know how your brand is helpful in their new everyday lives.” “We have seen a tremendous up-turn for clients that have continued to support their products and brands during this period and looking further ahead to what may come, numerous studies have demonstrated that brands who continue to invest in marketing and advertising during recessions are more likely to increase market share both during the recession and afterwards.” Eoghan Phelan, Managing Director, V360°

“Pharmacy staff have a wealth of knowledge about all products and they will be the key to helping patients get what they need.” Ambermed’s Jon believes the future is still bright. “Independent community pharmacy is very important to our business and when 'normality' returns for this sector we are expecting sales to begin an upward trajectory. This is a growing category and we are expecting it to continually grow. “If the Irish economy can resume operations as quickly as possible, in whatever form that may take, I believe the future is extremely promising for community pharmacy.” Martin Gallagher of Clonmel agrees. Pharmacies now need to safely open up customer to their stores – as many patients are left without important OTC medications. The ability of community pharmacists to refill a script has worked well.

Keith Sheridan, Sales & Marketing Manager, KRKA Ireland Keith Sheridan of KRKA concludes, “Until we see an easing of the current lockdown restrictions and a return to post-Covid life it is quite hard to predict the market and how the population will react. People will be very cautious and will be concerned over the coming weeks and months to see if we have a second wave, however with the population mixing again the common illnesses will return and patients will need to visit GPs and pharmacies more regularly so I’m optimistic about the future. “The OTC business has definitely taken a hard hit during the Covid-19 pandemic with most pharmacies restricting access in the pharmacy, however this is starting to change nationwide. “The restrictions of the number of people allowed in the pharmacy at any one time has meant the patient does not have the luxury of shopping around the pharmacy store and purchasing the OTC products. I feel that OTC companies will have to make it very easy for patients to pick their products off the shelves and let the patient know exactly what the product is for so that they can make a quick purchase without wasting time.

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difficult time to ensure continuation of medicines. “As Clonmel have done with our recent 'Thank the Pharmacists' video, I think it’s vital to once again acknowledge the pharmacists and frontline staff who have been working tirelessly on behalf of all.” Solid Foundations Keith McLernon adds that whilst it may be hard to know what is going to happen next, there is much to be applauded. “I wish I had a crystal ball to predict the future for community pharmacy but what were once solid foundations have shifted so quickly that it is hard to know what is going to happen next. One thing that is noticeable is that the speed in which decisions can be made in the Department of Health has quickened dramatically.

“It is important pharmacy reclaims OTC business, as there will undoubtedly have been a shift to mail orders and supermarkets over the last number of months.

“We have been calling for Electronic Transmission of Prescriptions for the past number of years and, indeed, the pilot set up in Mallow using a McLernons protocol was adopted by e-Health Ireland for a national roll out. Surely now is the time that initiatives such as this are extended across the country?

“As with all pharma companies and throughout the distribution chain, there has to be some acknowledgment as to the speed, agility and inventiveness that occurred in a very short and

“No matter what the future holds I would like to assure our customers that McLernons will continue to work hard to support them and help them look after their patients and protect their businesses.


COVID - Wholesalers

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Working Together for Supply and Demand One of the first forecasted casualties of the pandemic was a fear for Ireland’s supply chain. Ireland’s two largest wholesalers United Drug and Uniphar and their teams worked tirelessly with the best endeavours to ensure patients and the public were protected. It has been essential that everyone works together, from manufacturers to wholesalers, to pharmacy professionals and, to consumers. This includes protecting the sustainability of the medicine supply chain and supporting their own customers. of the Irish population is being told to stay at home. Therefore, our efforts to ensure the health and wellbeing of our teams became the number one priority and thankfully, with the support of a caring and conscientious team, we have managed to ride the initial storm and ensure the medicines supply chain is in place and working to normal standards.

Paul Reilly, Managing Director, McKesson Ireland Paul Reilly is Managing Director of McKesson Ireland, which includes United Drug Wholesale. He tells Irish Pharmacy News that whilst the initial market reaction created unprecedented increases in demand for a wide range of OTC medicines, hygiene products and a smaller group of prescription medicines particularly within the community pharmacy sector, they were able to act quickly. “Within our business we endeavoured to ensure equity of access of medicines. Whilst the initial surge in demand created some challenge the Irish pharmaceutical supply chain is robust and supplies are back to normal levels. “United Drug provides a high level of service to our customer base including twice daily deliveries to the majority of community pharmacies and daily deliveries to public and private hospitals across a wide portfolio of products. Whilst we have solid Crisis Management plans in place, and we have experiences of other natural events including storms and heavy periods of snow, there is no doubt the initial phase of Covid-19 created significant pressure within our business. “On the one hand we were dealing with enormous demand whilst also working to ensure a safe and accessible workplace for our teams. This is at a time when most

“The Irish supply chain is robust with many manufacturers holding on average 6-8 weeks stockholding. It is important to note the extensive levels of engagement with all manufacturers, the regulator, Department of Health, HSE and Industry bodies to ensure alignment across the supply chain.” So what does one of Ireland’s largest wholesalers foresee as the future? “The industry has shown that it is both adaptable and flexible and is hungry to support customers and consumers during challenging periods. Introducing new and flexible opportunities to engage including the strong use of digital media to support educational and commercial engagement will definitely be a feature of the new world. At United Drug we work closely and collaboratively with our manufacturer partners to ensure the supply chain is closely aligned to portfolio activities. “On behalf of the Country Board and Senior Management I would like to thank our customers for their continued support and to reassure them that we remain focused and committed to serving the needs of their communities during this pandemic.”

"Introducing new and flexible opportunities to engage including the strong use of digital media to support educational and commercial engagement will definitely be a feature of the new world"

Dermot Ryan, Managing Director, Uniphar Supply Chain & Retail The disruptive effects of COVID-19 have placed enormous strain on the global supply of medical products, increasing the risk of shortages. Uniphar’s Supply Chain & Retail Managing Director Dermot Ryan says the Irish supply chain remained robust and collaboration is key in managing the national supply.

national health infrastructure. I’m proud of that,” Dermot adds. “Pharmacy teams have dealt tremendously well with the crisis and continue to operate on the front line to meet patient needs. We’d like to thank our pharmacy customers both for their custom but also for the service they have been doing for the country, largely unacknowledged.”

“This has been a rollercoaster few months for pharmaceutical wholesaling. In March, we saw a huge spike in retail pharmacy and hospital purchases with all our teams working round the clock to meet the demand. The pharma industry, the HSE, the HPRA, the Department of Health and the wholesalers, we all worked together to make sure that medicines got to patients, through our pharmacy and hospital customers. Our supply chain has remained robust despite the unprecedented pressure. More normal buying patterns are only now slowly starting to return as the economy opens up.’

“I think the COVID-19 crisis is a watershed moment for the industry. We have a strong technology platform across our supply chain from warehouse to pharmacy and a well-established e-commerce platform. This has been critical to managing our supply chain and securing a smooth communication flow right through the pandemic. Across the pharmacy sector, the pace of technological change in the last three months has outstripped the last three years. How people engage with retail pharmacy has and will continue to evolve - technology and e-commerce growth will accelerate. I think we’re going to see a lot more innovation and quicker,” he adds.

‘From the outset, it was essential to protect the health of our staff and ensure continuity of supply. We quickly brought in a range of stringent safety procedures and practices in warehouses, and all Head Office teams worked from home and continue to operate remotely. Our operational teams and all of our warehouse staff, across all Uniphar sites, have been in situ right through this pandemic. We’ve delivered an essential service, done our bit as part of the

“Looking ahead, ensuring product availability is going to be key – short term, focussing on building OTC and antibiotic stock for the impending cold and flu season is critical. Longer term, I think we will continue to see greater collaboration across the supply chain as the industry finds new ways to work. Ireland remains a small market so ensuring security of supply is very important and it’s something we need to work on together.”

"I think we will see greater collaboration across the supply chain as the industry adapts. Ireland remains a small market so security of supply is so important" PHARMACYNEWSIRELAND.COM


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COVID - Profession

The Community Pharmacy Professional and Business Owner Perspectives Community pharmacies are vital to supporting a well-functioning healthcare system. Now, more than ever, pharmacy staff are being leant on by colleagues across the sector as a frontline, patient facing profession to ease pressure on hospitals. The coronavirus crisis has placed unprecedented demand on pharmacy staff and community pharmacies which are still functioning, albeit in a reduced fashion. We take a look here at what impact Covid-19 had on the profession as it moved into Ireland, and what some local pharmacists believe the future of the profession will look like in a post-Covid world.

Community pharmacy has clearly been at the forefront of delivering care, and this is a role Adrian would like to see acknowledged. Acknowledgement of Pharmacy “I see e-Prescribing being developed further. I’m looking forward to working with Allcare in the future on application development. I’d like to see the pharmacist role being acknowledged as being pivotal in primary healthcare delivery. Pharmacies will be at the forefront of vaccine delivery. I also see an increased consultancy role on the horizon.” Peter Weedle Pharmacy, has been a partner of Allcare for over 5 years. Peter is a seasoned clinical pharmacist in Mallow, with a keen eye for innovation and efficiency along with a relentless drive to provide expert pharmaceutical care for patients. Peter told Irish Pharmacy News that the Allcare team are planning to ramp up delivery and implementation of the flu vaccination this Autumn. “This is of upmost importance for the community at large for the months ahead,” he says. “The arrival of COVID-19 on our shores has meant that pharmacists have had to adapt in record time to such challenges as time pressure, changes to store lay-out and security of supply. “My big issue was not to let my patients and customers down. That’s where I really thank God for Allcare. Their buying power, backed by a national wholesaler

Adrian and Wendy Crehan, Allcare Pharmacy, Galtymore Road, Dublin

Adrian Crehan runs Allcare Pharmacy on Galtymore Road, Dublin and has been a partner of Allcare for three years. Looking at the changes he had to implement to get pandemic-ready he tells us, “Time has been the main pressure point for us. We had to obviously change store layout and erect screens, as well as heighten all our hygienic measures. It’s also taking a lot more time to serve customers. Naturally, some customers were in panic buying mode so we had to assure them that we had no issue with supply.”

In order to adapt to meet these challenges he adds, “Significant changes in staff rostering were necessary, as well as altering our store lay-out. Splitting the team into two worked really well and continues to work well. Hygiene of course has become of upmost priority. E-prescribing has been fast-tracked which is welcome. “Security of supply has been really important. As well as the usual supports, the support of our territory manager was invaluable during this time. We were offered invaluable guidance throughout.”

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Peter Weedle, Pharmacist, Mallow, Cork


27 has proved second to none during this time, and has without doubt been enabled me to provide all the necessary medicines and services to all customers on time. We have a robotics system which fills our trays. With Allcare’s supports we were able to manage 19,700 prescriptions items in the month of March. Without hoarding, we could feed our robot exactly what was required. Because critical business items were taken care of, I had time as a pharmacist to do what I do best, and that is to care for my customers and give them time and reassurance. “Our territory manager has helped immensely. She was always at the end the phone, at any time to reassure us. We were supplied with our regular RWA reports which help us significantly. Alternatives and generics for market shortages were arranged with ease. At the most critical time in our business history, the team has provided all the supports necessary to give us complete peace of mind.” Technology is the future, Peter also affirms. “Primary care is at the centre of every town, and pharmacies play more than ever a pivotal part our nations’ primary

Jane Brennan, Pharmacist, Brennan's Life Pharmacy, Donabate

normal practices were abandoned - the GPs closed their doors, and worked by phone. A&E was effectively closed," says Jane Brennan of Life Pharmacy in Donabate. “We had to restrict access to the premises to reduce the risk to our staff. This created new demands on our front of shop staff in trying to cater for patients’ needs effectively from the front door. “We split our staff into two teams to reduce the very real risk of the entire team going down in the event that one staff member became ill with Covid 19. This meant that our teams were working 12 hour days under enormous work-loads. “We had to adapt very quickly to new work practices. GPs were sending in hard copy scripts in bulk when it suited them, and by fax, and by mail. Some patients were told that their script had been sent when it hadn’t.

" Furthermore, the pharmacist will take a thought leadership role as has been the case throughout this pandemic. I believe there’s a huge future for pharmacists to develop their role in the community" care system. Technical innovation will be key for future adaptation. Increased focus on consultations and patient care can be facilitated via patient apps, e-prescribing and video links. Furthermore, the pharmacist will take a thought leadership role as has been the case throughout this pandemic. I believe there’s a huge future for pharmacists to develop their role in the community,” he says. Providing Professional Service “In the beginning, we had the enormous strain of continuing to provide a professional pharmaceutical service when all

“Phones were incredibly busy, with patients phoning repeatedly looking for scripts. We adapted the practice of phoning them once we had received scripts for them, but had to also monitor the scripts coming in as sometimes, it took more than a day for scripts to be sent. Customer Responsibilities “We immediately introduced a delivery service as a means to protect our customers who needed to self-isolate or were vulnerable. This had to be designed and organised, to have traceability and to be contact free.

Customers had to understand their responsibilities in this too they had to collect the items from their doorstep while the delivery person waited, and couldn’t give them any cash/scripts/gifts or other items, as it was a contact free service. This meant that we had to spend a little time on a call to each patient, ensuring any messages were given directly from the pharmacist, and to remind them to watch their phone for the delivery call, and to take payment remotely if necessary. “We also had the situation where some people were now living elsewhere to where they normally got their scripts e.g. their script was on file beside where they worked, or they had relocated to cocoon with family, or their travel was interrupted and they couldn’t return home. Each of these situations was different, and urgent, and required man hours to sort out. “The emergency prescription supply legislation was incredibly helpful. Once the GPs adapted to sending electronic scripts by Healthmail, the work flow could be planned, and it reduced the number of patients presenting at the premises. The ability to also repeat scripts, and give 30 days emergency supply of appropriate on hospital scripts was welcome. “For all of these changes, we had to have clear protocols, which

also was a further demand on our resources.” Looking to the future, as mentioned by Peter above, Jane is concerned about the residual coronavirus implications during typical ‘flu season. OTC Vibrancy “We will have a large flu vaccination drive, while presumably, coronavirus will still be circulating. We will need to be in a position to safely vaccinate a huge proportion of the population against flu to reduce the strain on our hospitals. What will that look like? Will we be vaccinating in community, and how will we safely do that? People will be very fearful if they experience any flu like symptoms. It is likely that pharmacy will be their first port of call, so we will need to remain very cognisant of our own safety, and that of our patients. It is vital that corona virus testing is available quickly, results preferably immediate, and contact tracing done within a day. If that is in place, then we have some hope of reducing transmission. “OTC will remain vibrant, once pharmacies are open, as the public is happier to come into a pharmacy for advice and medicines than any other outlet. They feel safe in our pharmacies, and unlike the doctors, we are easily accessible.”

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COVID Profession Cormac Loughnane, Group Superintendent Pharmacist, Allcare Pharmacy conference patient service in an Allcare pharmacy in Cork, which proved very popular with local patients. It’s now clear that the risk of contracting an infectious disease is not going to go away, even if COVID is under control at the moment. These kinds of enhanced services allow vulnerable patients to access the clinical expertise of a pharmacist, without taking any risk,” he explains. “Another Covid-19 related service was home delivery. During the height of the crisis, the support office team assisted their pharmacy colleagues by making themselves available to offer home deliveries to our pharmacies. This made a huge difference to vulnerable patients and to anyone who was cocooning or in self-isolation.

Cormac Loughnane is Group Superintendent Pharmacist with Allcare Pharmacy. “I think many pharmacy teams feel galvanised after the first stage of the Covid-19 crisis. It has been a real test for the sector. Our Allcare pharmacy teams and our support office team have worked incredibly hard throughout the pandemic. We put in hygiene and social distancing measures to protect staff quickly and we saw a return on the fact that not one of our pharmacies were closed due to illness. We also kept our doors open so we were better able to serve the public. Our pharmacy teams were incredibly dedicated to their patients and came in every day, despite how worrying that felt at times. That shows real strength and dedication,” he says. “One thing we’ve definitely seen is that the Covid-19 pandemic has accelerated technological change in the sector. It’s made people think differently about how they can access healthcare. Throughout the pandemic, pharmacists remained the most accessible of all the healthcare professionals. At Allcare, we’re looking at a changed landscape and thinking ‘How can we make sure this accessibility remains, while at the same time protecting our staff and customers?’” Allcare has been working on a number of initiatives that will give its customers the best of both worlds – the accessibility and expert advice they need, but with minimised risk of contracting infections. “We recently piloted a video

“Our ability to communicate to our customers via SMS and email through the customer rewards database - updating them regularly on any changes to their local pharmacy service, opening hours, delivery service etc – has been extremely useful. We’ve now accelerated the launch of our patient app, making prescriptions easier to manage and pre-order. Patients can book a delivery service if they can’t visit the pharmacy. In addition, the launch of a complete Allcare E-commerce platform is imminent, again underlying the importance of utilising digital in the pharmacy sector,” he adds. Cormac sees the traditional mechanisms changing, particularly with training. “On the staff training side, we had already developed an online platform that allows pharmacy staff to access OTC training, SOP’s, key product training and our customer service training. This online resource is now more valuable than ever before, with less event-based training being feasible. Furthermore, in some instances Eimear Nee our Allcare pharmacy trainer is using videoconferencing for additional store training sessions, replacing what would have been a store visit in the past. “There’s long been an argument that the face to face interaction between a pharmacist and patient

Dervila McGarry, Head of Marketing, LloydsPharmacy

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is essential, and when it comes to building a relationship of trust, that is certainly still the case. However, I think what we have seen through COVID is that once patients have that relationship, there are huge accessibility and safety benefits to using digital technologies in pharmacy, from Healthmail prescriptions to online consultations and eCommerce. We’re only at the beginning.” Importance of Self-Care Now, more than ever, the public are aware of the importance of looking after their health and wellbeing. LloydsPharmacy is on a mission to help people introduce healthier habits into their lives with their new campaign Hello Health. Each week different LloydsPharmacy Pharmacists share tips on how their customers and patients can improve their health and wellbeing from smoking cessation, heart health, boosting immunity, better sleep, weight management and tips on how to maintain good gut health. Each week tips and advice, blogs and videos are posted across their social media channels providing steps to proactively manage their health. Dervila McGarry, Head of Marketing at LloydsPharmacy, comments on the success of this campaign, “The response to the Hello Health initiative is really positive as it comes at a time when the Irish Public are acutely aware and motivated to take positive steps to improve their lifestyle. The expert advice from LloydsPharmacy teams is presented in a userfriendly way and customers are encouraged to reach out to their Local LloydsPharmacy by phone or in person to discuss any needs and requirements they have from lowering their blood pressure and cholesterol, boosting their immunity, to better sleep. All Lloyds Pharmacies remain open, the health and wellbeing of patients remains the number one priority during these unprecedented times.”

Dervila goes on to add that the wellbeing of colleagues across LloydsPharmacy stores and offices is critically important and measures have been put in place to maintain an accessible and safe work environment. “All our pharmacies have remained open throughout this pandemic and we are extremely grateful for the efforts, dedication and commitment from our Pharmacy teams. As restrictions are lifted we continue to review our protocols in line with advice from HSE and Government. “A key focus was to ensure a safe environment for our patients, and we implemented the following initiatives: 1) Our Express prescription service is available across all pharmacies where patients on repeat prescriptions can sign up to receive a free SMS when their scripts are ready for collection. 2) Local community and student volunteers supported our Pharmacy network collecting and delivering prescriptions to the vulnerable. 3) Local Pharmacy teams reached out to the vulnerable and elderly by phone to keep in touch and to offer any advice where required. 4) We increased the payment limits through contactless from ¤30 to ¤50. Paul Reilly, Managing Director, McKesson Ireland added, “On behalf of the Country Board and Senior Management I would like to thank our LloydsPharmacy colleagues for their hard work, dedication and unwavering commitment during these challenging times. It is incredible to see how colleagues have stepped up and responded doing an outstanding job. Our customers and the Irish Public can be reassured we remain focused and committed to serving the needs of their communities and to ensuring shopping in LloydsPharmacy is a safe environment.”


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References: 1. Merry A, et al. AFT-MX-1, a prospective parallel group, double-blind comparison of the analgesic effect of a combination inhibiting drug, an anti-inflammatory drug and thiazide diuretic at the same time increases the risk of renal impairment. Blood of paracetamol and ibuprofen, paracetamol alone, or ibuprofen alone in patients with post-operative pain. Department of Anaesthesiology, dyscrasias have been rarely reported. Patients on long-term therapy with ibuprofen should have regular haematological monitoring. University of Auckland, New Zealand 2008. *compared with the same daily dose of standard paracetamol or ibuprofen alone. Like other NSAIDs, ibuprofen can inhibit platelet aggregation. GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at anytime during treatment. Combination therapy with protective agents (e.g. misoprostol or proton pump Easolief Duo 500 mg/150 mg film-coated tablets Each tablet contains paracetamol 500 mg and ibuprofen 150 mg. inhibitors) should be considered. Use with concomitant NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided. Presentation: A White, capsule shaped tablet with breakline on one side and plain on the other side. Indications: Short-term NSAIDs may lead to onset of new hypertension or worsening of pre-existing hypertension and patients taking antihypertensive symptomatic treatment of mild to moderate pain. Dosage: Adults/elderly: The usual dosage is one to two tablets taken every medicines with NSAIDs may have an impaired anti-hypertensive response. Fluid retention and oedema have been observed in six hours up to a maximum of six tablets in 24 hours. Children: Easolief Duo is contraindicated in children under 18 years. some patients taking NSAIDs. NSAIDs may very rarely cause serious cutaneous adverse events such as exfoliative dermatitis, toxic Contraindications: Severe heart failure, known hypersensitivity to paracetamol, ibuprofen, other NSAIDs or to any of the epidermal necrolysis and Stevens-Johnson syndrome. Products containing ibuprofen should not be administered to patients with excipients, active alcoholism, asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid or other NSAIDs, history acetylsalicylic acid sensitive asthma and should be used with caution in patients with pre-existing asthma. Adverse ophthalmological of gastrointestinal bleeding or perforation related to previous NSAID therapy, active or history of recurrent peptic ulceration/ effects have been observed with NSAIDs. For products containing ibuprofen aseptic meningitis has been reported only rarely. NSAIDs haemorrhage, severe hepatic failure or severe renal failure, cerebrovascular or other active bleeding, blood-formation disturbances, may mask symptoms of infection and fever. Interactions: Warfarin, medicines to treat epilepsy, chloramphenicol, probenecid, during the third trimester of pregnancy. Warnings and precautions: This medicine is for short term use and is not recommended zidovudine, medicines used to treat tuberculosis such as isoniazid, acetylsalicylic acid, other NSAIDs, medicines to treat high blood for use beyond 3 days. Clinical studies suggest that use of ibuprofen, particularly at a high dose may be associated with a small pressure or other heart conditions, diuretics, lithium, methotrexate, corticosteroids. Refer to summary of product characteristics for increased risk of arterial thrombotic events. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic other interactions. Fertility, pregnancy and lactation: Easolief Duo is contraindicated during the third trimester of pregnancy. heart disease, peripheral arterial disease and/or cerebrovascular disease should only be treated with ibuprofen after careful Driving and operation of machinery: Dizziness, drowsiness, fatigue and visual disturbances are possible after taking NSAIDs. consideration and high doses should be avoided. Careful consideration should be exercised before initiating long-term treatment If affected patients should not drive or operate machinery. Undesirable effects: Dizziness, headache, nervousness, tinnitus, of patients with risk factors for cardiovascular events. The use of paracetamol at higher than recommended doses can lead to oedema, fluid retention, abdominal pain, diarrhoea, dyspepsia, nausea, stomach discomfort, vomiting, flatulence, constipation, slight hepatotoxicity, hepatic failure and death. Patients with impaired liver function or a history of liver disease or who are on long term gastrointestinal blood loss, rash, pruritus, alanine aminotransferase increased, gamma-glutamyltransferase increased, abnormal liver ibuprofen or paracetamol therapy should have hepatic function monitored at regular intervals. Severe hepatic reactions, including function tests, blood creatinine increased and blood urea increased. Refer to Summary of Product Characteristics for other adverse jaundice and cases of fatal hepatitis, though rare, have been reported with ibuprofen. Paracetamol can be used in patients with effects. Pack size: 24 tablets. Marketing authorisation holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Marketing chronic renal disease without dosage adjustment. There is minimal risk of paracetamol toxicity in patients with moderate to severe authorisation number: PA0126/294/1. Medicinal product not subject to medical prescription. For retail sale through pharmacy only. renal failure. Caution should be used when initiating treatment with ibuprofen in patients with dehydration. The use of an ACE A copy of the summary of product characteristics is available upon request. Date prepared: October 2019. 2019/ADV/EAS/120H.


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News

Link between selenium and outcome of COVID-19 An international team of researchers, led by Professor Margaret Rayman at the University of Surrey, has identified a link between the COVID-19 cure rate and regional selenium status in China. Margaret Rayman, Professor of Nutritional Medicine at the University of Surrey fish, meat and cereals) which has been found to affect the severity of a number of viral diseases in animals and humans. For example selenium status in those with HIV has been shown to be an important factor in the progression of the virus to AIDs and death from the condition. China is known to have populations that have both the lowest and highest selenium status in the world, due to geographical differences in the soil which affects how much of the trace element gets into the food chain.

Publishing their findings in the American Journal of Clinical Nutrition, researchers using data (up to 18 February), investigated possible links between selenium levels in the body and cure or death rates of those with the COVID-19 virus in China. Selenium is an essential trace element obtained from the diet (i.e.

Margaret Rayman, Professor of Nutritional Medicine at the University of Surrey, said, "Given the history of viral infections associated with selenium deficiency, we wondered whether the appearance of COVID-19 in China could possibly be linked to the belt of selenium deficiency that runs from the north-east to the south-west of the country." Examining data from provinces and municipalities with more than 200 cases and cities with more than

40 cases, researchers found that areas with high levels of selenium were more likely to recover from the virus. For example, in the city of Enshi in Hubei Province, which has the highest selenium intake in China, the cure rate (percentage of COVID-19 patients declared 'cured') was almost three-times higher than the average for all the other cities in Hubei Province. By contrast, in Heilongjiang Province, where selenium intake is among the lowest in the world, the death rate from COVID-19 was almost five-times as high as the average of all the other provinces outside of Hubei. Most convincingly, the researchers found that the COVID-19 cure rate was significantly associated with selenium status, as measured by the amount of selenium in hair, in 17 cities outside of Hubei. Kate Bennett, a medical statistician at the University of Surrey, said; “There is a significant link between selenium status and COVID-19 cure rate, however it is important not to overstate this finding; we have not been able to work with individual level data and have not been able to take account of other possible factors such as age and underlying disease.”

1Million views for TeleHealth Cork Cork pharmacist Garvan Lynch’s TeleHealth website recently marked a milestone, having 1 million views of their YouTube channel. As part of the Telehealth system, Garvan Lynch created 40 Health Clinic programs aimed at managing and even reversing the effects of many common illnesses. Through the Telehealth site, client patients can subscribe to a range of health courses at the Lynch Pharmacy, or via an online service. Education is the key and by powering his patients with knowledge, Garvan and his team of Assistants enable patients to take control of their illness and achieve better outcomes. Garvan has completed around 1,000 Health Videos on medicines and health conditions.

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Retail Recovery Plan Retail Excellence Ireland have published their Retail Recover Plan, with the stark warning that 110,000 retail jobs in Ireland could be lost permanently without a decisive Government plan. This would cost the State an estimated ¤2.2 billion in a full year in increased social welfare payments and would cost the State an estimated ¤800 million per annum in employee taxes foregone. “Ireland is in a period of unprecedented crisis that requires an unprecedented official policy response. Now is the time to be brave. The Irish retail industry believes that it will have a key role to play in rebuilding the Irish economy, but it needs a strong official policy response,” says a statement. Retail Excellence Ireland 5 key measures: Measure 1: Establishment of a Government backed commercial rent grant scheme equal to 60% of the rent and service charge cost during the emergency period. The cost of this measure to the Exchequer is estimated at ¤330 million for a 3-month period. Measure 2: The permanent cancellation of all Local Authority rates for all impacted businesses for a 12-month period. The cost to the Exchequer of this measure is estimated at ¤730 million for a 12-month cancelation. Measure 3: The implementation of liquidity supports for retail businesses and speedy and simplified implementation of these supports by the banks. Measure 4: The distribution of a gift card of ¤500 to all Irish households which can only be spent in bricks and mortar stores and will be zero balanced after a fixed window of time. The estimated cost to the State would be ¤850 million. Measure 5: The implementation of a back to work scheme such as a “Jobs Bridge” type initiative to re-employ the highest possible proportion of our retail industry colleagues who have been temporarily laid off.


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Corporate Profile

Keeping an ‘Eye’ on Care Driving innovation and providing optimum levels of care without compromise. These are the core values and ethos underpinning service provided by Ireland’s leading eye care company, TheaPamex. TheaPamex Country Manager, Mr Diarmuid Gavin

“Théa Global were very clear in their communication of support for every member of the Théa family. No one will be left behind” country and become their Number 1 choice for eye care.

Irish Pharmacy News recently spoke to Country Manager, Mr Diarmuid Gavin to find out more about the strengths which push the company continually to rate as number one within their market sector, and to understand the challenges faced recently as Ireland, and indeed the world, came face-to-face with Covid-19. Maintaining Close Links Théa is Europe’s leading and pioneering Eye Health Group founded in 1994 by Henri Chibret. The Chibret family has been dedicated to ophthalmology for more than 150 years. Théa headquarters are based in Clermont Ferrand in France and

ran by Jean Frederic Chibret and his uncle Henri. Jean-Frederic is married to Norma Quirke from County Tipperary so he has close links with Ireland and follows local Gaelic games closely. Théa is very much a family run company and being part of Théa is like be part of a global family where people always come first. Diarmuid Gavin explains, “TheaPamex is the Irish subsidiary of Laboratoires Théa and was set up in 2018 in Ireland. Within a year through our focus on education and quality we managed to earn the trust of Ophthalmologists, Pharmacists and consumers around the

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“Our strength lies within our people; a team of dedicated, highly motivated and driven professionals ready to satisfy with the most efficient and effective way the increasing needs and wants of our customers and consumers for eye health.” The company places a big emphasis on its values, education and its vision. The major pillars which continue to shape TheaPamex center around a strong belief in excellence of service. “Our motto is “Eye Care without Compromise” because we believe neither the consumers nor the health care professionals should be given sub-standard products,” Diarmuid continues. “Our company ethos is driving innovation, education and professionalism in improving eye health. Our vision is to remain the undisputed Number 1 choice in

the eye care industry in Ireland by creating lasting, quality value for both customers and consumers and staying close to their needs with integrity, truth and dignity. Education is Key “Education of our team and of our customer base is the cornerstone to our success. We have developed modules for pharmacy staff training to help understand the eye care category and to aid in the identification of eye conditions that may present to pharmacy. We have recently engaged with GP’s and we are now running educational meetings around eye care in General Practice. We are closely linked with the major secondary care eye centres and work closely with the Ophthalmologists to deliver educational talks to GP’s.” TheaPamex have recently partnered with Advanced Ophthalmic Systems who offer a software solution to Optometrists to enable remote triaging of patients during these current restricted times. “Preservative Free is in our DNA. Théa understand the importance of preservative free in maintaining the health of the ocular surface of the eye and have developed many Innovative solutions for eye care, their ABAK bottle is the most widely used, preservative free multi dose dispenser in the world. With many new products on the horizon, Théa’s innovative spirit drives new discoveries,” he adds. Coping with Covid No one individual, or company has escaped the challenges brought forth by Covid-19. Fast paced adapting and protecting of strong market brands is what Diarmuid believes has ensured TheaPamex has successfully risen to the challenge. “Firstly, our key message has been to ‘look after yourself and family’. All sales and office staff were asked to stay home once Covid 19 broke in early March. We quickly adapted with by weekly “town hall” meetings and Zoom coffees on a 1:1 basis. “The heart of our business is our fantastic team of people, as


35 TheaPamex Country Manager, Mr Diarmuid Gavin

Pharmacy staff are on the frontline every day and they have loved ones at home who may be vulnerable……... Keeping a fun factor even under current restrictions is crucial, the team who can laugh together can certainly work together” education is a core pillar in our business, we set up an internal training program spear headed by our training manager Mairead Heffernan. “We realised that our customers were busy and operating under new conditions and challenges so we supported from a distance if called upon. We realised that working from home can be difficult for some depending on circumstances with children, Wi-Fi and living space. So it was important to be flexible and understand each individual’s circumstance and adapt to support our colleagues. “Théa Global were very clear in their communication of support for every member of the Théa family. No one will be left behind.

“We have maintained the fun element to working at TheaPamex and developed “TheaGram”, weekly points that could be won for the best presentation, best work at home outfit, and this week is best 80’s love song with an eye theme! “Furthermore, we have prepared our team for a new world of e-detailing and limited access across all our customers, Pharmacies, GP’s, Optometrists, and Ophthalmologists. Our return to face-to-face meetings will be at the right time for our customers, we must be patient. In the meantime, there is much to do; PPE training, new product training and development of a five year strategic plan to see Théa grow a deeper and wider presence on your pharmacy shelf.” Future of the Industry The impact of Covid will continue to be felt long into the future. As Ireland starts to loosen restrictions and a ‘new normal’ emerges, we asked Diarmuid what he foresees as the future landscape of the industry. “Covid 19 has impacted heavily on all our lives. Safety is the most important consideration to keep front of mind for our teams and their families.

“I’m proud of Ireland and how we all rose to the challenge of containment, the message was clear right from the start, no ifs, buts or maybes. That’s good leadership. “The new norm will emerge and we will together adapt to ensure we play our part in preventing the spread of the virus. I expect we will see a progressive return to a new norm with visits to the pharmacy being reduced and customers having prepared their shopping list. “I see online as being a very important tool and service to provide customers. With the recent “push through” of e scripts, it shows that it can be done and that often Ireland can be held up by bureaucracy and red tape. Now is the time to learn new skills, change old habits, and build better systems to support our new world. “If not now, when?” In looking to the effects of longterm impact on footfall, and sales, he adds. “In business, cash flow is king, credit terms allow you sell what you have to get cash in to pay for your last order and place your next order. That will be a challenge if costs have risen (PPE) and sales are down (footfall).

“This will have a knock on effect on the ability to afford rentals, utilities and locum cover which gives the owner a chance to recharge and take a much needed break. Pharmacy staff are on the frontline every day and they have loved ones at home who may be vulnerable, keeping staff motivated over a sustained period is a challenge but I believe regular staff briefings with time for Q & As are most important. Keeping a fun factor even under current restrictions is crucial, the team who can laugh together can certainly work together.” There are many exciting developments coming to fruition within TheaPamex, as the company continues to build on their already incredibly strong brand. “Théa Ireland will emerge from a joint venture with Pamex Ltd in January 2022,” he says. “Our pipeline is hot with many exciting new products for Blepharitis and Dry Eye. Thealoz Duo is our flagship product for dry eye and we aim to launch four line extensions over the coming years. This will see your eye care category become decluttered from many of the older generation products to a new era of streamlined eye care from Théa.”

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News

Make use of Pharmacy – officials urged Government is being urged to make best use of the accessible network of community pharmacies across Ireland, and indeed the rest of Europe, in the fight against Covid-19. Since the beginning of the COVID-19 crisis community pharmacists have been working with tireless commitment and determination to guarantee patients continued access to treatments. They have been accessible 24/7 also during the lockdown and have arranged home delivery services for the most vulnerable people. Throughout the crisis, they have been the first line of advice, treatment and referral for many European citizens on common ailments, successfully preventing unnecessary visits to emergency rooms. Pharmaceutical Group of the European Union (PGEU) President Duarte Santos states, “Community pharmacists are ready and committed to further advance their support to European citizens and healthcare systems as the COVID-19 pandemic evolves and containment measures are gradually lifted.”

The wide local network of community pharmacies across Europe is assisting the health authorities in distributing certified protective equipment such as face masks and providing advice to the public on their correct and safe use together with information on other hygiene measures to prevent the spread of the virus. As recommended by the World Health Organization Regional Office for Europe (WHO Europe) and the Organisation for Economic Co-operation and Development (OECD) recently many European countries have introduced changes in legislation to expand the role of pharmacists and relieve pressure on the rest of the healthcare system. Some countries have also secured additional funds to empower pharmacists in their vital work on the frontline against COVID-19. In several countries pharmacists have been given the opportunity to renew

repeat prescriptions for chronic medications and distribute certain hospital medicines in pharmacies for patients who need them. In some countries community pharmacists have also activated protocols to help victims of domestic violence to report abuses during the lockdown. He adds, “Therefore we strongly recommend the health authorities to make use of the accessible network of pharmacies across Europe to help conducting reliable point-of-care tests for COVID-19 when these become available and to use the skills of community pharmacists to assist in effective and efficient immunisation strategies. At the same time, we also urge governments to provide adequate support to community pharmacists for their vital contribution to the healthcare systems and for their support to the population.”

Dettol Donation to Covid-19 Effort Dettol, Ireland’s leading disinfectant brand*, has pledged its support to the HSE in the fight against the Covid-19 pandemic in Ireland with a donation of 40,000 Dettol antibacterial products over the next 12 weeks. Paul Reid, CEO, HSE

The Dettol antibacterial products will be distributed to hospitals and health service facilities and sites around the country with the aim of helping to keep these environments hygienically clean. Speaking of the initiative, Paul Reid, CEO, HSE, said; ‘We are

grateful to Reckitt Benckiser and Dettol for their significant donation to the HSE and the Irish public. The HSE has had massive support from business, communities, social groups and individuals since the start of this crisis and for this we are hugely thankful.’

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Speaking of the initiative, William O’Brien, Country Manager Ireland at RB, said; “We want to extend our warmest and heartfelt thanks to all of those who have been working extremely hard, for exceptionally long hours, under extremely challenging circumstances to protect the nation against this virus and save lives. We are delighted to provide extra support to the HSE at this time and hope that this will help the HSE in fighting the pandemic in Ireland. I know everyone at RB feels privileged and indeed proud to work for a company that is playing its part, however small, in this fight.” Echoing the donation made to the HSE, Dettol is calling on the Irish public to continue their efforts in the fight against Covid-19 #WeAreAllProtectors

Pharmacists to urge on 'Sun Care' Pharmacists are well placed to help patients take care of themselves — from advising on sun protection and skin cancer risk to offering tips on managing hayfever. With the June bank holiday having brought more warm weather and the sun index high, pharmacists and their teams need to be urging people to enjoy the good weather by staying safe in the sun. Pharmacists can and should also advise parents to be sun smart and protect their children’s skin when they are outside enjoying the fine weather, as children’s skin is very sensitive to the sun’s rays. Community pharmacist and IPU Executive Committee Member Ann Marie Horan says, “It is important that everyone knows how to enjoy the sun responsibly. While it is fantastic that we’re promised good weather this weekend, unfortunately by Tuesday, pharmacists will see many people suffering from the aftereffects of sunburn. Our message is that we would much rather speak with you beforehand, when we can help you with all essential sun care products." Sun cream: Apply sun cream liberally 30 minutes before going outdoors. Wear protective clothing: Consider wearing a hat, particularly those with thin or thinning hair. Wear sunglasses that provide UVA and UVB protection. Check the UV Index. Limit time in the peak of the sun. Stay hydrated. Treat sun burn quickly. Protect Children: The World Health Organisation says that children are more susceptible to the effects of the sun. Sun exposure during childhood is a significant factor in the development of skin cancers in later life. Children should always wear sun cream when outdoors and it is important, that they cover their skin and use shade throughout the day to limit prolonged exposure.


CPD: PWID

Continuing Professional Development

CPD

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This module is suitable for use by community pharmacists as part of their Continuing Professional Development. After reading this module, in the magazine or online, complete the post-test on our website at www.pharmacynewsireland.com and include in your personal CPD ePorfolio. AUTHOR BIO: Bernadette Flood is a pharmacist with experience in a wide range of hospital pharmacy settings in Ireland. For the past 20 years she has provided pharmaceutical care for people ageing with intellectual disabilities living in long term residential care. This experience has awakened her interest in vulnerable populations, human rights, ethics, and quality person centred care. She was awarded a PhD by the School of Pharmacy in TCD in 2016.

People with Intellectual Disabilities and COVID-19 One pharmacist’s perspective 60 Second Summary People with intellectual disabilities (PWID) are a vulnerable population group due to the prevalence of co-morbid physical and mental health difficulties, sensory issues, behaviour problems, poor health literacy and long-term conditions that they may experience. Many PWID are not able to verbally report their symptoms of COVID-19 e.g. the typical symptoms of fever and breathlessness. Changes in appetite, diarrhoea, and other gastrointestinal symptoms, as well as behavioural changes may be atypical symptoms PWID present with. Pharmacists should be aware that PWID are at greater risk of infection because of the higher prevalence of comorbid health problems and personal habits. They often live in communal settings in the community or in in-patient services. During the COVID-19 pandemic, it is expected that some aspects of healthcare may need to be delivered by remote technology. G.P.s and psychiatrists and members of the MDT may not be in a position to attend in person due to public health advice. One obvious advantage of ‘telehealth’ and/or ‘remote consultation’ is that it will decrease the risk of communicable diseases which are transmitted by person-to-person contact. Pharmacists should be aware that direct support staff and family members supporting PWID are the most important people in their lives. During the COVID-19 crisis residential and supported living environments are likely to be under pressure on account of staff shortages due to illness or the need to self-isolate.

The Covid-19 pandemic presents challenges in the delivery of care to people with intellectual disabilities (ID) by pharmacists and other professional groups. People with intellectual disabilities (PWID) are a vulnerable population groupi due to the prevalence of co-morbid physical and mental health difficulties, sensory issues, behaviour problems, poor health literacy and long-term conditions that they may experience. They are likely to have frequent contact with family members (who may be older people), carers, support staff, and people in the community. This will increase their risk of contact with people infected with the virus. Many PWID who live at home are living with ageing parent carers, who themselves are a high-risk group when it comes to COVID-19. PWID may not understand why visiting restrictions are in place, increasing their sense of social isolation and distress. Many PWID are not able to verbally report their symptoms of COVID-19 e.g. the typical symptoms of fever and breathlessness. Changes in appetite, diarrhoea, and other gastrointestinal symptoms, as well as behavioural changes may be atypical symptoms PWID present with. Direct care staff and family members should know how to recognise, document and alert healthcare professionals, including pharmacists of such symptoms as early as possibleii. There will need to be sensitive yet close monitoring and support for PWID showing any symptoms. Like everyone else, most PWID who get COVID-19 will develop mild symptoms and will recover, some unfortunately will not and will die. The risk factors for poorer outcomes and mortality are the same for everyone: underlying multi-morbidity is the key concern in the general and the ID population. Many PWID have multiple health concernsiii, particularly pre-existing cardiovascular disease, diabetes and respiratory problems and are likely to have poorer experiences following transfer to an acute hospital settingiv. The added risk factors in terms of high levels of multi-morbidity in

Reflection - Is this area relevant to my practice? What is your existing knowledge of the subject area? Can you identify any knowledge gaps in the topic area? Planning - Will this article satisfy those knowledge gaps or will more reading be required? What resources are available? Action - After reading the article complete the summary questions at www. pharmacynewsireland.com/cpdtraining and record your learning for future use and assessment in your personal log. Evaluation - How will you put your learning into practice? Have I identified further learning needs? Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author.

the ID population mean we need a heightened focus on prevention. Pharmacists should be aware that PWID are at greater risk of infection because of the higher prevalence of comorbid health problems and personal habits. They often live in communal settings in the community or in in-patient services. Many PWID live in long term care settings in close proximity to other people and may not have control over a range of social contacts because of the level of support they require. Pharmacists have a role in making families and carers aware of the risks to the person with ID and highlighting reduction techniques where possiblev. COVID-19 has resulted in recent changes in clinical practice by medical practitioners and others. The current advice to reduce social and physical contact will have a direct effect on the delivery of clinical care by members of


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CPD: PWID

the multidisciplinary team (MDT) where clinical reviews often require the clinician to physically meet the person with ID. To implement social distancing effectively, MDT members will now need to consider what contacts are necessary for the tasks and to achieve specific clinical outcomes. Clinicians will consider alternatives to ‘face to face’ meetings in order to reduce physical contact as part of clinical assessment or review. Services and pharmacists have to support PWID and staff members who develop the infection in order to reduce the risk of spread.

The Royal College of Psychiatrists has identified six Cs (competence, communication, contingencies, confidentiality, consent and confidence) and three Ss (summarise, safety net and schedule follow up) of remote consulting that will be helpful to pharmacists and others engaged in this process https://www.rcpsych.ac.uk/about-us/ responding-to-covid-19/responding-to-covid19-guidance-for-clinicians/digital-covid-19guidance-for-clinicians .

Remote Clinical Prescribing and Consultation

Pharmacists should be aware that direct support staff and family members supporting PWID are the most important people in their lives. During the COVID-19 crisis residential and supported living environments are likely to be under pressure on account of staff shortages due to illness or the need to selfisolate. Staffing levels will be stressed with the potential for placements to break down at short notice. Pharmacists should work with MDT members and direct support staff to maintain PWID in their home environments where the medication related risks to their care can be managed effectively. Choking episodes are relatively specific to the population of people in disability servicesviii and this risk may increase when PWID are not supported by support staff or family members who are familiar with their medication administration needs and the various risks that may exist. Day services may be closed and this increases pressure on support staff and families when supporting PWID. Extra supports and expert advice will likely be required for an indefinite period of time.

Communication is likely the most important complex, nontechnical skill in medicine. During the COVID-19 pandemic, it is expected that some aspects of healthcare may need to be delivered by remote technology. G.P.s and psychiatrists and members of the MDT may not be in a position to attend in person due to public health advice. One obvious advantage of ‘telehealth’vi and/or ‘remote consultation’ is that it will decrease the risk of communicable diseases which are transmitted by person-toperson contact. The importance of clear communication between patient, direct care staff, nurse, Remote Clinical Team, G.P., psychiatrist, pharmacist, MDT and other staff is recognised. The standards expected of all personnel apply equally to digital and conventional consultation and healthcare settings. Safety-netting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia.

Support Services and Staff

There may be increased risk of the following particular safety issues for PWID occurring during the pandemic• Diagnostic overshadowing i.e. where staff can attribute all aspects of care to the intellectual disability e.g. failing to consider the potential contribution of medication side effects to a change in behaviour. • Healthcare by proxy i.e. PWID are very dependent on those providing direct care (e.g. unregulated non nursing staff) for access to healthcare • Staff competence to access and respond to changing clinical profile of vulnerable PWID including medication related side effects and risk of choking. Pharmacists should be aware of staff related threats to medication safety for PWID  miscommunication among health care provider/s  drug information that is not accessible or up to date  confusing directions and/or labelling  poor administration technique  being unfamiliar with the patient  lack of drug knowledge  incomplete patient medication history  lack of redundant safety checks*


39  lack of awareness of any particular individual patient risk factors e.g. pureed diet  lack of evidence-based protocols, and  staff assuming roles for which they are not prepared.

the health and disability sectors are not adequately prepared and equipped to meet the needs of people with intellectual disabilities.”

*Redundancy in healthcare implies that healthcare organisations have established multiple procedures or technologies to independently arrive at similar outcomes, in order to double check or ensure that routines and activities are conducted appropriately and to detect errors in their implementationix. Children’s Services Children and young people with ID are especially vulnerable to infection and to changes in their care. Special schools are closed causing confusion for families and schools and hence young PWID themselves. COVID-19 illness and isolation among education professionals will carry their own risks in delivering safe education. Disruption to the routines of children and young PWID and/or autism spectrum disorder can lead to significant increases in distressed behaviours. Changes in routines are inevitable at this time and may come from changes in the education setting, children being at home for prolonged periods, parent/carer health problems, and changes in other support services secondary to illness. Anxiety related to coronavirus and an increase in health-related anxiety in young people and their families/carers is likely. Mental Health Support The impact of the pandemic on the mental health of PWID and their families and support staff is uncertain at present. Restriction in regular activities and the concerns of family members and support staff could impact upon the mental health of PWID leading to evidence of mental health difficulties (e.g. anxiety and depression) and changes in behaviour. It will be important for pharmacists to be alert to the signs of distress in patients with ID and in support staff, and families. More frequent contact by the MDT members may be required to help people to remain well along with clinical interventions. PWID often use psychotropic medication and there are initiatives to ensure rational use of these valuable medicationsx. Prescribing and de-prescribing of medication for an individual with ID is a complex process. It is important that pharmacists support optimisation of all physical and mental health medications during the medication use process. Family members, support staff and PWID may seek drug therapy to help them support PWID experiencing distress secondary to COVID-19 restrictions. Clinicians should rationally review all requests for additional medication. Medical practitioners, pharmacists and MDT members should consider the context in which the

Professor Mary McCarron

person with ID is living and the changes that may have occurred in their support/care plans because of the impact of COVID-19 on their environment including their familiar support staff. Where additional medication is prescribed, regular medication review by the authorising psychiatrist and/or general practitioners is essential, supported by MDT and pharmacy input. Critical Care for PWID PWID in hospital or in-patient care services are among the most vulnerable patients because of their need for high-level clinical care and support from people who are familiar with them. Supporting PWID in-patient units to engage with treatment and recovery when restrictions on social contact are in place is challenging to hospital and in-patient staff. Pharmacists in hospitals have a role in ensuring safety for PWID in the medication use processxii. Where admission to a general hospital or critical care is required, support may be required for that person and their family to understand and manage the process. Some guidelines on critical care suggests frailty as a metric to guide access to treatment. Frailty scales may not be validated in population with ID and if used inappropriately may disadvantage the person with ID. Each person with ID should be assessed individually. Many PWID will need help with activities of daily living but this does not mean that they can't recover from a virus. The difficulties and challenges of caring for PWID should not be magnified and the safety net of reasonable adjustments must be retained in this vulnerable population group. The circumstances surrounding COVID-19 illness, care, and death of a PWID will have a

prolonged and significant impact on family and staff caregivers. Conclusion Professor Mary McCarron, lead investigator on the Intellectual Disability supplement to TILDA (IDS-TILDA) has pointed out that the health and disability sectors “are not adequately prepared and equipped to meet the needs of people with intellectual disabilities”xiii. In the past, this group has been subjected to “attitudinal bias and prejudice that has devalued their lives and reduced their timely access to appropriate healthcare.” Prof McCarronxiv has advocated for the relevant skills to be in place in healthcare and social care systems, in order to ensure that they can respond in the right way to those with ID. COVID-19 has placed increased pressure on all areas of healthcare in Ireland and internationally. Pharmacy has a pivotal role to play in adapting our health and social services to meet this challenge, for the benefit of patients, PWID, family members and society. The relevance of ‘specialist’ pharmacistsxv with insight into the complexity of healthcare and medication needs of the population with ID must be made apparent. Emily O’Reilly, the former Ombudsman has remarked ‘We all have a duty to make the public aware of what our contribution is’. Pharmacy must prioritise the vulnerable in society and ensure equal outcomes for PWID. The limited evidence available in the literature suggests that pharmacists can make positive interventions in relation to the quality of the medication use process, in collaboration with other healthcare professionals, carers and patients with ID.


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CPD: PWID www.google.com/search?q=handbook+of +human+factors+and+ergonomics+in+he alth+care+and+patient+safety&rlz=1C1GC EV_en&oq=Handbook+of+Human+Factors +and+Ergonomics+in+Health+Care+and+P atient+Safety&aqs=chrome.0.0j46j0j69i60l2. 2146j0j7&sourceid=chrome&ie=UTF-8 x: https://www.nationalelfservice.net/ treatment/antipsychotics/psychotropicmedication-finding-ways-forward-foradults-with-intellectual-disabilitiesrsmpsychotropics/ xi: Flood, Bernadette. De-Prescribing of Psychotropic Medications in the Adult Population with Intellectual Disabilities: A Commentary. Pharmacy 2018, 6(2), 28; https://doi.org/10.3390/pharmacy6020028 xii: Flood B. Safety of People with Intellectual Disabilities in Hospital. What Can the Hospital Pharmacist Do to Improve Quality of Care?. Pharmacy (Basel). 2017;5(3):44. Published 2017 Aug 4. https://pubmed. ncbi.nlm.nih.gov/28970456/ xiii: http://www.irishhealth.com/article. html?id=27072 COVID-19 and intellectual disabilities Particularly vulnerable group xiv: https://www.tcd.ie/news_events/articles/ timely-and-appropriate-covid-19-careurgent-for-people-with-an-intellectualdisability/

The following three principles will inform best practise by pharmacists in the care of the population with ID 1. The needs of PWID during the medication use process are greater and more complex and often present differently from those of the general population. 2. PWID are more likely to have impaired communication and therefore require special attention from pharmacists and others. 3. PWID have the right to access pharmaceutical care and health services and they should be provided within current legislative and professional frameworks. References i: https://www.rcpsych.ac.uk/docs/defaultsource/members/faculties/intellectualdisability/covid-19-facultypsychid. pdf?sfvrsn=86f6a7da_2 ii: https://www.scie.org.uk/care-providers/ coronavirus-covid-19/learning-disabilitiesautism/care-staff iii: Cooper, S., McLean, G., Guthrie, B. et al. Multiple physical and mental health comorbidity in adults with intellectual disabilities: population-based crosssectional analysis. BMC Fam Pract 16, 110 (2015). https://doi.org/10.1186/s12875-0150329-3

iv: Iacono T, Bigby C, Unsworth C, Douglas J, Fitzpatrick P. A systematic review of hospital experiences of people with intellectual disability. BMC Health Serv Res. 2014;14:505. Published 2014 Oct 25. doi:10.1186/s12913-014-0505-5 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4210514/ v: HSE. Coronavirus: Protect yourself and others https://www2.hse.ie/coronavirus/ vi: T Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19) [published online ahead of print, 2020 Mar 20]. J Telemed Telecare. 2020; https://pubmed.ncbi.nlm.nih.gov/32196391/ vii: Royal College of Psychiatrists 2020. COVID 19 and remote consultations. https://www. rcpsych.ac.uk/about-us/responding-tocovid-19/responding-to-covid-19-guidancefor-clinicians/digital-covid-19-guidance-forclinicians viii: NTMA and State Claims Agency, National Clinical Incidents, Claims and Costs Report. 2015 Smith et al. https://stateclaims.ie/ uploads/publications/State-Claims-AgencyNational-Clinical-Incidents-Claims-andCosts-Report.pdf ix: Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, 2016 edited by Pascale Carayon 12.7.2. Redundancy Page 180. https://

xv: Flood, Bernadette 2016. The Specialist Pharmacist and Quality Indicators for Medication Use in People with Intellectual Disabilities and Behaviour Disorders. Thesis, TCD. http://www.tara.tcd.ie/bitstream/ handle/2262/83126/Flood%2C%20 Bernadette_PhD%20Thesis%2029.08.16. pdf?sequence=1&isAllowed=y xvi: O'Dwyer, M., A. Mestrovic, and M. Henman, Pharmacists' medicines-related interventions for people with intellectual disabilities: a narrative review. Int J Clin Pharm, 2015. 37(4): p. 566-78 https://www. ncbi.nlm.nih.gov/pubmed/25903938


News Teva launch Life Effects There are 391,000 family carers in Ireland, who are going above and beyond for the person in their care. Ireland’s carers are under immense pressure and face new challenges daily during Covid-19. A new platform being launched by Teva Ireland, Life Effects is a peer to peer support platform where carers share advice, insights, tips and technologies to help other carers who are on the same or similar journey. In advance of Carers Week from 8-14th June, Life Effects shares an emotive video that tells the story of John and Mary, a loving couple whose lives are altered when one of them falls ill and the other assumes the role of caregiver, leading to a new normal for both people.

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Totalhealth show their support All ready to go - totalhealth Pharmacy teams continue to provide a crucial health service to their communities during the Coronavirus crisis. To further support those communities, totalhealth with the help of Calco Ireland Ltd. and Unilever are delighted to be shipping 2,000 care packs for acute and ICU staff to 10 hospitals. Each pack contains shower gel, shampoo, deodorant and energy snacks. Managing Director John Arnold says, “We hope this will provide the heroic staff in these hospitals some comfort and respite during their long and stressful shifts.” John Arnold, Managing Director, totalhealth Pharmacy Group

The short video illustrates the love and dedication a carer has for the person in their care. Through Life Effects, carers and patients share their invaluable advice and insights from their own life experiences dealing with chronic conditions and provide support for those looking for advice or tips to help with their role as a caregiver. The ability to connect with other people who have previously, or are currently, going on a similar journey is powerful and can provide the comfort and reassurance a carer is looking for, and needs. Yvonne Neeson, Senior Product Manager Generics at Teva Ireland says, “We are extremely proud to bring Life Effects to Ireland. We understand the immense challenges carers are under every day, particularly in light of Covid-19. “We salute carers across Ireland who sacrifice so much to make such a difference to the person in their care. We want to help make carers visible, to give them a voice – a platform to share tips, advice and support which is why Life Effects is very important.” For more information visit https:// lifeeffects.teva/eu/caregiver.

New website for TheaPamex TheaPamex, the Irish subsidiary of Laboratoires Théa, Europe’s leading, pioneering, and innovative Eye Health group, has launched its brand-new website www.theapharma.ie . TheaPamex, whose head office is located in Castlebar Co. Mayo employing several jobs to the local community, was introduced to Ireland in 2018. Within only a year it managed to earn the trust of Ophthalmologists, Pharmacists and Consumers all around the country and become their #1 choice for Eye Care. According to the new website, the award-winning eye care brand are committed to driving innovation, education, and professionalism in improving eye health with a range of 100% preservative-free eye care solutions. The new site offers an educational hub where visitors can learn about eye care and eye conditions. TheaPamex have also included a handy shopping tool making it easy for visitors to find and purchase the TheaPamex range from stockists around the

country. TheaPamex partners, most notably Pharmacists, can access all marketing collateral to help inform, educate, and connect better with their markets. For end users an online symptom checker is also available, where dry eye symptoms can be assessed, and suitable solutions offered. With expert care guaranteed, the brand is uncompromising in its approach to developing the best eye care solutions for its customers. “We are very excited to announce the launch of our new website”, says Yanni Kokosioulis, OTC Marketing Manager. “The site is not only beautifully designed but also has handy tools from a symptoms checker to our stockists list. We wanted a website that provides solutions, information and most of all eye health expertise

and education for our valuable partners and the Irish consumers. At TheaPamex, we are passionate about eye health and we believe the strength of the company lies in our people, a team of dedicated, highly motivated, and driven professionals.” Visit www.theapharma.ie to get up close and personal with Ireland’s number 1 choice for eye health.

PHARMACYNEWSIRELAND.COM


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Blink... and you'll miss it

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he impact of conditions affecting the eyes and sight loss can be far-reaching. For example, research has shown that depression affects those with sight loss more than in the general population, while people with sight loss are at increased risk of suffering from social isolation and experiencing accidents such as falls.

Impaired vision can lead to reduced workplace productivity, increased absenteeism and job losses. Yet, for a large proportion of sufferers, the causes are due to an uncorrected refractive error, meaning that vision could be improved or restored simply by wearing correctly prescribed glasses or contact lenses. The major medical conditions responsible for sight loss are age-related macular degeneration (AMD), cataracts, glaucoma and diabetic retinopathy. More than half of sight loss cases could be prevented by early identification and pharmacies could play a wider role in helping to raise awareness of the importance of eye health and regular eye examinations. AMD is a leading cause of blindness. There are two main types – dry and wet (neovascular AMD). Dry AMD has no treatment and patients rely on vision aids. Treatment for wet AMD includes photodynamic therapy and new agents (the VEGF inhibitors ranibizumab and afibercept), which are injected directly into the eye and can reduce vision impairment progression in around 90% of patients. As the name suggests, age is the major risk factor in AMD development, which normally affects people in their 50s and 60s. The exact causes of AMD are still unknown. Although there can be a history of the condition in certain families, AMD is still not believed to be genetic. However, if close relatives have suffered with sight loss in the past, then it may be worth advising patients to have their eyes checked more regularly. Studies have shown a definite link between smoking and AMD.

Other factors such as high blood pressure and poor diet can also lead to a greater risk of getting AMD. Vitamins (C & E), lutein, Zeaxanthin, copper and zinc supplements in the diet, can help reduce the risk of developing AMD. Research indicates that lutein can prevent or delay the progression of AMD. A healthy diet, high in antioxidant vitamins and minerals has long been associated with the prevention or delay of AMD. Good sources of lutein are green leafy vegetables, especially spinach. However, for people who don’t get adequate nutrition through their diet, a nutritional supplement containing lutein or zeaxanthin may help. Furthermore, as many as one in five cases of AMD may be caused by smoking. A smoker is more likely to develop AMD five years before a non-smoker. Smokers are also at increased risk of nuclear cataracts, thyroid eye disease, dry eye and poor colour vision. Pharmacists and their teams should enquire on the smoking status of all patients at least once per year and should discuss it during routine consultations. AMD is progressive and it is also painless. While AMD may affect central vision, most people still retain useful side (or peripheral) vision. Key symptoms of AMD include:  Distortion, where straight lines may appear wavy or bent. For example, lines of tiles in the bathroom appear wavy.  Difficulty in reading or doing any other activity which requires fine vision.  Difficulty in distinguishing faces.

 Dark patches or empty spaces, which appear in the centre of vision.  The need for increased illumination, sensitivity to glare, decreased night vision and poor colour sensitivity. Glaucoma Glaucoma is an increasingly, significant cause of preventable blindness in the western world. It is estimated that 3% of people over 50 in Ireland has glaucoma. Glaucoma in over 50s in Ireland is expected to increase in prevalence by 33% by 2021, linked to the forecasted increase in our ageing population as projected by the Central Statistics Office. Those most at risk of developing glaucoma are people over 60, people with a family history of the disease and individuals of African and Hispanic descent. Marking World Glaucoma Week, which recently ran from 8th -14th March 2020, Eye Surgeon and Glaucoma Specialist at the Royal Victoria Eye and Ear Hospital and St James’ Hospital, Dublin, Ms. Aoife Doyle, “The importance of having a regular routine eye exam to help prevent avoidable glaucoma-related vision loss cannot be over-emphasised. Often the early signs of glaucoma are picked up during a routine, spectacle prescription eye check up with an optometrist and a referral will be made for the individual to be seen by an ophthalmologist for a full comprehensive eye examination so a diagnosis can be made." Ms. Doyle, who specialises in the medical and surgical treatment of glaucoma patients in Ireland explains, “With glaucoma, vision

loss progresses at such a gradual rate that people affected by the condition are often unaware of it until their sight has already been compromised. It is crucial that people remember that once vision is lost to glaucoma, it cannot be restored, however, with early diagnosis and careful regular observation and treatment, damage can usually be kept to a minimum, and good vision can be enjoyed indefinitely. The test to detect the condition is non-invasive and gives an immediate result." Overall, women are at increased risk of experiencing sight loss compared to men – primarily due to their greater life expectancy. Currently, the lifetime risk of sight loss stands at around one in four for women compared to one in eight for men. Red Eye Red eye is commonly presented to pharmacists, and its causes vary from a minor subconjunctival hemorrhage to a more severe chemical burn; most often it is indicative of conjunctivitis, commonly referred to as pink eye. Other common causes include blepharitis, corneal abrasion, foreign body, keratitis, iritis, glaucoma, and scleritis. In addition to the redness, patients may experience eye discharge, pain, photophobia, itching, and visual changes. There are certain distinctive signs that assist in identifying the cause of red eye, such as watering and itching. Apart from red eye, pharmacists may come across a number of eye disorders in everyday practice. It is important to distinguish when to recommend nonprescription therapies and when a referral may be necessary.

PHARMACYNEWSIRELAND.COM | 43


FEATURES OF THE THREE TYPES OF CONJUNCTIVITIS

Pharmacists and OTC staff need to take a comprehensive optical and medical history to ensure that the patients are referred appropriately while others are treated with over the counter (OTC) medication. Blepharitis Blepharitis is one of the most common eye problems. It is a chronic inflammation of the eyelids, which can cause red or watery eyes, discomfort and an oily or flaky discharge around the lashes. The oil glands in the eyelid may become blocked or infected (Meibomian Gland Dysfunction) which can give rise to similar symptoms. Patients complain of a gritty, itchy, uncomfortable red eye that is worse upon waking. Patients should be advised that they should wash the eyelids with specialised blepharitis lotions/gels or eyelid scrub wipes. Non-irritating baby shampoos are recommended as lid cleansers in the past, however, some ophthalmologists advise against their use due to SLS (Sodium Lauryl Sulphate) allergy and the drying effect on the eye. Resting a warm compress such as a warm facecloth over the affected eye may soften and release any gland blockages. Commercial Warm compress products can also be used. While patients should experience some relief within one month the treatment generally needs to be continued for a few months. Ocular lubricants can be helpful to relieve the symptoms of associated dry eye. Key counselling point – Patients need to be reminded that this is a chronic eye condition and that frequent cleaning of the edge of the eyelids and warm compresses need to be continued daily for several months. Conjunctivitis The majority of patients presenting to the pharmacist with red eye will have some form of conjunctivitis. The conjunctiva is the membrane covering the eye (except for the cornea) and the inner surface of the eyelids. Conjunctivitis can result from either an infection (viral or bacterial) or an allergen. Conjunctivitis is subdivided into three types- bacterial, viral and allergic conjunctivitis. Staphylococcus or Haemophilus bacteria most frequently cause bacterial conjunctivitis. The adenovirus is most commonly implicated in causing isolated viral conjunctivitis. Pollen is the usual cause of seasonal allergic conjunctivitis. Non-allergic conjunctival irritation can result from foreign bodies - wind, dust, smoke, fumes, chemical vapours and other types of air pollution. Each of the three types of conjunctivitis presents with the three main symptoms of redness, discharge and discomfort.

Bacterial

Viral

Allergic

Eyes affected

Both, but one eye affected a day or so before the other

Both

Both

Discharge

Purulent

Clear and watery

Clear and watery

Pain

Gritty feeling

Gritty feeling

Itchy

Distribution of redness

Generalised and diffuse

Generalised

Generalised but greatest an the inner corners

Eye lid oedema

Moderate

Minimal

Moderate to severe

Itching

None

None

Mild to intense

Associated Symptoms

None

Cough and cold symptoms

Rhinitis (might also have a family history of atopy)

Classical appearance

Conjunctivitis - Allergic Allergic conjunctivitis is usually a bilateral ocular condition caused by pollen or other allergens. Typical symptoms are red, itchy eyes associated with tearing and burning that gradually disappear when the patient is no longer in proximity to the particular allergen. The condition is often associated with runny nose, itching of the soft palate of the mouth and sneezing. Approximately 70% of patients with allergic conjunctivitis also have hay-fever, asthma and/or eczema. Cold compresses and tear substitutes are useful in relieving burning and dry eyes in patients with a mild allergy. While first and second generation oral antihistamines are effective in treating allergic conjunctivitis, topical ophthalmic products are superior in treating the ocular symptoms and reduce systemic side effects. Products containing Sodium Cromoglicate 2% can be used prophylactically throughout hay-fever season in adults and children. Xylometazoline 0.5% and Antazoline sulphate 0.5% can be used in adults and children over 12 years to reduce symptoms. If

44 | PHARMACYNEWSIRELAND.COM

OTC medications do not provide effective relief within 7 days or the condition worsens patients should be referred for further investigation. Key Counselling Points – Advise the patient to wear wrap-around sunglasses and allergen avoidance to reduce symptoms/flare ups. Eye drops containing Xylometazoline should not be used for periods exceeding 7 days in order to avoid rebound nasal congestion. Dry Eye Conditions The eye is covered by a layer of fluid called the tear film which keeps the surface moist and comfortable and protects the eye from infection. Any change in the composition or amount of the tear film can lead to discomfort. There are many factors which can affect the tear film including illness, allergies, diet, atmospheric conditions and certain prescription medications e.g. anti-cholinergic medicines. Patients with dry eyes can complain of dry, gritty red eyes. The main treatment for dry eyes is artificial tears which are available OTC. There are a number of products on the market with good

ocular surface wetting properties which increase the moisture and lipid content of the ocular surface. Patients with mild dry eye may benefit from instillation of one of these artificial tear drops up to four times a day. However, in moderate to severe cases of dry eyes artificial tears would need to be instilled more frequently. To overcome this issue, preparations containing a longer-acting polymer, polyacrylic acid/PVA or carbomer 940 should be used for patients with moderate to severe dry eyes. These products have a longer retention time in the eye and symptom relief is obtained with fewer instillations. Patients who wear contact lenses or are allergic/sensitive or intolerant to the preservatives in dry eye drops should use the single dose unit eye drops in order to reduce exposure to preservatives which reduces eye irritation. Lubricating ointments are retained longer than the liquid dry eye drops. The patient’s vision can become blurred after instillation of ointment and this could affect activities such as driving so they are not generally recommended for day time use. They are, however,


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a useful adjunct to artificial tears if used at bedtime. If the patient does not respond to artificial tear substitute treatment after two months then the patient should be referred for further investigation. In certain cases where the patient is elderly, the symptoms of dry eye can be caused by drooping of the lower eyelid. Ectropion is where the lower eyelid droops away from the eye and turns outwards. Entropion is where the eyelid turns inwards towards the eye. It usually occurs as the patient becomes older when the tissues and muscles of the eyelids become weaker. The drooping eyelid can disrupt the drainage of tears which can make the eyes red, irritated, dry, gritty and more vulnerable to bacterial infections such as conjunctivitis. If the patient is experiencing these symptoms, it is advisable for them to have the condition checked by their general practitioner. In mild cases, it may not require treatment. In more severe cases, a minor operation to tighten and correct the eyelid defect may be recommended. Key counselling Point – Patients should be advised that products containing high levels of omega 3 such as fish oil supplements and flaxseed oil have been found to protect the eyes from dry eye syndrome and can be taken alongside ocular lubricants.

Episcleritis

systemic conditions such as rheumatoid arthritis. Red Eyes (Cosmetic) Pharmacists are often asked for treatment of red eyes where the patient’s main concern is the cosmetic appearance of their eyes. The cause of the redness should be established and sometimes is connected to the patient’s lifestyle, for example, the customer may had had less sleep than normal or they were in a smoky environment. There are a number of eye drop products containing naphazoline hydrochloride. Naphazoline acts on alpha-adrenergic receptors in the walls of blood vessels causing them to constrict and therefore redness is reduced. These drops are contraindicated in patients with glaucoma and are not suitable for patients who are contact lenses wearers. Key Counselling Point – Remind patients to remove contact lenses and that cosmetic red eye products are not recommended for long term use. Styes A stye (hordeolum) is usually caused by Stephylococcus Aureus infection of the eyelash follicle and in severe cases the infection can be associated with the infection spreading to the gland of Zeis (sebaceous gland) or the gland of Moll (sweat gland). It presents as a red swelling on the eyelid margin and in severe cases the eyelid can become swollen. As it is bacterial in origin, yellow discharge (pus) can be seen and sometimes it can be painful. Without treatment a stye is usually

Episcleritis The episclera is a layer of the eye found underneath the conjunctiva. Inflammation of this self-limiting and usually layer presents as redness (hyperaemia) as a result of dilation of thewill blood vesselsresolve that are within 7 to 14 days. Products The episclera a layer of the eye into two found in this layer.is Episcleritis is subdivided subtypes: containing Propamidine and warm be helpful. If the as redness (hyperaemia) as a result infection spreads and the eyelid thethree patient willwithout needtreatment. to be of dilation of the blood vessels Episcleritis is commonly self-limiting andthat resolvesswells, itself within weeks Inare rare casesinepisleritis has Episcleritis been associated with systemic as rheumatoid referred asconditions a topicalsuch or systemic found this layer. arthritis. Recurringinto episodes of episcleritis can antibiotic be associated with diseases that may besystemic necessary. is subdivided two subtypes: should be referred to a doctor. Topical steroids and topical NSAIDs can be prescribed for In certain cases, eyelashes are severe cases. a) Sectorial episcleritis is where removed to release the infection Keyone counselling Point – Using 2WHAM and TASTER questioning techniques check the part of the eye is affected. and the stye resolves. patients history and family history of systemic conditions such as rheumatoid arthritis. found underneath the conjunctiva.

a) Sectorial episcleritis is where part of the eye is affected. may compresses Inflammation of this layer one presents b) Diffuse episcleritis is when the entire eye is affected and inflamed.

Red Eyes (Cosmetic) b) Diffuse episcleritis

is when

Key Counselling Point – Advise

Pharmacists areeye oftenisasked for treatment of red eyes where patient’s main concern the entire affected and patients thatthe eye ointments are is the cosmetic appearance of their eyes. The cause of the redness should be established and inflamed. more effective than eye drops for sometimes is connected to the patient’s lifestyle, for example, the customer may had had treatmentThere of styes. less sleep than normal or they were in a smokythe environment. are a Remind number of eye Episcleritis is commonly self- hydrochloride. patients that eye ointments may drop products containing naphazoline Naphazoline acts on alpha-adrenergic receptors theresolves walls of blood themvision to constrict limiting in and itselfvessels withincausing blur and and not therefore to drive redness after is reduced. These drops are treatment. contraindicated in patients with glaucoma and are not suitable for three weeks without applying eye ointments. patients who are contact lenses wearers.

In rare cases episleritis has

Key Counselling Point – Remind patients to remove contact lenses and that cosmetic red been associated with systemic eye products are not recommended for long term use.

dry eyes (tear production is stimulated by dryness), blepharitis, allergy and infection. Treatment is usually by tear substitute drops and ointments. Warm compresses may also be useful. Prolonged excessive tear production is undesirable and may also be caused by a blocked tear duct. If treatment fails after two months the patient should be referred to a general practitioner for further investigation. This can be treated in hospital with syringing

or insertion of punctal plugs (synethic plug that keeps the tear drainage system permanently open therefore allowing tears to drain). Key Pharmacy Counselling Point – The most common cause of watery eyes is dry eye which is the opposite of what most patients believe. Patients may need counselling on how a dry eye stimulates the eye to produce excess tears.

Five Key Practice Points for patients presenting with red eye symptoms  General hygiene - Wash and dry hands before instilling eye drops, do not allow the tip of the eye drop to come in contact with the surface of the eye.  Check if patient is able to instill eye drops especially if they live alone.  Cease contact lenses wear.  The expiry date of all eye drops (without preservatives) is 28 days from the date of opening.  Check all OTC staff are aware of the symptoms requiring immediate referral. History Taking This is an example of the questions asked for a structured ophthalmic red eye history. • Presenting complaint - Reason for visit • History of presenting complaint TASTER Questioning Technique T - Time course (Onset): acute or chronic (sudden, hours, days, weeks), constant or intermittent? A - Associated symptoms: location of red eye (unilateral, bilateral, sectorial), reduced vision, blurry vision, gritty sensation, diplopia (double vision), pain, foreign body sensation, itch, discharge, watering eyes, headache, photophobia. S - Severity: mild, moderate, severe T - Treatment: previous treatment e.g. surgery, previous topical therapy, trauma. E - Exacerbating factors: wind, sunlight, and eye movements R - Relieving factors e.g. dry eye drops Past ophthalmic history - Exposure to another person with red eye signs and symptoms, contact lens wearer, trauma, surgery, recurrence Past medical history - Hypertension, diabetes, COAD/asthma, MS, inflammatory bowel disease, arthritis conditions should be noted. Any autoimmune conditions must be noted also. Medication history - Systemic, topical, over-the counter, herbal, drug allergies Systems review - Respiratory, cardiovascular, digestive, joints, skin Family history - Glaucoma, AMD, inherited retinal conditions, diabetes, and hypertension Social history - Living alone (e.g. can they instill eye drops themselves?), driving, smoking

conditions such as rheumatoid Symptoms of Red Eye Conditions that require Immediate Referral Recurring episodes of Aepiscleritis stye (hordeolum) is usually causedwith by Stephylococcus Aureus infection of the eyelash can be associated  Distortion of vision - including vision loss, reduction or blurring follicle and indiseases severe cases infection can be associated with the infection spreading to systemic thatthe should the gland of Zeis (sebaceous gland) or the gland of Moll (sweat gland). It presents as a red  Restriction of eye movement be referred to a doctor. Topical swelling on the eyelid margin and in severe cases the eyelid can become swollen. As it is steroids NSAIDs(pus) can can be seen and sometimes it can be painful. bacterial in and origin,topical yellow discharge  Abnormal/Irregular shaped pupil be prescribed severe cases. Without treatment for a stye is usually self-limiting and will usually resolve within 7 to 14 days. Watery eyes Products containing Propamidine and warm compresses may be helpful. If the infection  Photophobia Key counselling Using spreads and the eyelidPoint swells,– the patient will need to be referred as a topical or systemic Watery eyes  Redness caused by a foreign body antibiotic may be necessary. In certain cases, eyelashes are removed to release the Tears are necessary to keep the WWHAM and TASTER questioning Tears are necessary to keep the eye lubricated and clean. Causes of watery eyes (epiphora) infection and the stye resolves. eye lubricated clean. Causesby dryness), blepharitis, allergy and infection. techniques check the patients include: dry eyes (tearand production is stimulated  Severe pain or swelling around the eye Key Counselling Point – Advise eyewatery ointments areby more effective thanand eyeointments. Warm compresses may also be is usually tear substitute drops of eyes (epiphora) include: history and family history of patients that Treatment Styes arthritis.

Prolonged excessive tear production undesirable and may also be caused by a drops for the treatment of styes. Remind patientsuseful. that eye ointments may blur vision andisnot blocked tear duct. If treatment fails after two months the patient should be referred to a to drive after applying eye ointments.

general practitioner for further investigation. This can be treated in hospital with syringing or insertion of punctal plugs (synethic plug that keeps the tear drainage system permanently open therefore allowing tears to drain).

46 | PHARMACYNEWSIRELAND.COM Key Pharmacy Counselling Point – The most common cause of watery eyes is dry eye which is the opposite of what most patients believe. Patients may need counselling on how a dry eye stimulates the eye to produce excess tears.


The Rising Incidence of Allergies in Ireland

T

he number of children with allergies has soared 50% in just ten years, a documentary showed earlier this year.

Some 40,000 people in Ireland suffer from peanut allergy alone, which is a potentially fatal condition. Over 24% of Irish people now suffer from some kind of reaction to certain foods or products. Yet, there are only two public paediatric clinics in the country — Dublin and Cork — dealing with the crisis. Doctors have called for more experts and more facilities in all 19 paediatric units in Ireland. They say there is no one cause behind the frightening surge in allergies. Dr Paul Carson, of Allergy Ireland, says, “Children are more aggressively allergic than their parents were. Why that’s happening, I do not know.” Below, Dr 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’.

48 | PHARMACYNEWSIRELAND.COM

“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: Serousotitis 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


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1800 304 400

1

e in ยนCetrine Allergy7 1mg/ml Oral Solution, and available in 200ml bottle and launched 28 in November 2019. Cetrine Allergy 10mg FCT available in 7 and 30 packs, Lorat 10mg Tablets available in 7 and 28 C packs, or Rhinex Relief 50 micrograms/actuation to Nasal report spray, suspension, available as 1 x 60 doses. Medicinal products not subject to medical prescription. For further information, SPC or to report CF adverse drug reactions, No: contact the Marketing Authorisation 22863 Holder: Rowex Ltd., Bantry, Co. Cork. Ireland. Freephone: 1800 304 400. Fax: 027-50417. Date of preparation: (01-20) CCF No: 22863


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. Allergies and Asthma People who have allergies often also have asthma. And people with asthma often have allergies. While the two may not seem related, studies show about two-thirds or more of those with asthma also have an allergy. What many people don’t realise is that the same things that triggers their seasonal hay fever symptoms – things like pollen, dust mites, mould and pet dander – can also cause asthma symptoms.

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 allergy-focused 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.

50 | PHARMACYNEWSIRELAND.COM

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

Allergic asthma – where allergies are triggers for asthma symptoms – is the most common type of asthma. Researchers have long known that the frequency of children with allergies who also have asthma can be as high as 80%. Recent research has shown that about 75% of adults aged 2040 with asthma, and 65% of those with asthma aged 55 years and older, have at least one allergy. Local research has shown that up to 80% of Ireland’s 470,000 asthma sufferers also have hay fever. There are more than 30 types of pollen and 20 types of spores which can trigger hay fever. The majority of sufferers find that the allergy can severely disrupt their lives, with up to 94% of hay fever patients reporting that their symptoms have an impact on their day-to-day work. Dr Carson points to predictions by experts that the figure for allergies is set to increase by 50% in the next decade. Allergy is going to be an "enormous" healthcare burden in the coming years, he says, adding that it's believed the increase is driven by pollution in the atmosphere and the amount of chemical additives in our food, which he says are "swamping" our immune systems, particularly in young children.


The enticing scents of summer call for adventure and discovery!


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Educational

Smokers not Kicking the Habit – despite Covid Risk Despite the reported risk factors for smokers associated with Covid-19, they are not rushing to kick the habit, it has been said.

“There is compelling evidence that they are at much greater risk of serious harm from COVID and therefore a thorough overhaul of grossly underfunded cessation services should be implemented as an urgent and indispensable element of tackling the pandemic.”

Research has demonstrated that those who smoke may encounter a more severe form of the virus than others and that smoking is yet another risk factor. Just last month, it was announced that the sale of menthol flavoured tobacco including cigarettes will be prohibited. The purpose of the ban is to ensure that cigarette and tobacco products for sale can no longer include ingredients that would make smoking more palatable or make it easier for someone to start smoking by masking the taste of tobacco. The four year lead-in time for the prohibition was to allow smokers that use menthol flavoured products adequate time to switch to other products. The prohibition is contained in the EU (Manufacture, Presentation and Sale of Tobacco and Related Products) Regulations 2016 made by the Minister in 2016. The Regulations transposed the 2014 EU Tobacco Products Directive into Irish law. Health Minister Simon Harris said, “The COVID-19 pandemic has made it more important than ever to quit. On 11 May the World

Health Organisation said that a review of studies by public health experts found that smokers are more likely to develop severe disease with COVID-19, compared to non-smokers.

vast majority of the nearly 700,000 current smokers in Ireland want to quit and a lot more needed to be done to protect them, including from the deadly consequences of the virus.

“It also warned that tobacco is a major risk factor for noncommunicable diseases and these conditions increase the risk of developing severe illness when affected by COVID-19. I urge everyone who is thinking about quitting to contact the HSE Quit service for support.”

“There is compelling evidence that they are at much greater risk of serious harm from Covid-19 and therefore a thorough overhaul of grossly underfunded cessation services should be implemented as an urgent and indispensable element of tackling the pandemic.”

In advance of World No Tobacco Day on May 31st, the Irish Heart Foundation called for major investment in quit smoking services in response to mounting evidence that smokers are at higher risk of hospitalisation due to Covid-19. The incoming Government has been urged by the Irish Heart Foundation to quadruple spending on smoking cessation to ¤50 million at least, whilst also banning smoking throughout the Leinster House campus to show leadership on what remains Ireland’s leading cause of preventable death. Irish Heart Foundation Head of Advocacy, Chris Macey, said the

PHARMACYNEWSIRELAND.COM

New research among 2.4 million people in the UK showed that current smokers were 14% more likely to develop common Covid-19 symptoms, such as a persistent cough, shortness of breath, and fever than nonsmokers. They were 29% more likely to have more than five symptoms of the virus, and 50% more likely to have more than 10 symptoms. In addition, smokers who tested positive for Covid-19 were more than twice as likely to be hospitalised than non-smokers. “Regardless of the virus nowhere near enough is being done to support the 80% of smokers want to quit and to cut the rate of almost 6,000 tobacco-related deaths in Ireland each year”, added Mr

Macey. “The amount spent on cessation services is just 1% of the billion-euro that smokers pay to the Exchequer each year. It isn’t fair to place a large additional tax burden on people because of their addiction to nicotine and then fail to invest properly in helping them overcome it when many are desperate to quit.” Mr Macey added that if the incoming Government is serious about tobacco control an important signal of intent would be an immediate smoking ban covering the entire Leinster House campus. “Achieving a Tobacco Free Ireland by 2025 has been a flagship Government policy for more than seven years, but you’d have to wonder whether our policymakers will have even managed to remove smoking from their own workplace by the deadline that has been set. “Big strides have been made in cutting the smoking rate in recent years, but a lot more needs to be done to deal with the scourge of tobacco. A good place for our policymakers to start would be at their own front door.”


DOUBLE YOUR CUSTOMERS CHANCES OF QUITTING WITH NICORETTE * QUICKMIST

STARTS TO RELIEVE CRAVINGS IN JUST 30 SECONDS** *Compared to willpower alone. **Based on 2 x 1 mg dose

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

IE-NI-2000038


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What Can Pharmacy Learn from COVID19 (so far)? #COVID19 #FocusForward IPN’s Pharmacy Business Excellence Series is for community pharmacists committed to growing their professional and business knowledge and skills to overcome challenges and thrive as a community pharmacist. IPN is proud to partner with 4Front Pharmacy to bring you the ‘IPN/4Front Pharmacy Business Excellence Series.’ Our goal for you and your team is that you develop the knowledge, skill and the courage to embrace your challenges and opportunities, take the necessary leaps of faith to reap the rewards as you commit to pharmacy business excellence. Each month, Rachel Dungan poses strategic questions aligned with 4Front’s 6Ps of Pharmacy Excellence Framework. She shares best practice tips, insights from pharmacy leaders and showcases examples of pharmacy business excellence in action. LEARNING OUTCOMES At the end of article, you will be able to… • Evaluate the impact of COVID19 on your pharmacy business • Assess the risks of the status quo • Describe key changes community pharmacists must navigate to survive and thrive • Recognise opportunities to build on the leadership demonstrated through COVID19 • Showcase examples of pharmacy business excellence in action • Reflect on what is possible for you beauty and personal care. Forward-thinking pharmacies have proactively communicated this value to their customers. Meeting customers’ OTC, beauty and personal care needs builds customer loyalty, especially during these unprecedented times.

60 SECOND SUMMARY: In Oct 2019, in the IPN Business CPD Series, Rachel wrote: ‘The Rules of the Game are Changing… How ready are you to play by the new rules?’ Who knew, back then, just how fast the rules would change? Who would have guessed the health, social, economic, technological, logistic and educational upheaval we would face?

Strategy Questions: If you are NOT adopting this strategy, what is it costing your business now? What will it cost you over the coming months?

Now, as our businesses, colleagues, patients and customers begin to emerge from lockdown, it is time to evaluate • where you are, • where you are going and • what you must do differently as you adapt to your new normal. Times of great change present great opportunity. And great risk. The stakes are high. These are three ways to navigate these choppy waters. 1. You nail your colours to the mast, then innovate at pharmacy’s leading edge 2. You are forced to change course at the last minute to stay afloat 3. You hit an iceberg and sink Community pharmacies are at the frontline, supplying essential medicines and pharmaceutical care in a time of heightened fear, high demand but low footfall. How will you transition from crisis management to creating a compelling future, grounded in the new reality? In this article, you will receive business strategy tips from pharmacy accountant Fiona Cottell FCA. You will examine three pervasive myths that could hold you and your team back as you plan for the future. Finally, you will review a sample CPD Cycle to use as inspiration to take action and record the impact in your own CPD Cycle in your ePortfolio. Share your successes and submit your questions for the IPN/4Front Pharmacy Business Excellence Series to Rachel.Dungan@4FrontPharmacy.ie

PHARMACYNEWSIRELAND.COM

PHARMACY BUSINESS TIPS – Fiona Cottell FCA As you can see from the graph on page 55, the fall in front of shop sales has been partially masked by strong sales of a limited number of ‘COVID lines.’ These lines include fever control, pain killers, vitamins, sanitiser and face masks which peaked in March and early April. Front of Shop performance in the autumn and winter will be influenced by whether or not Ireland is hit by a ‘second wave’ of COVID19 infection. As a local and essential service provider, pharmacy has had a unique opportunity to be a one-stop shop to meet both prescription and non-prescription needs of patients, including

What trends have you seen in dispensing? What opportunity to you see? As a rule, pharmacies in shopping centres and high streets have experienced a significant drop in footfall. Their customers have been quarantining in residential areas. Conversely, many pharmacies in suburban and rural areas have seen an increase in dispensing volume, as customers who have not been commuting are shopping local. Strategy Questions: Do you know who your lost / new patients are? Do you know what their needs are? Do you know how their needs have changed in the past 3 months? What approaches will you use to find out? What will happen if you don’t?


Showcase examples of pharmacy business excellence in action Reflect on what is possible for you

• •

55

PHARMACY BUSINESS TIPS – – Fiona Cottell FCA – 470 words meantMarch? they most of them As aapharmacy accountant, what Front Shop trends have you noticed As pharmacy accountant, whatofFront of Shop trends havesince you noticedThis since did not collect their prescription March?opportunity What opportunity do you see? What do you see? in person. Suddenly, to provide

services to our customers, we needed to use different methods of communication. Due to COVID19, they haven’t been able to come to us. 'If the mountain will not come to Muhammad, then Muhammad must go to the mountain.' Finding new ways to drive footfall into community pharmacy and expanding your reach is a problem worth solving.

Pharmacy Industry - FOS sales 350,000 300,000 250,000 200,000

How will this lockdown affect customer behaviour in the future? What opportunities do you see? How can you mitigate the risks?

150,000 100,000

MYTH 3: I am not a sales-person

50,000 -

Jan Covid 19 lines

Feb

Mar Beauty & Personal care

Apr

May All other lines

While front of shop staff often identify themselves as sales people, I have found that many pharmacists and pharmacy technicians do not. But here’s the truth. You ARE a salesperson. You might not be very skilled at it, but this is a critical role which you are duty bound to develop. You received your qualification, so that you could ethically sell. Sell prescriptions and over the counter medicines. Sell (promote) evidence based healthcare advice. Sell (influence) benefits of vaccinations. Sell (convince) benefits of social distancing. Sell (persuade) referrals to the GP. In every pharmacy consultation you have, I believe you are not doing your job unless you are influencing the other person to be proactive about managing their own health and wellbeing and providing them with the tools to assist them. Selling is your job! Indeed, it could be argued that it is unethical not to sell, when the products, expertise and services you have to offer could improve the patient’s health and wellbeing. The first step to get better at sales,

is to ask questions to find out what What trends have you seen in dispensing? What opportunity to you see? they want and need first – Seek to As a rule, pharmacies in shopping centres and high streets have experiencedUnderstand, a significant THEN be Understood – as Stephen Covey phrased it. This approach is an inspiration for 4FrontPharmacy’s STEPS Consultation (Sales) Framework. Summary

Remember, in a volatile, uncertain chaotic and ambiguous (VUCA) world, often the most risky strategy is to make assumptions, cling to the status quo and hope for the best. Instead, be proactive. Challenge your assumptions. Ask questions. Lead with curiosity. Know your numbers. Connect with your customers. Invest in training your frontline staff. Expand your circle.

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that disprove it. structure effective pharmacy during COVID19, special attention consultations. should be paid to ensure delivery Think of a time where you couldn’t staff and the staff answering the afford something, but you found MYTH 2: Open the door, and phone are trained to the highest a way to buy it anyway. Your car? they will come standard. They are your customer’s Your house? Your business? A For decades, our service model contact – perhaps the ONLY holiday? Your wedding? has been based on customers contact. They are the face and Example: In the last recession, voice of your pharmacy business. walking into our pharmacy of my staff members wanted The quality Dungan of your pharmacy Rachel – 4Front one Pharmacy 07 June 2020premises. We became a reactive service will be strongly influenced to discontinue stocking a high profession, responding to whoever by your frontline staff’s ability to quality fish oil supplement. When I walked in the door to us. Up until identify and respond to customer’s asked why, she responded ‘It’s too recently, many of us have never needs and recommend appropriate expensive. Nobody can afford that needed to proactively consider products. From there all things price in a recession. Everybody is how to meet our customers will come. strapped for cash.’ I responded where THEY are at, rather than ‘That is an interesting theory. Let’s where WE were at. While trends, Strategy Questions: Are all test it.’ That afternoon, a medical such as online shopping home, your frontline staff trained card patient who had collected delivery services and technology and competent to identify and her prescription the previous day, have been slowly eroding this respond to your customer’s came into the pharmacy to seek myth, COVID19 has blown it out needs? How do you know? my advice. In her hand were a of the water. In March, a large What will be the business proportion of our highest need consequences of NOT investing in fish oil supplement with a price their continuing education now? patients were suddenly cocooned. tag of ¤59.99 and a multivitamin

2

As you can seeandfrom theKeep fallusin front of shop salesalsohas supplement, withbeen a price partially masked by Pharmacy owners their the graph, Myths that Stuck: teams have significant of ¤59.99. She wanted to strong sales of a limited number of of‘COVID lines.’tagThese lines include fever control, pain Here are three the most toxic constraints on time and money. know if they were safe to take pervasive I believe are peaked killers, vitamins, sanitiserand and face myths masks which in Marchmedicines. and early April. Front of If you were to invest in ONE with her prescription holding our profession ransom. By area over the next 6 months, What lesson would YOU take Shop performance winter will befrom influenced by whether or not Ireland is unshacklingand ourselves from these where would you invest? in the autumn an experience like ours? seductive myths, and choosing a My colleague and I decided that hit byinvest a ‘second COVID19 infection. I would first in the wave’ frontline of different approach, our chances we needed to challenge our staff. I would insist that they of medium to long term success As a local and essential service provider, pharmacyassumptions has had(ina this unique opportunity to be a onecase about completed online training to improve dramatically. ability to pay). We realised that upgrade and demonstrate stop shop to meet their both prescription and non-prescription needs of patients, including beauty if we had asked, we could have knowledge and skill, so that they MYTH 1: He/She/I can’t afford it and care. toForward-thinking proactively communicated this value found out what she wanted and betterpersonal identify and respond (or won’t pay). pharmacies have met her needs customer’s needs. to their customers. Meeting customers’ OTC, beauty and personal care needs builds Ask yourself…. Is that true? This experience became Who do you define as Always? customer loyalty, especially during these unprecedented times. an inspiration for 4FrontPharmacy’s frontline staff? While thinking of examples to STEPS Consultation Framework, Question: If you are NOT adopting this strategy, what is it costing your business now? The most obvious are your prove your belief will be easier, I which we now use to enable door staff and your in-store What will it cost you overinvite theyou coming months? now to think of examples pharmacists and their teams to customer facing staff. However,


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RESOURCE ANNOUNCEMENTS 1. For tips to help you solve problems, communicate more powerfully and get buy-in from your team, follow @4Front on Facebook and @4FrontPharmacy on Instagram and @4FrontPharmacy LinkedIn. 2. As an IPN reader, we invite you to register for FREE COVID19 Certified Online Training, go to www.4FrontPharmacy.ie. You can also browse our range of online programmes to support you and your team to develop your consultation skills this summer. 3. 4  FrontPharmacy will be hosting a series of online workshops specifically for pharmacy owners and their teams over the summer. Contact Rachel. Dungan@4FrontPharmacy.ie with expressions of interest or topic suggestions. AUTHOR: Rachel Dungan MPSI, ACC. Rachel Dungan MPSI, ACC. Community Pharmacist. Award-Winning Medical and Leadership Coach and CEO of www.4FrontPharmacy.ie. Known as ‘The Pharmacist Coach,’ Rachel worked for 20 years as a supervising and superintendent pharmacist. Now, more than ever, her vision is to empower, equip, enable and engage pharmacists and their teams with the knowledge and skills required to embrace the future. Since Mar 2020, 1173 pharmacy staff members have become COVID19 Certified. To register for FREE, go to www.4FrontPharmacy.ie

S

Self-Appraisal WHAT I intend to learn and why COVID19 has fast-tracked irreversible changes in how pharmacies deliver healthcare. These include technology, regulatory, safety changes and roster changes. There have also been dramatic changes in patient and consumer behaviour. I want to review my leadership performance over the past 3 months, to identify learnings to position me to lead my team to face these challenges, identify opportunities and mitigate risk.

P

Personal Plan HOW I intend to learn it I plan to review my pharmacy’s financial performance (Target V Actual) and staffing levels (Target V Actual) year to date. I plan to call a team meeting on Zoom to thank my team and celebrate successes, identify my staff’s perspective on risks and brainstorm ways to solve problems. I plan to invest in myself and my team so we have the knowledge and skills required to embrace opportunities.

A

Action What I actually did • I met the book-keeper, accountant and operations manager on Zoom to review our pharmacy’s business performance and the impact of COVID19. • I enrolled all my staff on 4FrontPharmacy’s Online COVID19 training. All staff were required to gain COVID19 Certification prior to our staff meeting. • As we cannot meet face to face, I called a staff meeting on Zoom. This was more difficult to facilitate effectively than I thought. • Having attended an online workshop facilitated by Rachel Dungan, I have now hired her to chair our online meetings and support us to implement our evolving business strategy.

D

Document What I have learned specifically • By reviewing my rosters, I realised that due to COVID19, 95% of annual leave for 2020 has not yet been taken and it is already nearly 6 months into the year. • By reviewing my business financials, I realised that despite a rise in the number of items dispensed, outside of COVID specific products, our front of shop sales have fallen off a cliff. We must proactively address this. • Until I asked my staff to share their key learnings from the COVID19 online training, I had no idea of the extent of their knowledge gaps. It opened my eyes to the assumptions that I make about what my team know. • I hadn’t realised how stressed, fearful and overwhelmed my team was, nor how much the change in work practices has affected pharmacy operations. • I hadn’t realised how much skill is required to facilitate an effective online meeting. This is a skill gap I need to address.

E

Evaluate ONE example of how I put my learning into practice • I decided to work with my team to create a roster to the end of the year by 30th June. For workplace and health & safety reasons, all staff are to have taken 50% of their annual leave by Aug 31st, while maintaining sufficient cover. • I am personally phoning customers we have not seen in the past three months to find out how we can best serve them during COVID19. Their responses will inform our strategy. • I have enrolled myself and my team on 4FrontPharmacy Annual Membership - including staff on reduced hours or on furlough. Now is the time for US ALL up-skill and prepare for what I believe will be a busy and challenging winter. • We have created business growth and contingency plans and rostered monthly strategy review meetings on Zoom. We must invest to grow.

CCF Domains (and Competencies) The Pharmacist selected Competencies under the following domains for this CPD Professional Practice (Engages in appropriate CPD), 2. Personal Skills (Leadership Skills, Decision Making Skills, Team-Working Skills, Communication Skills) Contributed by Rachel Dungan MPSI of 4Front Pharmacy. To find out more about how 4Front Pharmacy’s ONLINE training can help you drive your sales, improve patient safety and engage with your patients and team, (even in a pandemic), email Rachel. Dungan@4FrontPharmacy.ie and use the subject line ‘IPN June 2020.’

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Skincare

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Skincare in Lock Down Written by Laura Dowling - 'The Fabulous Pharmacist' in association with RELIFE™

I don’t think that there is a person in the country who is not now aware that frequent handwashing with soap plays an extremely important role in the fight against Covid-19! The surfactants in soap break down the lipid layer that keeps the virus particles intact. Using soap, in combination with the mechanical disruption of the virus – washing all surfaces of the hands for at least 20 secs- is the most simple and basic way to control the spread of Covid-19. Unfortunately, the surfactants in soap also break down the lipid layer on the surface of the skin. Frequent exposure to soap, water and harsh alcohol hand sanitisers can wreak havoc on our hands. They can cause dryness, sensitivity, soreness and/or itchiness and ultimately lead to an increase in the number of people presenting with the condition known as irritant contact dermatitis. The skin can break down causing dryness and crackswhich will sting when washing with soap and sanitizing with alcohol hand gel. Regardless of this, it is still imperative that frequent handwashing is maintained. Many people are coming into the pharmacy and indeed contacting me on my social media looking for advice about this. The condition usually presents on the backs of the hands and can extend up beyond the wrists as people are washing these areas more often than ever. The skin in the webs of the fingers is thinner and can also become quite irritated. Soap and hand sanitiser can get trapped under rings so it is important that people are advised to take these off while washing and drying their hands or indeed, to abandon wearing them altogether during this time. Some people are more predisposed to irritant contact dermatitis- those who already suffer from eczema or asthma, the elderly, who have naturally thinner skin and those patients taking medications which are known to dry or thin the skin, such as statins, antihistamines or isotretinoin.

Fabulous Pharmacist Laura Dowling

Applying an emollient after hand washing is an essential part of maintaining the integrity of the skin barrier. It will help to prevent moisture loss, dryness, skin breakdown and irritation. The HSE advise that if you have dry skin or a skin condition that you apply moisturiser after washing your hands and at night (www.hse.ie). Applying a thick layer moisturiser at night before bed and then wearing a pair of cotton gloves overnight may be an excellent way that people can help their skin health. Usually we recommend people to apply their emollient to slightly damp skin, to ‘lock-in’ the moisture. For hygiene purposes however hands must be dried thoroughly. It is advisable that people suffering with irritated skin gently pat their hands dry and avoid rubbing harshly with a towel or paper towel. I have been working with RELIFE™ since its Irish launch last year. It is a clinically proven and evidencedbased skincare brand from Italy, made by the Menarini group. I use it on my own children, one of whom suffers from chronic eczema and recommend it to patients and

customers on a regular basis. I also train pharmacy colleagues about the range. The RELIFE Relizema cream™ is a medical device. It can be applied to the skin in lieu of a steroid cream, where appropriate, for a flare up of mild to moderate eczema or dermatitis. It forms a barrier on the skin, preventing allergens from irritating the skin from the outside and reducing moisture loss from the inside. It should be applied twice daily to treat a flare up and can be used for up to thirty days. I have seen really excellent results from this cream with eczema and dermatitis in a variety of patients over many different areas of the skin. The Relizema ultra hydrating lotion™ may be used as an emollient after handwashing and can be used regularly throughout the day to help to protect the

integrity of the skin. The range also has an excellent soap substitute, Relizema lipid replenishing cleanser™, which does not strip the skin of its natural oils and maintains its suppleness, however soap substitutes have not been recommended to replace soap when washing hands in the current COVID 19 situation. The key advice I give to my patients and customers is to moisturise, moisturise, moisturisethey can never moisturise too much! I also remind them that their skin is the largest organ of the body and should be treated with the respect that it deserves. If the dermatitis is severe and/ or you suspect an infection it is always advisable to tell a person to seek medical advice from a GP.

Laura graduated from Trinity College Dublin in 2002 and has been a practising as a Community Pharmacist for 17 years. Passionate about health and lifestyle wellness… Laura loves to share her practical and research-based scientific knowledge with others, in a fun and engaging manner. Her primary audience is women and girls of all ages, accessed primarily through social media, TV & radio appearances, corporate speaking events and written articles. Fabulous Pharmacist is relatable, funny and a mine of information on a wide range of topics - everything from mental health, asthma, skin concerns and constipation! In her daily posts she discusses medicines, illnesses, natural therapies, healthy food, vitamins and exercise, in-between performing advanced yoga poses and baking sourdough bread with her three sons. Her aim is to make everybody feel as fabulous as possible by inspiring them to lead balanced, healthier lives – always in a consistent and achievable way, and by avoiding short term crazes and fads! Find her on Instagram and Facebook @fabulouspharmacist

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Pharmacy management of Elderly Care

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t 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. This article looks at some of the most commonly presenting issues within the context of ‘Care of the Elderly’ and the role pharmacy may play within them. 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.

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At present it is estimated that 300,000 people in Ireland have osteoporosis. One in 4 men and 1 in 2 women over 50 will develop a fracture due to osteoporosis in their lifetime. The disease can also affect children. A broken bone from a trip and fall or less is known as: an osteoporotic fracture, a low trauma fracture or a fragility fracture. However, broken bones can be prevented in most cases, and is a treatable disease in most people. Early diagnosis is essential for the best results. Signs and Symptoms of undiagnosed osteoporosis Usually the first sign of Osteoporosis is a fragility (low trauma) fracture e.g. a broken bone due to a trip and fall from a standing position or less.

Symptoms that a person may have undiagnosed osteoporosis include upper, middle or low back pain, especially if the pain is intermittent. Loss of height is another potential symptom. It should not be considered normal to lose height as people age. Someone with their head protruding forward from their body, shoulders becoming rounded, the development of a hump on the back and / or a change in body shape (waist appears bigger or a pot belly develops) are also symptoms. Most people have no pain till a fracture occurs, but a very small percentage of people have had back or hip pain, prior to a fracture. Treatments and Vitamins For both men and women at increased risk of fracture, the most


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ADD MAGNESIUM OR TURMERIC TO YOUR DAILY ROUTINE


widely prescribed osteoporosis medications are bisphosphonates. Bisphosphonates are also known as Antiresorptive medications. These are non-hormonal drugs which help maintain bone density and prevent further bone loss. The patient receives this medication in the form of tablets, an injection or by means of infusions. Side effects such as nausea and abdominal pain are much less likely to occur if the medicine is taken properly and pharmacists can help advise patients on this. Denosumab is a Monoclonal antibody which binds to RANK Ligand, inhibiting the maturation of osteoclasts, therefore protecting the bone from degradation. Compared with bisphosphonates, denosumab produces similar or better bone density results and reduces the chance of all types of fractures. Denosumab is delivered via a shot under the skin every six months. Those who take denosumab, might have to continue to do so indefinitely. Recent research indicates there could be a high risk of spinal column fractures after stopping the drug. There are oestrogen replacement therapies for women going through the menopause which help to maintain bone density and reduce fracture rates for the time they are on the treatment. Oestrogen therapy and oestrogen 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 agerelated 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. Here are the four vitamins that, in addition to vitamin D, are important to bone heath. Vitamin A is a fat-soluble vitamin that is important to building strong, healthy bones. Both osteoblasts (bone building cells) and osteoclasts (bone breaking down cells) are influenced by vitamin A. Despite its good effects, most clinical research links higher vitamin A levels with lower bone density and fractures. Too much vitamin A (more than

3,000 mcg or 10,000 IU/day) can lead to headaches and has been linked to bone loss. Vitamin B12 appears to have an effect on bone building cells. A recent study showed that low levels of vitamin B12 are linked to a higher risk of osteoporosis in both men and women. Vitamin B12 is found in meat and fish, making vegans, who don’t eat meat or dairy, at risk for bone loss. People who have had a gastric bypass or have gastrointestinal disorders that cause poor absorption of fat lose the ability to absorb B12. Elderly people in their 80s and 90s may develop changes in the linings of the stomach that prevents them from absorbing iron and B12. Vitamin C is important for healthy gums and healthy bones. Vitamin C is essential to the formation of collagen, the foundation that bone mineralisation is built on. Studies have associated increased vitamin C levels with greater bone density. Vitamin C is water-soluble and the most common reason for low levels is poor intake. Some people with poor absorption will have lower levels of vitamin C. The elderly who are in nursing homes tend to have lower levels of vitamin C. Smokers also tend to have lower blood levels of vitamin C because their intestines do not absorb vitamin C normally. Vitamin K is important to normal bone growth and development. It helps attract calcium to the bone. Low blood levels of vitamin K are associated with lower bone density and possibly increased fracture risk. However, clinical trials have not shown vitamin K supplementation to be helpful in improving bone density. The current pandemic has seen the importance of Vitamin D in overall health. Not only is vitamin D essential for bone health, but it helps to regulate cell growth and the immune system. It is the only vitamin that does not have to be consumed in food or supplements as it can be manufactured through the skin when exposed to the sun. Low levels of Vitamin D have been linked to: multiple forms of cancer, TB, MS, osteoarthritis and Type 1 Diabetes. Low levels of Vitamin D mimics the symptoms of Fibromyalgia (therefore Vitamin D levels should be checked on those diagnosed or thought to have possible Fibromyalgia). Calcium and Vitamin D supplementation have been shown to reduce the risk of fracture and falls and improve muscle function in the elderly. How much Vitamin D is needed? Babies 0-12 months breast fed or formula fed = 5μ/200 IU * Children 1-18 years= 10μ/400 IU per day***

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Adult women 19-49 years = 1020μ/400-800 IU per day** Adult women 50+ years = 2030μ/800-1000 IU per day** 19+ years pregnant and/or breastfeeding = 20-30μ/800-1000 IU per day** Adult men 19-49 years =1020μ/400-800 IU per day** Adult men 50+ years =20-30μ/8001000 IU per day** Medicines Management Challenges There is a fairly high prevalence of swallowing difficulties in poly pharmacy patients visiting their local community pharmacy, highlighting the need for a better communication between patients and health professionals for addressing such issues. Anyone at any stage of their lives from infants, children and adults, can be affected by dysphagia. Those affected includes: • 95% of people with Motor Neurone Disease; • 68% of people with dementia in care homes; • 65% of people who have had a stroke; • 50% of people with Parkinson’s Disease; • 33% of people with multiple sclerosis. As dysphagia is not a single disease, but a symptom of an underlying medical problem, it is difficult to estimate how many patients are suffering from it. Stroke is considered to be one of the major causes of dysphagia. In many patients, the swallowing function will recover within two months. In a small group, recovery of swallowing function may take many months to several years. In several cases of stroke patients this recovery does not occur. A sufferer may present to a member of the pharmacy team and identify that they are having difficulty swallowing medication. This is an opportunity to establish whether they have difficulty swallowing food or liquids and whether there has been any associated weight loss. A patient with these symptoms can then be referred via GP services to speech and language services. Knowledge of dysphagia and interpreting the various stages of fluid and consistency of foods can assist pharmacists in advising in the most appropriate and safe manner in administering medication to patients with dysphagia. Medication administration in people with dysphagia is complex. Key questions to ask • Is the medication necessary?

• Is it making the swallow worse (dry mouth, confusion, reduced alertness)? • Could the medication actually be assisting the swallow? • If the medication is necessary what is the best method of drug delivery? This will depend on where the problem is in the swallowing process and the severity of the dysphagia. • Drug interactions, available formulations, enteral feed and tube/drug interaction are all important areas. Mechanical factors are also key, what bore is the tube, the smaller the gauge, the greater the risk of blockage. • For those who are able to take medication orally, are tablets feasible or not? Parkinsons Disease Risk People with Parkinson’s disease are at greater risk of hip fractures and other non-vertebral fractures due to balance problems and poorer bone health, a recent review study found. The researchers argue that these findings support making fracture risk assessment a part of standard care for Parkinson’s patients. Published in the journal Bone, the review analysed data from 18 studies including more than 2.3 million people to assess whether patients with Parkinson’s are at greater risk of fractures compared to the general population. “Neurological conditions are emerging as important risk factors for fracture and this metaanalysis confirms that people with Parkinson’s are at significant risk,” says our nurse consultant, Sarah Leyland. “They should be considered for fracture risk assessment, as well as falls risk assessment, and advised appropriately to prevent future fractures,” she added. Bladder weakness Urinary incontinence is common in both older men and women. This is due to changes in the body that occur as people get older, such as weakened pelvic floor muscles and loss of sensitivity in the nerves that control the bladder. Urinary incontinence can also be a symptom of certain longterm health conditions such as multiple sclerosis and Alzheimer’s disease. For elderly patients with dementia, it is wise to suggest the use incontinence pants rather than pads. These will provide good security and odour protection, and require less changing for the patient or their carer. Sources: * HSE 2011 ** National Osteoporosis Foundation USA *** American Academy of Paediatrics.


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

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New President for RCSI The Royal College of Surgeons in Ireland (RCSI) has announced the election of Professor Ronan O’Connell as the new President of the College. Professor O’Connell takes up office following the College’s biennial Council Elections. He replaces outgoing President, Mr Kenneth Mealy. Professor Ronan O’Connell, New President, RCSI

Professor Ronan O’Connell is Emeritus Professor of Surgery UCD and Consultant Surgeon at St Vincent’s University Hospital. An international leader in the field of colorectal surgery, he is also the incoming President of the European Surgical Association. Professor Laura Viani, Consultant Otolaryngologist and Neurotologist at Beaumont Hospital and the Children’s University Hospital Temple Street has been elected as the new Vice-President. She is Director and Professor of the National Cochlear Implant Programme and Hearing Research Centre. Speaking on his appointment, Professor O’Connell said: "It is my great honour to be elected today as President of the Royal College of Surgeons in Ireland. “My presidency of RCSI will be like no other in our 236 year history as the COVID-19

pandemic has presented our surgical community with unprecedented challenges that will shape the future of surgery for years to come. “COVID-19 may at present keep us apart physically but as a community of surgeons we are united in the task of re-establishing safe, timely and equitable access to elective surgery. I look forward to working with our community of 9,500 Fellows and Members across 86 countries as we face the challenges ahead, to sharing our expertise and to building a

virtual network for continuing surgical education. “I am particularly conscious of supporting our surgical trainees whose training has been disrupted by the COVID restrictions. RCSI will use the excellent facilities of the National Clinical and Surgical Skills Centre at 26 York Street to provide innovative ways of training to compliment hospital experience. I will advocate on behalf of our trainees and will work with the Irish Medical Council and sister Colleges to ensure training and career progression is secure.”

CarePlus Pharmacy Asthma Healthpacks The Asthma Society of Ireland has recently partnered with CarePlus Pharmacy to supply free COVID-19 Asthma Healthpacks to people with asthma in Ireland. These packs, which people with asthma and their families/friends can pick up for free from the 64 CarePlus Pharmacies nationwide, contain information and support to help people stay safe during this COVID-19 pandemic. The resources within these packs were put together with the assistance of members of the Asthma Society’s Medical Advisory Group, and they draw on expertise from the HSE and the National Respiratory Clinical Programme, including some of the top respiratory healthcare professionals in the country. These packs consist of patient education materials on asthma or COPD and COVID-19, as well as information on general asthma management, dealing with an asthma attack (the 5 Step Rule), gardening with asthma

and hayfever, and details of key services offered by the Asthma Society during this pandemic. This COVID-19 Healthpack initiative is only the first step in a new partnership between CarePlus and the Asthma Society. Asthma Society COVID-19 packs will be available to pick up for free in all CarePlus Pharmacies and CarePlus Pharmacists will be on hand to help people with asthma with advice on asthma management and to address their concerns. Brand Manager Carla Crerar says, “Community pharmacies play

a key role in providing support to vulnerable members of the community, and this initiative will enable us to reach and support more asthma patients, and their carers, who may have additional concerns around the current pandemic. Many of our own pharmacists and their staff live with asthma, and fully understand the challenges that the condition can throw up. We look forward to continuing our relationship with the Asthma Society of Ireland, and offering more support in the future through our network of over 60 community pharmacies nationwide.”

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News

Accelerating Bone regrowth

Irish Aids Day

Scientists at RCSI University of Medicine and Health Sciences have developed a new biomaterial that has the potential to accelerate bone regeneration by promoting an immune response that encourages repair and lowers the risk of inflammation.

“The Government should invest in the expansion of HIV testing services if it is serious about reversing record high newly notified HIV cases.” These were the words of Mr Stephen O’Hare, Executive Director with HIV Ireland as he spoke recently to coincide with the organisation’s new media messaging campaign to mark Irish AIDS Day, 15 June 2020.

Dr Caroline Curtin, Lecturer in Anatomy and Regenerative Medicine at RCSI

for patients with fractures that fail to repair naturally or have degenerative bone diseases such as osteoporosis, although further pre-clinical and clinical trials are still required before the technology could be used to treat humans,” said Dr Caroline Curtin, Lecturer in Anatomy and Regenerative Medicine at RCSI.

The study, conducted by researchers at RCSI Tissue Engineering Research Group (TERG) and AMBER, the SFI Research Centre for Advanced Materials and BioEngineering Research, is published in Acta Biomaterialia. The researchers have developed a technology that is a combination of nanoparticles and a collagenbased biomaterial called a scaffold, specifically designed by RCSI TERG that can be surgically implanted to aid bone tissue repair. The material allows for the delivery of a microRNA silencer,

a molecule capable of influencing the way our cells function. In laboratory conditions, researchers successfully demonstrated that damaged bone tissue is restored as the particular microRNA delivered by the biomaterial works to increase cells responsible for bone repair. The technology also assists in promoting a pro-repair immune system response, lowering the risk of inflammation and other complications. “The results of our research are a promising step towards improving health outcomes

“We are confident that this biomaterial system will have several potential applications beyond bone repair, as it can be tailored to deliver other therapeutic molecules that address degenerated or diseased tissue in the body. At RCSI Tissue Engineering Research Group, we are exploring these possibilities through the development of similar methods to repair articular joints like the knee and hip, and attempting to apply the microRNA delivery systems to inhibit breast cancer cell growth and other novel research,” said Professor. Fergal O’Brien RCSI Director of Research and Innovation, Professor of Bioengineering and Regenerative Medicine and Deputy Director of the SFI AMBER Centre.

Sharing the Vision for Mental Health Minister for Health Simon Harris TD and Minister of State for Mental Health Jim Daly have recently published 'Sharing the Vision – a Mental Health Policy for Everyone'. 'A Vision for Change' ended its ten-year-term in 2016 and the mental health landscape in Ireland has changed dramatically since 2006. Sharing the Vision is the successor policy and was agreed by Cabinet two weeks ago.

an implementation roadmap. It allocates ownership of recommendations to lead agencies and sets time-bound implementation targets against each recommendation's actions. This will be key to its delivery.

Minister Harris said, "Sharing the Vision is our new mental health policy and it is a policy for everyone.

"Its publication comes at a time when our world is rapidly changing, particularly in light of the Covid-19 pandemic, and it is my sincere hope that this policy will play an essential role in shaping our responses to these challenges we face now, and those that are to come.”

"It focuses on key areas promotion, prevention and early intervention, service access, coordination and continuity of care, social inclusion and accountability and continuous improvement. "Importantly, Sharing the Vision includes

Hugh Kane, Chair, Oversight Group said, "There is a need to develop stronger, more

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appropriate mental health supports at community and primary care level. The new policy focusses on developing a broad based, whole-of-system mental health policy for the whole population while providing effective specialist mental health services. The new policy is action orientated and focussed on bringing about tangible changes in people's lives. Central to this policy is the right of people with mental health difficulties to be centrally involved in their own care and recovery, as well as a continuing focus on recovery and the need for recovery to be supported throughout the mental health system.”

Launched online due to the continued restrictions on public gathering imposed during Phase 2 of the Roadmap on Reopening Society and Business, the campaign seeks to promote the re-evaluation of the current approach to ending HIV transmission in the wake of record high rates of newly notified cases of HIV and the Government’s robust response to the COVID-19 pandemic. “Now, more than ever…” boasts the campaign messaging, “We must end HIV and HIV-related stigma”, “We can end new HIV transmissions”, “We must ensure barrier free access to PrEP.”, “We can get to Zero”, the last a reference to zero new HIV transmissions by the target date 2030 set out in the Sustainable Development Goals, to which Ireland has committed. “The scale of the response to COVID-19 is unlikely to be repeated, unless the virus returns in more virulent waves,” he added. “The impact on existing service provision, on our economy and on our society has been stark. There are, however, key lessons to be learned from this experience, which should inform the Government’s approach to HIV prevention.” New (provisional) data from the Health Protection Surveillance Centre indicates that for the third year in a row, the number of newly notified HIV cases continues to climb (536 in 2019 – the highest on record) with a corresponding increase in the rate of diagnoses (11.3 per 100,000 of the population).


HSE Updates

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Innovative 24/7 text service launches A new text based mental health service funded by the HSE launched this month. ‘50808’ is a first of its kind for Ireland, a free 24/7 text service, providing everything from a calming chat to immediate support for people going through a mental health or emotional crisis. Doireann Garrihy launched the service via a Zoom event with Simon Harris TD, Minister for Health, Jim Daly, Minister for Mental Health and Anne O’Connor, Chief Operations Officer HSE. Since the service began its pilot in September last year, it has provided support to 3,801 people through 6,694 conversations. It is expected that ‘50808’ will support over 50,000 people each year once fully operational. Of the almost four thousand people supported;  832 people were thinking about suicide  360 people were self-harming  The top issues discussed were: Anxiety/stress (40%), Depression/sadness (32%), Relationships (29%), Isolation/loneliness (23%) and Suicide (18%)  80% of texters have been between the ages of 16 and 34

 65% of texters were female, 24% male, 2% transgender and 2% non-binary The service uses an artificial intelligence (AI) system to analyse a texter’s initial message, scanning keywords, phrases, and even emojis to determine the level of severity. The texter’s at most imminent risk are placed at the top of the queue. Covid-19 Investigative Study In other news, the HSE is issuing letters to more than 5,000 people inviting them to participate in the Study to Investigate COVID-19 Infection in People Living in Ireland (SCOPI). The seroprevalence study will measure exposure to COVID-19 infection in the population using an antibody blood test.

The letters are being sent to people in Dublin and Sligo. Those who participate in the study will be representative of the wider population. Dublin and Sligo have been selected as sample locations as they represent areas of the country with higher and lower known levels of infection respectively. Using a representative sample of participants in both locations, it will be possible to provide an overall national estimate of infection in the Irish population. The intention is to repeat the antibody research in other areas of the country over the coming year. Those who consent to take part in the study will be asked to complete a short questionnaire by phone. The questionnaire will

be carried out by trained staff on behalf of the HSE’s Health Protection Surveillance Centre (HPSC). In addition to responding to a series of questions participants will be asked to provide a blood sample to test for antibodies. The sample will be taken by a phlebotomist in a local centre arranged by the HSE. Participants will be provided with their individual results and those who are found to have antibodies for COVID-19 will be asked to take part in a follow-up study. This will include further questions relating to COVID -19 symptoms and involve three further blood tests over a 12-month period.

Macu-SAVE As we grow older our eye health becomes under increasing pressure and in particular our macula. The macula is a small, delicate area of the retina located at the back of our eyes. It is the part of the eye responsible for our central vision. It is essential for reading, writing, driving or even recognising faces. Research shows that depletion of the macular may impact on our eye health and vision. Did you know that all three macular carotenoids are derived from our diets and we cannot produce them in our body. The macular pigment can become severely depleted in those of us with poor diets lacking in the right foods. If you are not a fan of kale, egg, shrimp and fish skin smoothies for breakfast, lunch and dinner, then a supplement contains all three macular carotenoids is beneficial to our eye health and vision. Macu-SAVE is a once a day, easy to swallow, food supplement, which provides advanced nutrition for the eyes. Macu-SAVE contains ALL three macular carotenoids 10mg Meso-Zeaxanthin, 10mg Lutein and 2mg of Zeaxanthin, the formulation supported by research and that is essential for macular health. Macu-SAVE contains no artificial preservatives or sweeteners, it is free from yeast, lactose and gluten, while also suitable for diabetics too. All three macular carotenoids in Macu-SAVE are of the highest quality. Macu-SAVE contains FloraGLO® Lutein, the most clinically research lutein brand worldwide with over 70 human clinical trials. Clinically proven to show bioavailability is similar to that obtained from foods which naturally contain these nutrients. OPTISHARP™ Natural, also in Macu-SAVE is a naturally-sourced dietary zeaxanthin ingredient for eye health that's naturally-sourced from marigold flowers. Macu-SAVE is available in a convenient 30 day and 90 day pack in leading pharmacies nationwide. If you are concerned about your eye health, talk to your health care professional. www.macu-save.com

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A personalised service your patients can really smile about Ostomy For more information please contact: Free Phone 1800 540 540 I OstomySource@uniphar.ie I www.uniphar.ie

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