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November 2019 Volume 11  Issue 11 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS: Health Minister loses pharmacy rules bid Page 6

PROFILE: Lucy Walker’s Pharmacy Adventure Page 10

THE GAME CHANGER

REPORT:

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Pharmacist views on role of Regulator Page 18

FEATURE: Resource for New Mums Page 27

CASE STUDY: Medication Adherence Page 35

TEAM TRAINING: Seasonal Ailments Page 40

EDUCATION:

Valeo Healthcare are excited to announce the launch of Aqua Biome – the worlds first fish oil with DPA designed for a healthy microbiome.

Rising Incidence of Falls & Osteoporosis Page 48

For more information on sales and media plans, contact your Valeo Healthcare Sales Representative or Account Manager.

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Voltarol gel gel with with new new Voltarol No Mess Mess applicator applicator No Voltarol Emulgel P 1% w/w Gel Voltarol Emulgel P 1%diethylammonium. w/w Gel contains diclofenac contains diethylammonium. Always diclofenac read the label/leaflet. Always read the label/leaflet.

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Voltarol Emulgel P 1% w/w Gel (diclofenac). Indications: For the local symptomatic relief of pain and inflammation in trauma of tendons, ligaments, muscles, Voltarol Emulgel P 1%forms w/w of Gelsoft (diclofenac). Indications: For the localand symptomatic relief of pain and inflammation in trauma tendons,3-4 ligaments, muscles, joints and localised tissue rheumatism. Dosage: Adults adolescents 14 years and over: 2g to 4g of gel, appliedoftopically times daily for joints and localised forms of soft tissuea rheumatism. Dosage: Adults andimprove. adolescents 14 years and over: 2g towith 4g of applied topically 3-4in times daily for up to a maximum of 7 days. Consult doctor if the condition does not Contraindications: Patients or gel, without chronic asthma whom attacks upof toasthma, a maximum of 7or days. Consult a doctor if the condition does improve. Contraindications: Patients with or without chronic in whom attacks urticaria acute rhinitis are precipitated by aspirin ornot other non-steroidal anti-inflammatory agents. Hypersensitivity toasthma diclofenac, acetylsalicylic of acid, asthma, urticaria oranti-inflammatory acute rhinitis are drugs precipitated aspirin or otherUse non-steroidal anti-inflammatory agents. Hypersensitivity to diclofenac, non-steroidal or any by other ingredients. in third trimester of pregnancy, in children and adolescents aged lessacetylsalicylic than 14 years. acid, non-steroidal anti-inflammatory or any other Use in third trimester of pregnancy, in children and adolescents aged less than 14 years. Warnings and Precautions: Caution drugs with oral NSAIDs asingredients. may result in unwanted side effects. Avoid use with other products containing diclofenac. Apply only Warnings Precautions: Caution with oralwounds NSAIDs or as open may result in It unwanted side Avoid use with other products containing diclofenac. Applywith only to intact,and non-diseased skin and not to skin injuries. should not beeffects. used with occlusion. It should not be allowed to come into contact to the intact, non-diseased skin and notand to skin wounds injuries. It should not beover usedextensive with occlusion. It should not be allowed to come into eyes or mucous membranes should neveror beopen taken by mouth. Application areas for prolonged periods or application in contact excess ofwith therecommended eyes or mucous membranes and never effects. be taken by mouth. over extensive areas forbleeding, prolonged periodsfluid or application excess of dosage may give riseshould to systemic These includeApplication gastrointestinal disturbances and irritability, retention, in rash, hepatitis, recommended dosage may give and rise to systemic These include gastrointestinal disturbances and bleeding, irritability, fluid retention, hepatitis, renal dysfunction, anaphylaxis rarely bloodeffects. dyscrasias, bronchospasm and erythema multiforme. Discontinue if rash develops. Use with rash, caution in renal dysfunction, anaphylaxis andulcers, rarelygastrointestinal blood dyscrasias, bronchospasm and erythema multiforme. Discontinue if rash develops.inflammation. Use with caution in patients with a history of peptic bleeding, hepatic or renal insufficiency, or bleeding diathesis, or intestinal Pregnancy patients with a history of pepticconcentration ulcers, gastrointestinal bleeding, or renal insufficiency,compared or bleeding or intestinal inflammation. and Lactation: The systemic of diclofenac is lowerhepatic after topical administration, to diathesis, oral formulations. During the first andPregnancy second and Lactation: The systemic concentration diclofenac lowerclearly after topical administration, compared to oral formulations. the first and second trimester of pregnancy, diclofenac shouldof not be given is unless necessary. Only use during lactation on the advice of a During health professional. Diclofenac is trimester of pregnancy, should not given unless clearly necessary. Only use during on the advice of a health Diclofenac contraindicated duringdiclofenac the third trimester ofbe pregnancy. Should not be applied on the breasts oflactation nursing mothers, nor elsewhere onprofessional. large areas of skin or foris contraindicated duringofthe third trimester pregnancy. nothypersensitivity be applied on the breastsurticaria), of nursing mothers, nor elsewhere on large areas of skinRare: or for a prolonged period time. Side effects: of Very rare: rashShould pustular, (including angioedema, asthma, photosensitivity reaction. a prolonged ofCommon: time. SideDermatitis effects: Very rare: rash pustular, hypersensitivity (including urticaria), angioedema, reaction. Rare: Dermatitisperiod bullous. (including contact dermatitis), rash, erythema, eczema, pruritus. Overdose:asthma, The lowphotosensitivity systemic absorption of topical Dermatitis bullous. Common: Dermatitis (including dermatitis), rash, erythema, eczema, pruritus.(Ireland) Overdose: The low systemic absorption of topical diclofenac renders overdosage extremely unlikely.contact MA Holder: GlaxoSmithKline Consumer Healthcare Limited, 12 Riverwalk, Citywest Business diclofenac overdosage extremely MA Holder: Consumer Healthcare (Ireland) Riverwalk,available Cityweston Business Campus, renders Dublin 24, Ireland. MA Number:unlikely. PA 678/140/2. Legal GlaxoSmithKline Category: Pharmacy only. Text revised: May 2019.Limited, Further 12 information request. Campus, Dublin 24, Ireland. MA Number: PA 678/140/2. Legal Category: Pharmacy only. Text revised: May 2019. Further information available on request. Trade marks are owned by or licensed to the GSK group of companies. CHGBI/CHVOLT/0275/17a(1) Trade marks are owned by or licensed to the GSK group of companies. CHGBI/CHVOLT/0275/17a(1)


3

Contents

Foreword

Page 5: Sustainability of pharmacy is at risk, warn profession

The ‘Brexit Budget’ was announced last month, announcing the largest ever total health budget for 2020 at over ¤17.4bn. There will be a supplementary health budget of ¤335m targeted at HSE overspending – part of this includes a ¤26 million winter plan.

Page 9: Vulnerable medicine shortages targeted

The Irish Pharmaceutical Healthcare Authority (IPHA) has come out stating that adequate allocation must be set aside for new medicines. Continuing to make new medicines available in a timely way is as important as continuing the supply of existing medicines, they say. You can read the full story on page 12.

Page 14: Douglas Pharmacists rising from the ashes

9

Page 18: Regulation of pharmacy under the spotlight Page 22: 9th All Ireland Pharmacy Conference Page 39: Importance of pharmacy in flu vaccine roll-out Page 54: Life Pharmacy celebrate excellence

14

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

ADVERTISING DIRECTOR Debbie Graham: 00353 (87) 288 2371 debbie@ipn.ie DESIGN DIRECTOR Ian Stoddart Design

PHARMACYNEWSIRELAND.COM

@Irish_PharmNews

IrishPharmacyNews

A recent budget briefing hosted in Dublin was attended by Mary Butler TD, Senator Paudie Coffey, and IPU members and community pharmacists, including Mr Connolly, of Haven Pharmacy Connollys in Dungarvan. “Pharmacies continue to bear the scars of FEMPI and are getting tired of waiting around for a reversal of these cuts,” he adds. On page 22 we carry full coverage of the 2019 All Ireland Pharmacy Conference which took place in the Ballymascanlon Hotel. Organised jointly by the Irish Institute of Pharmacy and Northern Ireland Centre for Pharmacy Learning and Development. With a theme centred around the FIP Pharmaceutical Workforce Development goals, the event, now in its ninth year, provided delegates with an opportunity to share in best practice across both primary and secondary care.

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

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

In other news, the Irish Pharmacy Union has also reiterated calls for a reversal of FEMPI fee cuts. “There are currently over 1,900 community pharmacies providing services to people throughout the country. The majority (89%) of these are family owned businesses, each of whom bears the scars of cuts which removed a total of ¤1.54 billion in revenues from the sector between 2009 and 2018,” says President Darragh Connolly.

24 Irish Pharmacy IRISH News is PHARMACY circulated to all NEWS independent, multiple Pharmacists and academics in Ireland. All rights reserved by Irish Pharmacy News. All material published in Irish Pharmacy News is copyright and no part of this magazine may be reproduced, stored in a retrieval system or transmitted in any form without written permission. IPN Communications Ltd. has taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

This issue has clinical features and educational articles looking at conditions ranging from the effects of winter on skin, seasonal ailments, and anorectal conditions. Our end of year December Dynamic 100 issue is up next. If you know someone who has made a difference to the pharmacy profession, or who have demonstrated themselves to be ‘dynamic’ through their work and practice, then please send your nominations directly to the Editor at kelly-jo@ipn.ie

Regulars EDUCATIONAL: RESOURCE FOR NEW MUMS FEATURE: SOUND ADVICE IN EAR CARE TEAM TRAINING: SEASONAL AILMENTS FEATURE: TREATING SKIN IN WINTER PRODUCT PROFILES

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4

News

Pharmacy a ‘valued’ role Health Minister Simon Harris says he ‘values the role pharmacists play in the health service.’ He was making the comments in response to questions put to him during a recent Dail debate. Anne Rabbitte, TD for Galway East

community pharmacy. Important new services, such as influenza vaccination and emergency contraception, have already been introduced.

Two questions were put to the Minister by Anne Rabbitte, TD for Galway East, Fianna Fáil Spokesperson on Children and Youth Affairs. She asked, “if he will honour the commitment he made at a conference to expand the role of community pharmacies to include the full and immediate national roll-out of a minor ailments scheme; the timeframe for the expansion of community pharmacy services to include a minor ailments scheme and the provision of chronic disease management services. “I value the role pharmacists play in the Irish health service. As you

are aware, the Programme for a Partnership Government and the Sláintecare implementation strategy contain commitments to expanding the role of community pharmacy in managing patient health in the community. “Work has been done in recent years on wider healthcare roles for pharmacies, including the Pharmaceutical Society of Ireland’s Future Pharmacy report, on the expansion of professional pharmacy practice. It is clear from this and other work that there is potential to increase the range of both private and publicly funded health services delivered through

“To be funded by the taxpayer, new public health services in community pharmacy, as elsewhere, should improve health outcomes and provide value for money and benefits for patients. Any new or transferred services should be based on sound evidence, with matching improvements in governance and administration. “I recently met with the Irish Pharmacy Union (IPU) when these and other issues were discussed. My officials will be engaging with the IPU on new fee regulations before the end of the year and the intention is to broaden the discussions to contractual and service arrangements during 2020,” she said.

Minister loses Pharmacy Rules split bid The Minister for Health has lost his application to have proceedings challenging proposed new pharmacy rules split into two separate hearings. Pharmaceutical assistants have brought a High Court challenge to proposed new rules restricting the amount of time they can cover for a temporarily absent pharmacist to one hour per day. The Pharmaceutical Assistants Association Company and four women pharmaceutical assistants have brought the case against the Pharmaceutical Society of Ireland (PSI), the Minister for Health and the State. Some 248 women, mostly in their late 50s with an average of 35 years experience, say their livelihoods as assistants will be

seriously affected or lost if the new rules are approved by the Minister. Refusing the application, Mr Justice Anthony Barr said splitting the trial was likely to raise the overall costs of the action and that it important not to deter the applicants from exercising their constitutional right of access to the courts. Pharmaceutical assistants are permitted to carry out the duties of a pharmacist if the pharmacist is temporarily absent. The last course to train and qualify as a pharmaceutical assistant in Ireland commenced in 1982, thus no new

PHARMACYNEWSIRELAND.COM

pharmaceutical assistants have qualified in Ireland since 1985. Mr Justice Barr explained that most pharmaceutical assistants are women over the age of 55. In February 2019, the Pharmaceutical Society of Ireland (PSI) drew up draft rules on the temporary absence of pharmacists – which, if implemented, will have an impact on pharmaceutical assistants. The draft rules can only become effective with the consent of the Minister for Health, who has agreed not to furnish his consent pending the determination of the present proceedings.

Brexit Budget 2020 Budget 2020, also known as Ireland’s ‘Brexit Budget’, is about bringing the Sláintecare health reform programme to life in communities across the country by delivering investment in key strategic supports, according to Health Minister Simon Harris. Minister Harris said the Budget would also provide for expanded eligibility including free GP care for children under 8, free dental care for children under 6 and increased income limits for people over 70 to qualify for a full medical card. The cost of medicines will also be reduced in line with previous Budgets and the Sláintecare Plan. The total health budget for 2020 will be over ¤17.4bn - the largest allocation ever. There will be a supplementary health budget of ¤335m targeted at HSE overspending – part of this includes a ¤26 million winter plan. The main news was a 50 cent reduction in Prescription Charges for all and a monthly threshold for the Drug Payment Scheme is being reduced by ¤10 per month. Furthermore, in an effort to reduce spiraling waiting lists, an additional ¤25 million has been announced in the National Treatment Purchase Fund Other proposals include: • ¤100 million for the National Treatment Purchase Fund (NTPF) to help reduce waiting lists • a reduction of 50c in prescription charges from July • expansion of free GP care to children under 8 and free dental care for under 6s from September • the monthly threshold of ¤124 for the Drug Payment Scheme will be reduced by ¤10 to ¤114 from September • 55 new hospice beds opening in counties Kildare, Mayo, Waterford and Wicklow • opening the new National Forensic Mental Health Hospital at Portrane • the full roll-out of a HIV PrEP programme • ¤25 million in disability funding • investment in the maternity, cancer and dementia strategies, and a new autism plan


News Self-Care key to Health Future Pharmacists and the profession as a whole have said Governments and health insurers should include self-care as an important element of the care continuum and include its coverage as part of their health benefit offerings. The International Pharmaceutical Federation (FIP) and the Global Self-Care Federation (GSCF) issued a joint Statement of Policy last month. The statement, on responsible and effective self-care describes the united intention of the pharmacy profession and the pharmaceutical industry to deliver solutions to facilitate people with self-care and to further develop self-care as a “core pillar of sustainable healthcare systems.” It describes responsibilities for pharmacists and for manufacturers of self-care products. Among the 14 professional responsibilities for pharmacists are to encourage people to use health system resources responsibly and to engage in self-care where appropriate, and to document patients’ self-care conditions and products used in an appropriate patient record. Among 10 responsibilities described for manufacturers are to provide healthcare professionals with available information and scientific evidence that will allow the provision of evidence-based guidance, and to encourage collaboration with healthcare professionals on information on product labels and package inserts. “Pharmacists are key in ensuring the rational selection, the administration and the responsible use of self-care products. Effective care is augmented by a pharmacist’s counselling, support and follow up of an individual to ensure safety and efficacy. We are pleased to work with the GSCF,” said Dr Catherine Duggan, CEO, FIP. “Governments and health insurers are increasingly recognising the value of self-care for its accessibility, enabling individuals to take greater responsibility for their health, and contributing to disease prevention and positive health outcomes,” Judy Stenmark, Director General, GSCF.

5

Sustainability of pharmacy at risk The Irish Pharmacy Union (IPU) is calling for a reversal to the savage FEMPI fee cuts imposed on pharmacies since the recession and the expansion of the services pharmacies can provide in Waterford and around the country. There are currently over 1,900 community pharmacies providing services to people throughout the country. The majority (89%) of these are family owned businesses, each of whom bears the scars of cuts which removed a total of ¤1.54 billion in revenues from the sector between 2009 and 2018. On average, family-run pharmacies saw their income from the State schemes fall by a third during this period. A budget briefing hosted in Dublin was attended by Mary Butler TD, Senator Paudie Coffey, and IPU members and community pharmacists, including IPU President Daragh Connolly, of Haven Pharmacy Connollys in Dungarvan. Speaking at the event Mr Connolly said, “Pharmacies continue to bear the scars of FEMPI and are getting tired of waiting around for a reversal of these cuts. Three years

ago, the Government committed to starting the restoration of fees to pharmacists, to date nothing has happened.

the introduction of nicotine replacement therapy and smoking cessation counselling for medical card holders.

“We have consistently put forward proposals that would help patients in Waterford. In other countries allowing pharmacists practise to full scope delivers better patient outcomes. Pharmacists should be empowered to take pressure off other parts of the healthcare system, including GPs and hospitals.”

“In response to the capacity crisis that appears to be impacting on GPs across the country the IPU has long advocated for a Minor Ailment Scheme. This would allow medical card patients to receive treatment for common illnesses directly from their local community pharmacy without the need for a visit to the GP.”

According to Mr Connolly allowing pharmacists to provide healthcare has been proven to pay dividends. “We would like to see an expansion of the range of vaccines that pharmacists can administer to include vaccination against meningococcal disease, tetanus and hepatitis A and B, as well as travel vaccines. Since July 2017 we have been proposing

He concluded stating that there is, “no shortage of ambition in the pharmacy sector. This is combined with a strong desire to innovate for our patients and deliver primary care system for all. However a failure by Government to do anything meaningful for pharmacy in Budget 2020 risks doing structural damage to the whole profession.”

Meaghers ‘Enterprising’ in Online Retail Meaghers Pharmacy Managing Director recently shared her expertise of the profession with the future generation. Giving a talk to pharmacy students at the Royal College of Surgeons Ireland, Oonagh shared the lessons she has learned to date on leadership. The pharmacy group were also thrilled to have recently been named as one of the Irish retail companies announced for Enterprise Ireland support for our online business. Minister for Business, Enterprise and Innovation, Heather Humphreys TD, recently announced that the pharmacy group are one of 29 recipients of the second call of the pilot Online Retail Scheme. A total of 29 retailers have been awarded ¤659,550 in funding as part of the ¤1.25m fund, which is targeted at online retailers to strengthen their online offering to enable them to reach a wider customer base. Under this second competitive call, the successful applicants will receive funding ranging from ¤10,000 to ¤25,000 to strengthen their online offering. Thomas Burke, Director, Retail Ireland, says, “Online retail remains a challenging space for most Irish retailers. While great strides have been made towards improving the offer to Irish consumers in recent

Oonagh O’Hagan, Pharmacist and MD, Meaghers Pharmacy Group

years, initiatives such as the pilot Online Retail Scheme are a crucial support for our sector and will act as a catalyst to encouraging ever greater numbers of Irish retailers to take on the challenge of selling online. We know more and more Irish consumers are shopping online and we must do all we can to support the Irish retail sector react to that shift in buying patterns and seize the opportunities that exist.” “We will be flying the Irish flag proudly as we take our business into new International markets,” adds Oonagh. “Thank you to all our amazing team who have worked so hard to bring our business this far and to every single customer who have supported us along the way.”

PHARMACYNEWSIRELAND.COM


6

News

On your Marks! Satipharm Brand Ambassador and Ultra Athlete Shane Finn was on hand at the Satipharm stand during the Dublin Marathon talking about how he ran 24 Marathons in 24 days and ran and cycled across America in 36 days. Satipharm Brand Ambassador and Ultra Athlete Shane Finn and Ger Browne, Pharmacist, Carrigtwohill Pharmacy a significant advancement over the current CBD oils and capsules found on shelves in many stores today.

Also taking part in the Marathon was Carrigtwohill Pharmacist Ger Browne who finished with a fantastic time of 3hrs:3:17. As IPN was going to press, Ger and his team raised an over ¤2,000. This money is going towards the Cork Simon Community & Cork Association for Autism. Satipharm have recently released a new CBD capsule, which has clinically proven bioavailability, provides a reliable dose and is GMP manufactured, and which is now nationally available in pharmacy in Ireland.

The new CBD capsule comes from Satipharm, a health and wellness company specialising in the development and manufacture of cannabinoid-based products from the cannabis and hemp plants. Satipharm CBD capsules are 350% more effective than CBD oils*. The capsule contains Satipharm’s advanced Gelpell® technology, which places CBD into seamless micro-beads. These Gelpell® beads provide a clinically proven level of bioavailability, which is over three and a half times higher than that of standard CBD oils, representing

CEO of Satipharm Ireland Jonathan Hartshorn said, “Our goal at Satipharm is to provide CBD and other cannabinoids in the best possible formats and, importantly, to educate pharmacists, counter staff and consumers in the proven benefits of Satipharm products. “Placing CBD into our proprietary Gelpell® technology ensures over three times more CBD reaches the body than the same dose of CBD oil.” * Single-Dose Pharmacokinetics of Oral Cannabidiol Following Administration of PTL101: A New Formulation Based on Gelatin Matrix Pellets Technology.

Working Group report on Access to Contraception An overview of the challenges involved in providing free contraception but also a clear pathway to doing so, has been published by the Minister for Health Simon Harris TD. “I strongly believe cost should not be a barrier to accessing contraception,” the Minister said on publishing the Report of the Working Group on Access to Contraception. The Minister established the Group earlier this year to consider the policy, regulatory and legislative issues relating to enhanced access to contraception, following the recommendation of the Joint Committee on the Eighth Amendment. Publishing the report, the Minister said, “I want to thank my Department for this piece of work and to those who contributed through the public consultation. The Oireachtas Committee on the Eighth Amendment recommended free contraception and we have made significant progress in this regard. “In 2018, more than 409,300 condoms and 288,000 lubricant sachets were delivered through the National Condom Distribution Service to organisations working directly with people at increased

risk of unplanned pregnancy or STIs. Later this year, we will expand this service and introduce vending machines across third level colleges to increase the distribution of free condoms and further promote safer sex among young people.” The Minister acknowledged that the cost to the state of introducing a free contraception scheme would be significant and welcomed the report's consideration of other options to reduce the costs involved in accessing contraception. Minister Harris added, “It is important to note that the report says that there are considerations beyond the economic that should be taken into account when developing policy in this area, and this is something with which I wholeheartedly agree. “I will continue to work with my Department officials to move forward on this issue and I hope to make progress in this regard next year.”

PHARMACYNEWSIRELAND.COM

Some key messages in the report are as follows:  the policy issues arising around improved access to contraception are complex and multi-faceted;  barriers to accessing contraception do exist for some people, including lack of local access, cost, embarrassment, inconvenience and lack of knowledge. However, the vast majority of people can and do access contraception without any difficulty and contraception use in Ireland is high and stable;  evidence suggests that there is not a widespread affordability issue, with only 3% of respondents in the Irish Contraception and Crisis Pregnancy Study 2010 identifying cost as a barrier to contraception.  simply making contraception free to the user is not necessarily a solution, and it is essential that any policy proposal focuses on accessibility, education and workforce capacity as well as cost.

Vitamin D Deficiency New research from Trinity College Dublin shows that vitamin D deficiency is an important determinant of poor skeletal muscle function in adults aged 60 years and over. Maintaining skeletal muscle function throughout life is a crucial component of successful ageing, in promoting independence, mobility, quality of life and reducing falls and frailty. While resistance exercise is known to preserve muscle function, there is growing evidence that adequate vitamin D status may also be protective. The paper was recently published in the international journal Clinical Interventions in Ageing. • The prevalence of muscle weakness was twice as high among older adults with vitamin D deficiency (40.4%) compared with vitamin D adequacy (21.6%). • Similarly, impaired ‘muscle performance’ was 3 times higher in older adults with vitamin D deficiency (25.2%) compared with vitamin D adequacy (7.9%). • Based on more complex statistical analysis, the study showed that vitamin D deficiency significantly increased the likelihood of impaired muscle strength and performance. • In summary, vitamin D deficiency was associated with impaired muscle strength and performance in a large study of community-dwelling older people. • It is generally accepted that vitamin D deficiency (at the 25(OH)D <30 nmol/L cut-off) should be reversed to prevent bone disease, this strategy may also protect skeletal muscle function in ageing. Maria O’Sullivan, Associate Professor in Nutrition at Trinity College Dublin said, “Our results show that vitamin D deficiency increased the likelihood of poor muscle function in older adults and confirms the protective effect of physical activity. Maintaining muscle function is incredibly important, and often overlooked, in promoting healthy ageing. Addressing this through multimodal approaches that incorporate physical activity, reversing vitamin D deficiency and other modifiable diet and lifestyle components require further investigation.”


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News Patient level Pharmacy Recalls The Healthcare Products Regulatory Authority (HPRA) has advised that PharmaSwiss (Ceska republika s.r.o.) is recalling all lots (batches) of Emerade 150mcg pre-filled pens, Emerade 300mcg pre-filled pens and Emerade 500mcg pre-filled pens. These products are used for the emergency treatment of acute allergic (anaphylactic) reactions. The recall is taking place as some Emerade pens may fail to produce an injection when used, due to failure of the pen to activate and the potential for a blocked needle. Anyone who possesses an Emerade pen for their own use or for someone in their care is urged to ensure that their pens are brought back to their pharmacy and immediately replaced with an alternative product. The HPRA states that no other brand of adrenaline pens is impacted by this recall. The affected products are all batches of: • Emerade 150mcg pre-filled pens • Emerade 300mcg pre-filled pens • Emerade 500mcg pre-filled pens The HPRA has also been notified of a shortage of the following products: • Champix 1mg Film Coated Tablet – EU/1/06/360/016 • Cykloapron 500mg/5ml Solution for Injection/Infusion – PA0822/117/001 • Femoston-Conti 0.5mg/2.5mg Tablet – PA2010/012/003 • Losartan Hydrochlorothiazide 100mg/25mg Tablet – PA0749/026/002 • Mitomycin Kyowa 10mg Powder for Solution for Injection – PA2288/002/001 • Mitomycin Kyowa 40mg Powder for Solution for Injection – PA2288/002/002 • Septrin Forte 160mg/800mg Tablet – PA1691/010/002 • Tamoxifen 20mg Tablet – PA0577/207/001 • Tractocile 6.75mg/0.9ml Solution for Injection – EU/1/99/124/001 • Warfant 3mg Tablet – PA0073/139/002

9

Filling the Gap in Pharmacy Shortages A new Irish pharmaceutical company, Azure Pharmaceuticals (‘Azure’), has officially launched in the medicines market. Azure’s focus will be on prescription medicines, those older, off-patent medicines which have disappeared or are at risk of disappearing from the market. Aideen Kenny, Director and Sandra Gannon, CEO, Azure Pharmaceuticals These medicines, still seen by physicians as staples in their arsenal, are used by tens of thousands of Irish patients but are vulnerable to shortages. As the focus of payers and healthcare professionals move to newer and more expensive medicines, the prices for older medicines have been consistently reduced, while the cost of regulation has unerringly risen. As a result, the number of suppliers has, in many cases, been dwindled to one single supplier. The latter scenario has increased the risk of shortages, if that last supplier then itself experiences manufacturing issues. Medicine shortages in the Irish and global markets are not new phenomena, but they have become a much larger issue in recent years. Internationally, it has been termed “pharma famine”, and it often occurs as a result of manufacturing issues which then interrupt the global and Irish supply chains. Ireland is particularly vulnerable because of its small market size and lack of multiple suppliers. According to the HPRA, there are currently more than 150 medicines out of stock, and it is feared that this number will grow significantly post-Brexit. For patients, medicine shortages are more than just an inconvenience: they can have detrimental impacts on their treatment regimes. Pharmacists are spending increasing amounts of time trying to source alternative medicines rather than consulting with patients on the frontline. From the perspective of the HSE and taxpayers, when medicines are out of stock the HSE is often forced to use unlicensed medicines to meet patient needs. These can cost multiples of the original out-ofstock medicine. To address these issues, Azure has established several strategic partnerships with global manufacturers to re-introduce these medicines to the Irish market and to offer alternative supply for single-source, older medicines to pharmacists and the HSE. The first products in the pipeline will

“Medicines that regularly experience shortages or are only available without a license undermine patients’ access to treatment. Not only is it challenging for patients day-to-day, it also risks causing larger health issues and placing a greater burden of care on our already stretched health services” reach the market here in November 2019 with a continuous stream of launches coming to market over the coming years. Azure management track record The management team behind Azure Pharmaceuticals have decades of experience in the Irish medicines market and were to the fore in bringing generics to the market here; they were later instrumental to the significant growth of the generic medicine usage. This now stands at almost 60% of all medicines consumed in the Irish market. With this strong track-record, Azure are now seeking to once again bring this entrepreneurial and commercial drive to this latest venture to create a new dynamic in the Irish medicines market. Azure CEO Sandra Gannon says, “We are delighted to be officially launching in the Irish market. We are particularly pleased that the company’s commercial focus will help address a growing problem for patients, pharmacists, and our health service. “Medicines that regularly experience shortages or are only available without a license undermine patients’ access to treatment. Not only is it challenging for patients day-to-day, it also risks

causing larger health issues and placing a greater burden of care on our already stretched health services. “Feedback from pharmacists on Azure’s proposition has been overwhelmingly positive. Dealing with medicine shortages or sourcing unlicensed medicines is time-consuming for pharmacists and costly to the State. We want to work with stakeholders to tackle these supply issues. “In terms of our business model, we understand the dynamics in medicines market here and where the weaknesses are and will be in the future. We will bring a new focus to this part of the market and in doing so, deliver better service and value to the State and healthcare professionals. “For patients, our products will grant greater access to essential medicines. We believe that Azure’s arrival in the market is timely given the current extent of medicine shortages and the fact that they are likely to worsen after Brexit. “As a new company, with an ability to be agile and innovative, we believe that we can make a significant contribution to address supply issue while also driving competitive pricing.”

PHARMACYNEWSIRELAND.COM


These Shoes are Made for Walking! Australian Pharmacist recently set foot on Irish soil as she continued her pharmacy adventure in pursuit of innovation and education. Goondiwindi’s Lucy Walker is currently on a global tour visiting pharmacies around the world in order to observe different approaches, new offerings and professional services with the aim of bringing back to her native country some fresh ideas for pharmacy practice. Award-winning pharmacist Lucy was this year awarded a prestigious Churchill Fellowship worth $27,000 in honour of the former UK Prime Minister Global Inspiration She is one of only a handful of pharmacists to win the honour and is now spending seven weeks visiting pharmacies overseas to learn about professional services on offer.

She is one of 112 Australians awarded a 2018 fellowship and says she's keen to bring back new ideas from overseas. Lucy says, "It's an opportunity to go outside of what we see here in Australia and discover what people throughout the world are doing. I would like to try and bring those ideas and concepts back to Australia to improve our healthcare. “All pharmacists love going to other pharmacies to see what they are doing, so this is just a chance to go that little bit further.” The fellowship aims to allow Australians to travel overseas to conduct research that isn’t readily available to them.

A non-pharmacist friend suggested she apply while they were discussing her 2017 Guild Pharmacy of the Year win and what learning challenge she could tackle next. “It’s an involved process,” she says. “I had to submit an itinerary for where I wanted to go and why and there was an interview process that was quite scary. I had 12 people firing off all these questions.” Building an Itinerary

Lucy also plans to use the knowledge she has gained to help advance pharmacy practice nationally, through her position on the Guild’s national pharmacy transformation committee and the TerryWhite Chemmart advisory group. “I’m hoping I can try things in my pharmacy and if it works, we can take it further.”

The funds have enabledLucy to travel to Abu Dhabi for the 2019 FIP conference held last September, at which her networking helped build on her itinerary of pharmacy visits.

Ms Walker believes the fellowship provides broader endorsement of the need to expand pharmacy services and to allow pharmacists to practice to their full scope.

From there, she visited Scotland and England before touching down in Ireland. The USA, Canada and New Zealand are also on her itinerary, with the aim of bringing back innovative pharmacy practices to her own pharmacy, TerryWhite Chemmart Goondiwindi.

Reflecting on Innovation

Her goal is to focus on the aspects each country do best, focusing on professional services, technology enablers and education of pharmacists and the public. In Scotland, for example, pharmacists run a minor ailment

Des Morrissey and Jonathon Morrissey, Marrons Pharmacy Clane with Lucy Walker

10 | PHARMACYNEWSIRELAND.COM

service, while US pharmacies have an important role in medication adherence.

“I think the general community is starting to appreciate what pharmacists and pharmacies can do for our health.”

Whilst in Ireland, she visited with the Irish Pharmacy Union, Marron’s Pharmacy in Clane, Killian’s CarePlus in Louhgrea and spent time with the team at Pharmapod. “I have immensely enjoyed the hospitality I was shown on my trip to Ireland,” she reflects. “Ireland is definitely ahead of Australia in some respects, such as in funding for opiate substitution, flu vaccinations, specialty medications and soon contraception and PrEP. “But not in all instances, thinking of medication reviews and of course,


Lucy Walker, the Pharmacy Adventurer

owner I am really impressed with how under the NHS, pharmacists and all in the healthcare team collaborate well to improve health. “In Scotland I was greatly encouraged by the advanced scope of pharmacist practice, collaboration with GP's and innovative use of technology in Scotland. I love their consumer focused think Pharmacy First and consultation practices.

the Rugby! It was very interesting to hear more about Pharmapod, a health learning system to reduce medication errors that started here and is spreading around the world. “I also had an amazing, inspiring time visiting Marron's Pharmacy, the multi award winning family pharmacy of Jonathan Morrissey. Luckily for me, the legendary past owner and grandfather of Jonathan, Des and Edel, Jonathon’s Aunt and Front of Shop Manager sang for me in the pharmacy too. “I was really impressed with Jonathan’s ear and throat exams, plus the 24-hour ambulatory blood pressure monitoring program. “We share similar challenges and it's interesting to see how Ireland approach them differently, together I believe, we can improve access to pharmacy services in both our countries.” Lucy’s TerryWhite Chemmart Goondiwindi in South West Queensland is a standout rural pharmacy which has a widelyrecognised connection with the community in the town and surrounding rural areas. “I am really enjoying this pharmacy adventure, the highlight is meeting other inspiring pharmacists. It’s my aim to bring global innovative pharmacy practices to my rural practice in Goondiwindi, and try to add value to services nationally,” she adds. Whilst visiting England, she spent time with Boots UK. “Fifteen years ago I was a pharmacist for Boots UK and the British have continued to advance pharmacy practice.Gary Primrose shared what Boots is currently doing and introduced me to Bina, their advanced pharmacist at Piccadilly Circus who described all their services. I spent time with Anita Burdon who is an independent prescriber at St Cuthbert's Hospice and pharmacy

“I really have to say a huge ‘Thank You’ to the awesome people who shared their time, knowledge, ideas and passion, it’s been a highlight so far on my Pharmacy adventure,” she added.

Lucy Walker with Eoghan Hanley, Killian’s CarePlus Pharmacy, Galway

Whilst visiting pharmacy services across the US, Lucy was able to gain insights into their programmes. “USA has the most amazing well trained, DPharm pharmacists and the best programs to improve patient medication adherence, but their healthcare system has some flaws,” she said. “Supermarkets with pharmacies can give away diabetic medications to get the ‘right customers’ coming into their grocery stores. Insurance companies incentivise 90 days initial supply to improve patient compliance but removes regular touch points to address questions and concerns. “Pharmacy Benefit Manager’s (PBM), a layer of bureaucracy between pharmacy and insurance companies, pay pharmacies months after dispensing without a known agreed value and medication costs are high. This left me worried about the sustainability of community pharmacy in the USA and concerned that Australia may follow you.

Irish Pharmacy Union Secretary General Darragh O’Loughlin with Lucy Walker

“Everyone I met in the states was extremely smart and focused on improving the health of their patients using the most innovative practice, so I hope they can improve the system to better the health of all Americans. An unexpected learning during my adventure.” In Canada she visited Calgary and Edmonton where she met with the Alberta College of Pharmacy, Alberta Pharmacist’s Association and the EPICORE Centre “It was amazing to hear their insights, challenges and wins and how we could implement change in Australia. Thought provoking visits and amazing hospitality,” she added.

Lucy Walker and Claire Fitzell, Professional Services Pharmacist, Irish Pharmacy Union

PHARMACYNEWSIRELAND.COM | 11


12

Budget 2020

New Medicines vital to ¤1bn health budget An adequate allocation out of Ireland’s €1bn health budget must be made for new medicines, it has been claimed. The Irish Pharmaceutical Healthcare Association (IPHA) has said the ‘Brexit budget’ must not further delay the Health Service Executive’s approval of new medicines, causing standards of care for patients to fall relative to European countries. The industry body said the large savings generated by its members’ discounts and rebates on existing medicines should be clearly and deliberately invested into new, innovative treatments. The move would arrest the continued slide in State funding for new medicines in recent years, with the shortfall causing patients in Ireland to wait much longer than their peers in western Europe for access to the latest treatments. “The pharmaceutical industry is a key presence in Ireland’s economy, generating value through jobs and investments that are regionally spread. The industry appreciates the challenges posed by a potential no-deal Brexit. We continue to support the Government’s efforts to ensure the supply of medicines to

patients in all scenarios,” said IPHA’s Chief Executive, Oliver O’Connor. “However, continuing to make new medicines available in a timely way is as important as continuing the supply of existing medicines. Otherwise, the standard of care for Irish patients falls back. Over recent years, Ireland has been slow and late in approving new medicines. Today’s Budget must not further slow the approval of vital new medicines for patients,” he added. “In this Brexit budget, it is all the more important that savings be transparently invested in new medicines. “We are convinced the promising new medicines and therapies can be funded for timely access. We are open to discussing further solutions with the Government but the priorities must be clear: faster access to new medicines, funded transparently both by savings and an Exchequer allocation. As the HSE prepares its service plan over the coming weeks, medicines must be treated as an investment in standards of

Healthwest open Second Store Healthwest Community Pharmacy have recently opened their second store in Ballyhaunis.

care for patients - and not just as another cost,” said Mr O’Connor. The Government’s own analysis in summer showed that health spending increased by ¤4 billion over 2014-18. “More than 90% of health spending growth was on areas other than medicines, like pay and pensions. Less than 10% was on medicines. Without an additional Exchequer allocation for new medicines, today’s Budget will worsen that trend. New staff without new medicines on time will not add up to best standards of care,” said Mr O’Connor. The industry has an agreement in play with the State on the pricing and supply of medicines. This is the last year of the agreement’s four-year lifespan. The agreement provides stability and certainty for the State and for patients, setting certain parameters on the pricing of medicines and ensuring continuity in the supply of medicines. The projected savings over the four years through discounts and rebates is ¤785 million.

Brian joins Stacks Pharmacy Brian Battles has joined the team at Stacks Pharmacy Group as Dispensary Operations Manager. Brian brings with him a wealth of experience and looks forward to becoming a key member of the Stacks team.

Pharmacist and Owner Ultan Molloy says, “This opening represents a significant investment in the locality, and we've had fantastic support and

visits to date. It’s an ethnically diverse and engaged community, and we are delighted to be part of it.”

PHARMACYNEWSIRELAND.COM

Progress of FMD The National Safety Features Oversight Group comprising the Irish Medicines Verification Organisation (IMVO), the Department of Health, the Health Products Regulatory Authority (HPRA), the Pharmaceutical Society of Ireland (PSI), the Health Service Executive (HSE) and the Private Hospitals Association (PHA) continues to meet regularly to monitor implementation of FMD in Ireland. The use and learn period will end on a phased basis starting from 31st January 2020. Wholesalers, pharmacies and hospitals:  Ensure your FMD system(s) is connected to the IMVS and working correctly.  Scan medicines bearing safety features in accordance with the obligations to verify and decommission packs placed on wholesalers, pharmacies and hospitals by the Commission Delegated Regulation on Safety Features and Irish national legislation (see also IMVO website for guidance). The data generated from these scans is critical for identifying root causes of alerts and other issues that need to be resolved in order to ensure an orderly ending of the use and learn period, with minimal disruption to end-user workflow and patient supply.  If an alert or any other unexpected message is flagged, continue to supply packs in accordance with your existing procedures, unless there are overriding concerns that a falsified medicine is involved.  Notwithstanding the above, if you have reason to believe that packaging has been interfered with, based on your examination of the anti-tamper device or anything else unusual with the pack or its contents, you must report this concern to the HPRA as a suspected quality defect (via the usual reporting mechanisms) and not supply the pack.  Pharmacies with wholesaler’s authorisations are reminded that they require a separate registration with IMVO and connection to the national system for their wholesaling activities. The pharmacy connection to the national system must not be used for wholesaling activities (and vice versa).


NEW

TREATS HEARTBURN AND ACID REFLUX. ONE TABLET PER DAY. LASTS 24 HOURS. AVAILABLE IN PACKS OF 7s AND 14s. Marketed by

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

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


Michael O’Connor, Pharmacist & Director, Pharmacy First Plus Group

Pharmacy Rising from the Ashes A recent fire at a shopping centre in Douglas, Cork, is bringing misery to two local community pharmacy owners and stirring memories for another in Donabate. The blaze broke out at the Douglas Village Shopping Centre last month. Twelve fire appliances attended the incident with one firefighter sustaining minor injuries, it was reported. The cause of the fire is not yet known. Gardaí (Irish police) have launched an investigation. A Douglas based pharmacy that has been closed since the fire has been delivering medication to its patients in need. Michael O'Connor of Pharmacy First Plus, based in Douglas Village Shopping Centre, revealed the pharmacy has turned to deliveries to ensure patients who require medicine from the pharmacy are not impacted. He said the delivery service has been busy. "We started deliveries on and are working every day and late into the day. “We're just trying to maintain as much of our customer base as possible and to facilitate people. “They're worried about their own medication and we're trying to alleviate that and facilitate them as best we can," he added. The pharmacy has been in business at the shopping centre since 1976, when it

was established by Mr O'Connor's father.

pharmacy in the group which are accommodating our staff.

He explained that there needs to be support for the existing tenants. He also called for the elimination of parking charges in Douglas Village. “That's 1,000 parking spaces gone as a result of the fire,” he explained.

“That has been a huge help to us and has allowed us to get up and running. We also got our phones diverted to a mobile early on Monday morning so we are taking calls and directing people on what they can do.”

“The only spaces that are available now are those that are charging by the hour and that's a huge disincentive now to come into Douglas.

Disaster for the Community

“There are other businesses in Douglas that are going to be impacted by the loss of parking spaces in the shopping centre,” he added. “They're going to start feeling that pain so for the area of Douglas, we need help from local government to alleviate as much of that pain as possible.” In terms of his own staff, Mr Connor said management was able to redeploy them and the pharmacy is taking calls on a mobile phone. We're lucky to have the support of another

Conor Falvey, Pharmacist & Owner, Falvey’s Pharmacy, Douglas

14 | PHARMACYNEWSIRELAND.COM

“It’s a disaster for the village,” is how the owner of Falvey’s pharmacy, Conor Falvey, summed up the fallout from the fire in Douglas Shopping Centre that has forced its temporary closure. His pharmacy is, as he describes it himself, “part of the centre, but

also part of the village”, located right outside the automated exit doors that front onto Main Street. Mr Falvey said the closure of the shopping centre, a terrible blow for the traders located within and their employees, would also seriously affect footfall in the village, with the number of carparking spaces reduced by over 1,000 overnight. Mr Falvey recalled the damage caused by flooding in 2012 when businesses in the area were forced into temporary closures. He said the village was also blighted by many empty retail units and the introduction of paid parking, which traders had tried to resist.


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16

News

Pharmacies vying for National Store Accolade Three pharmacies have made the shortlist for the Retail Excellence’s National Store of the Year Award. Cunningham’s Pharmacy in Monksland Athlone, McCauley Health & Beauty Pharmacy, Charlemont Dublin and Phelan’s Pharmacy, Skehard Road, Cork are all in the running. Great excitement at Cunningham’s Pharmacy Monksland who made it to the Top 30

November 9th in the Great Southern Hotel, Killarney, County Kerry at the AIB Merchant Services Retail Excellence Awards 2019. Owner and Pharmacist of Cunningham’s Pharmacy, Paul Cunningham stated, “We are thrilled to that our Monksland Store made it to the Top 30 and for our Dublin Road Store to have made it to the Top 100 Stores we are super proud. A huge thank you to our entire team across both stores.” The Store of the Year competition is the central part of the Retail Excellence Annual Awards, which were established in 1997 to promote best practice and encourage the highest standards in the Irish Retail Industry. They are now the largest and most prestigious of their kind in Ireland. Retail Excellence, the largest retail industry representative organisation in Ireland, will announce the National Store of the Year winner at a black-tie Awards banquet on Saturday,

David Fitzsimons, Group Chief Executive of Retail Excellence commented, “All our finalists are superb retail offerings and we are delighted to see them progress to this stage of the competition. Their journey through our Awards

Cunningham’s Pharmacy Monksland and Dublin Road who both made the Top 100

process will culminate on November 9th in Killarney where we will announce our National Store of the Year Winner along with the sectoral winners. “As always the competition is intense and with the coveted nature of the title every finalist has reached new heights in promoting

retail excellence within their operations which makes it all the more difficult to select the overall winner. Unfortunately, there can only be one National Store of the Year but their journey to this point is testament to the hard work of the owners, their staff and investment in their retail operations.”

Local Pharmacies champion Breast Cancer awareness Community pharmacies across Ireland have been playing their part in encouraging women to be breast aware. October marks Breast Cancer Awareness month and with one in 10 women developing breast cancer during their lifetime this message has become even more important. One of those taking part was Foxford Pharmacy in Co Mayo, who held a bake sale and raised a staggering ¤900 for the Breast Cancer ‘Cups to Cancer’ Campaign. Every year over 3,000 people are diagnosed with breast cancer in Ireland.

The pharmacy team from Foxford Pharmacy, Co Mayo with Hamper prize winner Mary Molloy

PHARMACYNEWSIRELAND.COM


Budesonide/Formoterol Easyhaler

Maintenance and Reliever Therapy

1. SHAKE

2. CLICK

3. INHALE

5 MIN

LESS THAN 5 MIN TO MASTER.1

Prescribing Information Bufomix Easyhaler 80 mcg/4.5 mcg, 160 mcg/4.5 mcg and 320 mcg/9.0 mcg/inhalation, inhalation powder (budesonide/ formoterol fumarate dihydrate) Indication: Asthma All strengths: Bufomix Easyhaler is indicated in adults and adolescents aged 12-17 years, for the regular treatment of asthma where use of a combination (inhaled corticosteroid and long-acting ß2 adrenoceptor agonist) is appropriate: patients not adequately controlled with inhaled corticosteroids and “as needed” inhaled short acting ß2 adrenoceptor agonists or patients already adequately controlled on both inhaled corticosteroids and long acting ß2 adrenoceptor agonists. Bufomix Easyhaler 80 mcg/4.5 mcg: is also indicated for asthma in children aged 6 years and older; not appropriate in patients with severe asthma. COPD 160 mcg /4.5 mcg and 320 mcg /9.0 mcg: Symptomatic treatment of patients with severe COPD (FEV1 < 70% predicted normal) and a history of repeated exacerbations, who have significant symptoms despite regular therapy with long acting bronchodilators. Dosage and Administration: Asthma Not intended for the initial management of asthma. The dosage of the components is individual and should be adjusted to the severity of the disease; Maintenance therapy: Advise patients to have their separate rapid acting bronchodilator available for rescue use at all times. Increasing use of a separate rapid-acting bronchodilator warrants a reassessment of the asthma therapy. Bufomix Easyhaler 80 mcg/4.5 mcg and 160 mcg/4.5 mcg: Adults (18 years and older): 1-2 inhalations twice daily, up to a maximum of 4 inhalations twice daily. Adolescents (12- 17 years): 1-2 inhalations twice daily. Children (6-11 years): Bufomix Easyhaler 80 mcg/4.5 mcg 2 inhalations twice daily. Bufomix Easyhaler 160 mcg/4.5 mcg is not recommended for children under 12 years. Bufomix Easyhaler 320 mcg/9 mcg: Adults (18 years and older): 1 inhalation twice daily, up to a maximum of 2 inhalations twice daily. Adolescents (12–17 years): 1 inhalation twice daily. Bufomix Easyhaler 320 mcg/9 mcg should be used as maintenance therapy only, and is not recommended for children under 12 years. All strengths: When control of symptoms is achieved with the twice daily regimen, titration to the lowest effective dose could include once daily use, when a long acting bronchodilator would be required to maintain control. Maintenance and reliever therapy: Advise patients to always have Bufomix Easyhaler available for rescue use at all times. Monitor closely for dose-related adverse effects in patients who frequently take high numbers of Bufomix Easyhaler as-needed inhalations. Bufomix Easyhaler 80 mcg/4.5 mcg and 160 mcg/4.5 mcg: Adults and adolescents (12 years and older): Usually 2 inhalations daily; for 160mcg/4.5mcg only, a maintenance dose of 2 inhalations twice daily may be appropriate. 1 additional inhalation as needed in response to symptoms; if symptoms persist after a few minutes, an additional inhalation should be taken, maximum 6 inhalations on any single occasion. A total daily dose of more than 8 inhalations is not normally needed; however, a total daily dose of up to 12 inhalations could be used for a limited period. Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice. Children under 12 years: maintenance and reliever therapy not recommended. COPD Bufomix Easyhaler, 160 mcg/4.5 mcg: Adults: Two inhalations twice daily. Bufomix Easyhaler 320 mcg/9mcg: Adults: 1 inhalation twice daily. Contraindications: Hypersensitivity to budesonide, formoterol or lactose. Warnings and Precautions: Taper dose when the treatment is discontinued. Patients should seek medical attention if treatment is ineffective, or they exceed the highest recommended dose of Bufomix Easyhaler. Reassess if dose of rescue bronchodilators increases. Sudden and progressive deterioration in control of asthma or COPD is potentially life threatening and the patient should undergo urgent medical assessment. Patients should be advised to have their rescue inhaler available at all times. Remind patients to take their maintenance dose, even when asymptomatic. Once asthma symptoms controlled, consideration may be given to gradually reducing the dose. Regular review of patients as treatment is stepped down is important. The lowest effective dose should be used. Do not initiate during an exacerbation, or significantly worsening or acutely deteriorating asthma. Serious asthma-related adverse events and exacerbations may occur during treatment. Patients should continue treatment but seek medical advice if asthma symptoms

remain uncontrolled or worsen. Paradoxical bronchospasm may occur. Not intended for regular prophylactic use, e.g. before exercise. Systemic effects may occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. Visual disturbance may be reported with corticosteroids, consider referral to an ophthalmologist for symptoms such as blurred vision or other visual disturbances. Potential effects on bone density should be considered, particularly in patients on high doses for prolonged periods that have coexisting risk factors for osteoporosis. If adrenal function is impaired from previous systemic steroid therapy, care should be taken when transferring patients. Oral steroid dependent patients transferred to inhaled budesonide may remain at risk from impaired adrenal function for some time, regularly monitor HPA axis function. Prolonged treatment with high doses of inhaled corticosteroids may result in clinically significant adrenal suppression. Consider additional systemic corticosteroid cover during periods of stress. Rapid reduction in the dose of steroids can induce acute adrenal crisis. Do not stop abruptly. During transfer from oral therapy a generally lower systemic steroid action will be experienced which may result in the appearance of allergic or arthritic symptoms. Specific treatment should be initiated for these conditions. A general insufficient glucocorticosteroid effect should be suspected if, in rare cases, symptoms such as tiredness, headache, nausea and vomiting should occur. To minimise risk of oropharyngeal candida infection, patients should rinse their mouth with water after inhaling the maintenance dose. Avoid concomitant treatment with itraconazole, ritonavir or other potent CYP3A4 inhibitors. Administer with caution in patients with thyrotoxicosis, phaeochromocytoma, diabetes mellitus, untreated hypokalaemia, hypertrophic obstructive cardiomyopathy, idiopathic subvalvular aortic stenosis, severe hypertension, aneurysm or other severe cardiovascular disorders, such as ischaemic heart disease, tachyarrhythmias or severe heart failure. Caution when treating patients with prolongation of the QTc interval. Special care needed in patients with active or quiescent pulmonary tuberculosis, and fungal and viral infections in the airways. Potentially serious hypokalaemia may result from high doses of β2 adrenoceptor agonists; this may be potentiated by hypoxia and concomitant treatment with xanthine-derivatives, steroids and diuretics; use particular caution in acute severe asthma, monitor serum potassium levels. Additional blood An increased incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids, so physicians should be vigilant for the possible development of pneumonia. glucose controls should be considered in diabetic patients. Contains lactose. The amount does not normally cause problems in lactose intolerant people. The excipient lactose contains small amounts of milk proteins, which may cause allergic reactions. Paediatric population: Regularly monitor the height of children receiving prolonged treatment; consider referring the patient to a paediatric respiratory specialist. Undesirable Effects: The most common drug related adverse reactions, such as tremor and palpitations, tend to be mild and usually disappear within a few days of treatment. Common (≥ 1/100 to < 1/10), candida infections in the oropharynx, pneumonia (in COPD patients), headache, tremor, palpitations, mild irritation in the throat, coughing, hoarseness. Uncommon ( 1/1000 to < 1/100), aggression, psychomotor hyperactivity, anxiety, sleep disorders, dizziness, vision blurred, tachycardia, nausea, bruises, muscle cramps. Rare ( 1/10 000 to < 1/1000), Immediate and delayed hypersensitivity reactions, hypokalaemia, cardiac arrhythmias, bronchospasm. Very rare (< 1/10 000), Cushing’s syndrome, adrenal suppression, growth retardation, decrease in bone mineral density, hyperglycaemia, depression, behavioural changes (predominantly in children), taste disturbance, cataract and glaucoma, angina pectoris, prolongation of QTc interval, variations in blood pressure. Legal Category: POM S1B. Product Authorisation Numbers: Bufomix Easyhaler 80 mcg/4.5 mcg/inhalation, inhalation powder, PA1327/015/004 Bufomix Easyhaler, 160 mcg/4.5  mcg/inhalation, inhalation powder, PA1327/015/002; Bufomix Easyhaler, 320 mcg/9 mcg/inhalation, inhalation powder, PA1327/015/003. Distributed by: Orion Pharma (Ireland) Ltd. c/o Allphar Services Ltd, 4045 Kingswood Road, Citywest Business Park, Co Dublin, Ireland . Full prescribing information is available on request. Bufomix Easyhaler is a registered trademark. Date of Prescribing Information: December 2018.

REFERENCES 1. Tamási L, Szilasi M, Gálffy G. Clinical Effectiveness of Budesonide/Formoterol Fumarate Easyhaler® for Patients with Poorly Controlled Obstructive Airway Disease: a Real-World Study of Patient-Reported Outcomes. Adv Ther 2018;35(8):1140–52.

Date of Item: July 2019 /Code EASYH-438


18

News

Experiences of the Regulation of the Pharmacy Profession The Pharmacy Act 2007 updated and revised the regulatory model for the profession and practice of pharmacy in Ireland. Since its introduction, no review of the Act or its implementation had been undertaken. share their experiences of the Act and its implementation by the PSI. Dr Lynch told the All Ireland Pharmacy delegates, “Overall, the community pharmacists interviewed did not perceive the Act and its implementation by the PSI interviewed as fulfilling the principles of better regulation. While there was agreement that the Act was necessary, they did not view its implementation as effective, targeted proportional, transparent or consistent. “They perceived the PSI as not being sufficiently accountable for the discharge of its statutory duties under the Act and participants did not view the Act as sufficiently agile to respond to on-going changes in pharmacy practice.”

A new study has been carried out to address this, and was presented last month at the ninth All Ireland Pharmacy Conference. It examined how community pharmacists in Ireland experience the Act and its implementation. The study was carried out earlier this year by Dr Matthew Lynch from the School of Pharmacy at the Royal College of Surgeons

Ireland and Dr Naonori Kodate from the School of Social Policy, Social Work & Social Justice, University College Dublin, Dublin and the Public Policy Research Centre, Hokkaido University, Japan in association with the Institute of Public Administration.

by the Act, its implementation and their perception of it as fulfilling the seven principles of ‘better regulation’: Necessity; Effectiveness/Targeted; Proportionality; Transparency; Accountability; Consistency and Agility.

They undertook to describe how community pharmacists experience the model of regulation introduced

20 community pharmacists were selected to participate in a semistructured, one-to-one interview to

The study concludes that those community pharmacists who took part acknowledged the need for a Pharmacy Act to regulate the practice and profession of pharmacy but considered that the PSI needs to adopt a more responsive approach if it is to fulfil the principles of better regulation. The principles of better regulation provide an effective methodology to qualitatively study models of professional regulation. The study findings are of interest, says the study authors, as there is little research published on how those who are subject to regulation experience its provisions.

First of its kind Study A new study carried out in Cork has shown that bifidobacteria, which is commonly found in the guts of newborns but tends to decline as people age, can prevent and heal ulcers caused by the painkiller aspirin. A first-of-its-kind study, it builds on scientific observations from APC Microbiome Ireland published earlier this year, which showed that some bifidobacteria produce a protective protein which promotes healing of the intestinal epithelial lining. Secondly, the new work now provides objective endoscopic (photographic) evidence in human volunteers that aspirininduced ulcers can be reduced by bifidobacteria. Finally, the work involved a

four-way collaboration among clinicians at the Mercy Hospital in Cork under the direction of Dr Martin Buckley, investigators at Cork’s APC Microbiome Ireland directed by Fergus Shanahan, in collaboration with local Cork company Atlantia Food Clinical Trials and the multinational biosciences company Chr Hansen. “Although prior studies have described stomach damage from aspirin and non-steroidal antiinflammatory drugs, this is, to the best of our knowledge, the first trial to record a detailed time-course

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of aspirin-induced, small-intestinal damage. Even more impressive was the subsequent reversal of the damage by the bifidobacterium that could be added as a natural supplement to the diet of patients on long-term aspirin,” said Dr Martin Buckley.

Hospital” said Prof Fergus Shanahan, Principal Investigator APC Microbiome Ireland. “The four partners collaborated synergistically to deliver a highquality clinical study, which could not have been carried out by the teams individually.”

“This case study is an excellent example of a collaboration between an SFI Research Centre, APC Microbiome Ireland, an innovative Irish SME, Atlantia Food Clinical Trials, multinational biosciences company Chr. Hansen and the Mercy University

Atlantia Food Clinical Trials designs and delivers clinical studies for functional ingredients, supplements, pre- and probiotics, medical foods, infant formula and microbiome-based therapeutic sectors.


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20

News

Pharmacy Demands – Why the Delay? Darragh O’Loughlin, Secretary General of the Irish Pharmacy Union reflects on Budget 2020 and highlights why it makes sense to provide the pharmacy sector with an opportunity to significantly expand its scope to the benefit of patients, the public and the health system itself. Darragh O’Loughlin, Secretary General, Irish Pharmacy Union

lives within one kilometre of their nearest pharmacy. This is a significant outreach that provides an unprecedented level of access to the general public.

There were several commitments regarding pharmacy services in the 2016 Programme for Government which, if implemented, would have provided greater access to safe, timely care, closer to patients’ homes. Among them was the promise that ‘within two years, we will expand the role of community pharmacists in managing the health of patients and medicine prescription’ – a bold pledge that would have made a real difference to the primary care system. However, three years later, we have had no progress, and we continue to drift further away from international best practice in terms of how we allow pharmacists to contribute to the health service. At a time of major crisis in our own health service, the range of services Irish pharmacists can currently offer is in stark contrast to what is on offer in countries such as the UK, Canada and New Zealand.

While we look on in awe at what is happening in other countries, there is a commonality in the theme emerging right across the Irish health system: delays. Delays with appointments, which delays diagnoses and treatment and, more critically, the delivery of health solutions for the patient. To exacerbate the situation further, any physician will tell you that early intervention is crucial so not only does this frustrate the operation of the health system, but also the patient’s experience of it and can worsen their health outcome. This needs to be urgently dealt with, and community pharmacists are keen to play their part. Significant outreach The IPU represents 95% of all pharmacists in Ireland and our members receive 78 million visits to their premises every year – or 17 visits per annum per man, woman and child in the State – and over half the population

Therefore, providing the pharmacy sector with an opportunity to significantly expand our scope to the benefit of patients, the public and the health system itself makes sense. Numerous detailed proposals have already been presented to Government. These include a minor ailment scheme that would enable medical card patients to receive treatment for common illnesses such as hay fever, migraine or skin conditions free of charge and direct from their local pharmacy. They also include a structured pharmacy led monitoring service for patients on newly prescribed medications for long term illnesses including chronic obstructive pulmonary disease (COPD) and type 2 diabetes. A pilot in Ireland has already shown this improves ‘optimal adherence’ to medications and could bring about longer term savings to the health system. Our ambition for the delivery of primary care doesn’t stop there: we want to develop a Chronic Disease Management programme in partnership with GPs, roll out smoking cessation supports to

medical card holders and provide contraception to women, without prescription and free of charge. Since the 2016 Programme for Government we have seen further Government commitments for community pharmacists. The Sláintecare Action Plan 2019, published in March, reiterated initial commitments in the Programme for Government to involve pharmacists in developing more local services. However, specifying what these are and putting flesh on the bones of these commitments is now required for the pharmacy to evolve and deliver 21st century patient and, indeed, health system solutions. With public satisfaction ratings of over 90% for community pharmacists, there is nothing to fear and in fact our profession is ideally positioned to deliver on the Government’s Sláintecare healthcare strategy. We have consistently put forward proposals that would help alleviate current primary healthcare deficits, offer significant savings and efficiencies to the health service. While many of our proposals have been met with apathy, we continue to be enthusiastic about the additional contribution we could make. Let’s do a little for a lot. It makes sense and Budget 2020 provides an opportunity for progress. The Government recognises this, we know this, and our patients want this. So, why the delay?

Life Long Learning in Pharmacy The Irish Institute of Pharmacy (IIOP), on behalf of the Royal College of Surgeons in Ireland, are inviting community pharmacists to join them at Life Long Learning in Pharmacy 2020 (LLLP2020) International Conference which will be held at our Dublin Campus on St. Stephen’s Green, from Friday 3rd – Monday 6th July 2020. Abstract submission is now open. Abstracts must be submitted online using this official 13th Life Long Learning in Pharmacy Conference Abstract online application tool. Abstracts submissions will close on 7 February 2020. All abstract submissions will be acknowledged on receipt and peer reviewed after the closing date. You will be advised of the status of your abstract by 27 March 2020. To submit your abstract, go to https://lllp2020.exordo.com/login and follow the instructions (you will be required to set up an account first). Please note that submissions will be accepted ONLY via the online system: email submissions will not be accepted.

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22

All Ireland Conference

Sharing Best Practice in Pharmacy Care Sharing a focus on best practice in pharmaceutical care and practice development across the primary and secondary care sectors, the 2019 All Ireland Pharmacy conference recently took place in the Ballymascanlon Hotel. Cathy Harrison, Chief Pharmaceutical Officer, Department of Health Northern Ireland, Colin Adair, Postgraduate Pharmacy Dean, NICPLD, Queen's University Belfast Dr Catherine Duggan, CEO, International Pharmaceutical Federation, Dr Catriona Bradley, Executive Director, IIOP and Kate Mulvenna, Chief Pharmacist, HSE

Now in its ninth year, the conference was jointly coordinated by the Northern Ireland Centre for Pharmacy Learning and Development and the Irish Institute of Pharmacy. Pharmacists, technicians and qualified assistants were in attendance and encouraged to exchange ideas for pharmaceutical service development in the Republic of Ireland and Northern Ireland. Development Goals This year, the conference was themed around the FIP Pharmaceutical Workforce Development Goals. The conference was opened by Kate Mulvenna, Chief Pharmacist at the HSE followed by a keynote address from Dr Catherine Duggan, CEO of the International Pharmaceutical Federation (FIP). In her speech, Dr Duggan focused on policy formation for clear and manageable strategies to implement comprehensive needs-based development of the pharmaceutical workforce.

The FIPâ&#x20AC;&#x2122;s Pharmaceutical Workforce Development Goals (WGDs) underpinned the IIOP conference, which aims to ensure the global pharmaceutical workforce is trained so it can adapt to changing health needs. The 13 landmark goalsfocus on education providers, professional pharmacy development and government policy, strategy and monitoring. Over 100 attendees heard oral presentations from a range of speakers on topics including workforce impact, working with others and competency development. The closing remarks were provided by Cathy Harrison, Chief Pharmaceutical Officer, Department of Health, Northern Ireland.

Dr Catriona Bradley, Executive Director and James Oâ&#x20AC;&#x2122;Hagan, Operations Co-Ordinator, Irish institute of Pharmacy

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IMBRUVICA® (ibrutinib) is now available as One Tablet, Once a Day1 From September 2019 there will be four new formulations available of IMBRUVICA® for patients1 For patients with CLL or WM 3 x 140 mg

capsules a day

For patients with MCL

1 x 420 mg

tablet one a day

4 x 140 mg

1 x 560 mg

capsules a day

tablet one a day

For full dosing information, please see the IMBRUVICA® Summary of Product Characteristics available at www.medicines.ie. Tablets shown not to scale.

• The same IMBRUVICA® efficacy and safety in a more convenient formulation1,2 • IMBRUVICA® tablets are smaller than the existing capsules and film–coated to help patients take their medication1,3 • Different doses are available1 to facilitate dose reductions, if recommended by the IMBRUVICA® Summary of Product Characteristics and prescribed by the treating physician.

1 x 140 mg

1 x 280 mg

1 x 420 mg

1 x 560 mg

Scan here to learn more about IMBRUVICA®, or visit www.janssenmedicalcloud.ie/imbruvica Experience you can rely on

IMBRUVICA® 140 mg, 280 mg, 420 mg and 560 mg Film-coated Tablets PRESCRIBING INFORMATION. ACTIVE INGREDIENT: Ibrutinib. Please refer to Summary of Product Characteristics (SmPC) before prescribing. INDICATIONS: As a single agent, for adults with: relapsed or refractory mantle cell lymphoma (MCL). As a single agent or in combination with obinutuzumab for adults with chronic lymphocytic leukaemia (CLL) who are previously untreated. As a single agent or in combination with bendamustine and rituximab (BR) for adults with CLL who have received ≥ one prior therapy. As a single agent for adults with Waldenström’s macroglobulinaemia (WM) who have received ≥ one prior therapy, or first line in patients unsuitable for chemo immunotherapy. In combination with rituximab for adults with WM. DOSAGE & ADMINISTRATION: Adults: Orally, once daily, swallowed whole with water. MCL - 560 mg. CLL and WM - 420 mg as single agent or in combination (refer to SmPC). Concomitant strong CYP3A4 inhibitors – reduce dose to 140 mg (or withhold IMBRUVICA for up to 7 days). Concomitant moderate CYP3A4 inhibitors – reduce dose to 280 mg. Withhold IMBRUVICA therapy for any new onset/worsening grade ≥ 3 non-haematological toxicity, grade ≥ 3 neutropenia with infection/fever, or grade 4 haematological toxicities. Re-initiate when toxicities resolved to grade 1 or baseline. If toxicities recur, reduce dose by 140 mg. A second dose reduction of 140 mg may be considered if needed. Discontinue IMBRUVICA if toxicities persist/recur following two dose reductions. Children: Safety/efficacy not established ≤ 18 years old. Elderly: No dose adjustment required. Renal impairment: Mild/moderate - no dose adjustment. Severe – no data; consider benefit/risk and monitor closely. No data with dialysis. Hepatic impairment: Mild (Child-Pugh class A) – 280 mg daily; moderate (Child-Pugh class B) – 140 mg daily; severe (Child-Pugh class C) – not recommended. Monitor for toxicities. Severe cardiac disease: No clinical data. CONTRAINDICATIONS: Hypersensitivity to active substance/excipients. St. John’s Wort preparations. SPECIAL WARNINGS & PRECAUTIONS: Bleeding-related events: minor and major events reported, some fatal. Do not use with warfarin or other vitamin K antagonists. Risk of major bleeding increased with use of anticoagulants and antiplatelet agents. Monitor for signs, symptoms of bleeding. Avoid fish oil and vitamin E preparations. Withhold IMBRUVICA ≥ 3 to 7 days pre/post-surgery. Leukostasis: cases reported; consider temporary withhold of IMBRUVICA; monitor closely, give supportive care. Infections: infections seen, some resulting in hospitalisation and death; monitor for fever, neutropenia and infections and give anti-infective therapy. Consider prophylaxis in increased risk patients. Invasive fungal infections have been associated with fatal outcomes. Progressive Multifocal Leukoencephalopathy (PML): including fatal cases, reported with prior or concomitant immunosuppressive therapy; monitor for new/worsening neurological, cognitive or behavioural signs/symptoms; if suspected, suspend treatment until PML excluded; if in doubt refer to neurologist for diagnostic tests. Cytopenias: treatment-emergent grade 3/4 cytopenias reported; monitor complete blood counts monthly. Interstitial Lung Disease (ILD): cases reported; IMBRUVICA® is co-developed with Pharmacyclics. Janssen-Cilag International NV is the marketing authorisation holder and Janssen-Cilag International NV is the responsible editor of this document. © Pharmacyclics LLC 2019 | © Janssen Pharmaceutica NV. 2019 September 2019 | CP-111045

monitor patients for pulmonary symptoms of ILD; interrupt IMBRUVICA and manage ILD if symptoms develop, if symptoms persist, consider risk/benefit of IMBRUVICA treatment and follow dose modification guidelines. Cardiac arrhythmia: atrial fibrillation/flutter and ventricular tachyarrhythmia reported. Atrial fibrillation/flutter reported particularly in patients with cardiac risk factors/hypertension/acute infections/previous history of atrial fibrillation. Periodic clinical monitoring; consider ECG if arrhythmic symptoms or new onset dyspnoea, dizziness or fainting develop; if signs/symptoms of ventricular tachyarrhythmia develop, temporarily discontinue IMBRUVICA and carry out thorough clinical benefit/risk assessment before considering restarting; consider alternative to IMBRUVICA when pre-existing atrial fibrillation requiring anticoagulant therapy or high risk of thromboembolic disease; where no suitable alternatives to IMBRUVICA, consider tightly controlled treatment with anticoagulants. Viral reactivation: hepatitis B reactivation reported; establish HBV status before starting treatment; if positive HBV consult specialist physician; if positive hepatitis B serology, consult a liver disease expert before starting treatment and monitor/manage to prevent hepatitis B reactivation. Tumour lysis syndrome: cases reported. Monitor at risk patients closely, take precautions. Non-melanoma skin cancer: cases reported; monitor patients. Hypertension: Monitor BP regularly, treat as appropriate. Drug-drug interactions: strong/moderate CYP3A4 inhibitors may increase ibrutinib exposure; CYP3A4 inducers may decrease ibrutinib exposure; avoid strong inhibitors, and strong/moderate inducers, of CYP3A4 where possible; if not monitor closely for toxicities/lack of efficacy. SIDE EFFECTS: Very common: Pneumonia, upper respiratory tract infection, skin infection, neutropenia, thrombocytopenia, headache, haemorrhage, bruising, hypertension, diarrhoea, vomiting, stomatitis, nausea, constipation, rash, arthralgia, musculoskeletal pain, pyrexia, oedema peripheral, muscle spasms. Common: Sepsis, urinary tract sinusitis, infection, nonmelanoma skin cancer, basal cell carcinoma, squamous cell carcinoma, febrile neutropenia, leukocytosis, interstitial lung disease, lymphocytosis, tumour lysis syndrome, hyperuricaemia, peripheral neuropathy, dizziness, vision blurred, atrial fibrillation, epistaxis, petechiae, urticaria, erythema, onychoclasis. Other side effects: Hepatitis B reactivation, leukostasis syndrome, hepatic failure, panniculitis, StevensJohnson syndrome, angioedema, ventricular tachyarrhythmia, subdural haematoma, fungal infections (Cryprococcal, Pneumocystis, Aspergillus). Refer to SmPC for other side effects. PREGNANCY: Women of child-bearing potential must use highly effective contraceptive measures during and for 3 months after stopping treatment; if using hormonal contraceptives, add barrier method. Not to be used during pregnancy. LACTATION: Discontinue breast-feeding during treatment. INTERACTIONS: CYP3A4 inhibitors: Strong: Avoid where possible or reduce IMBRUVICA dose (or withhold for ≤ 7 days) and monitor closely; e.g. ketoconazole, indinavir, nelfinavir, ritonavir, saquinavir, clarithromycin, telithromycin, itraconazole, nefazodone, cobicistat, voriconazole,

posaconazole. Moderate: Avoid where possible or reduce IMBRUVICA dose and monitor closely; e.g. erythromycin, amprenavir, aprepitant, atazanavir, ciprofloxacin, crizotinib, diltiazem, fluconazole, fosamprenavir, imatinib, verapamil, amiodarone, dronedarone. Avoid grapefruit and Seville oranges. Mild: No dose adjustment required; monitor closely. CYP3A4 inducers: Strong/moderate: Avoid or monitor closely for lack of efficacy; e.g. carbamazepine, rifampicin, phenytoin. Mild: may be used; monitor for lack of efficacy. Potential interactions: Oral narrow therapeutic range P gp or breast cancer resistance protein (BCRP) substrates (e.g. digoxin, methotrexate) should be taken ≥ 6 h before/after IMBRUVICA. Ibrutinib may inhibit BCRP in the liver and so increase exposure of drugs undergoing BCRP-mediated hepatic efflux (e.g. rosuvastatin). Ibrutinib may inhibit intestinal CYP3A4 and thus increase exposure of some CYP3A4 substrates sensitive to gut CYP3A metabolism; caution with narrow therapeutic range oral CYP3A4 substrates (e.g. dihydroergotamine, ergotamine, fentanyl, cyclosporine, sirolimus, tacrolimus). Ibrutinib is a weak CYP2B6 inducer and may affect expression of other enzymes and transporters regulated via the constitutive androstane receptor (CAR) (e.g. CYP2C9, CYP2C19, UGT1A1, MRP2). Exposure to substrates of CYP2B6 (e.g. efavirenz, bupropion) and coregulated enzymes may be reduced with ibrutinib. Refer to SmPC for full details of interactions. LEGAL CATEGORY: Prescription only medicine. PRESENTATIONS, PACK SIZES, MARKETING AUTHORISATION NUMBER(S): 140 mg blister pack, 28 tablets, EU/1/14/945/007; 280 mg blister pack, 28 tablets, EU/1/14/945/009; 480 mg blister pack, 28 tablets, EU/1/14/945/011; 520 mg blister pack, 28 tablets, EU/1/14/945/012. MARKETING AUTHORISATION HOLDER: Janssen-Cilag International NV, Turnhoutseweg 30, B-2340 Beerse, Belgium. FURTHER INFORMATION IS AVAILABLE FROM: Janssen Sciences Ireland UC, Barnahely, Ringaskiddy, IRL - Co. Cork, P43 FA46. Prescribing information last revised: September 2019 Adverse events should be reported. Healthcare professionals are asked to report any suspected adverse events 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 Janssen Sciences Ireland UC on +353 1 800 709 122 or at dsafety@its.jnj.com.. References: 1. IMBRUVICA® Summary of Product Characteristics. Available from www. medicines.ie. 2. Janssen Data on File: Imbruvica_DOF_16Jan2019_MI_TN_001. 3. Wright D, et al. How to help if a patient can’t swallow. The Pharmaceutical Journal 2011;286:271-274. For full dosing information please consult the Summary of Product Characteristics, available from www.medicines.ie.


24

All Ireland Conference

1

2

3

4

5

6 Detecting Hypertension One of the oral presentations given on the day was by Sinead McCool from the Irish Pharmacy Union who spoke about a recent IPU Pilot to detect hypertension and atrial fibrillation in the community. Irish data on hypertension and atrial fibrillation suggest that the prevalence of each is rising

PHARMACYNEWSIRELAND.COM

7 with the growing elderly population and is projected to at least double in the next 50 years.

healthcare to be delivered at the lowest level of complexity and is safe, efficient and good for the patients.

The need for prevention, early detection and comprehensive patient centred management of chronic illnesses, has been recognised by a number of Irish health system reports and the Oireachtas Committee on the Future of Healthcareâ&#x20AC;&#x2122;s Slaintecare Report. This called for

The aim of this pilot was to identify those people over 50 years of age who were at risk of hypertension or atrial fibrillation or both. The IPU worked with the Irish Heart Foundation to deliver a standardised intervention of a blood pressure and pulse check to patients,


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13 provision of heart healthy lifestyle advice and referral to their GP where appropriate. More than 1,100 patients were checked during the 2-month pilot period. The results showed that:  An irregular pulse (possible atrial fibrillation) was detected in 5.5% of participants who were checked;  27% of participants were identified with high blood pressure (possible hypertension);  Both an irregular pulse (possible atrial fibrillation) and high blood pressure (possible hypertension) were noted in 2% of participants;  26% of all participants checked were referred to their GP;  4% of the total population checked were commenced on medicines for hypertension, atrial fibrillation or both. The Pilot demonstrated that, by carrying out a standardised population health check for hypertension and atrial fibrillation in the community pharmacy, a highly accessible healthcare location, community pharmacists can deliver an extremely positive benefit to participants in terms of prevention, detection and initial management of the conditions of hypertension and atrial fibrillation.

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“There are continuously increasing demands on nursing time and resources in Wexford General Hospital,” she reflected. “The expansion of the role of the pharmaceutical technician to support medicines management activities at ward level could support nursing staff, reduce pharmacy workload and optimise the skills and expertise of the pharmaceutical technician.”

Advancing Practice

The responses from her study found that 80% strongly agreed that medication management improved during the pilot whilst 70% strongly agreed that the pharmacy service has reduced the number of missed drug doses.

A series of parallel sessions were held during the day. This included a morning talk given by Clare Kinahan, Senior Pharmacist at Portiuncula University Hospital.

“Nursing and pharmacy staff noticed an improvement in communication between the ward and the pharmacy during the pilot,” she added.

“People are living longer, with more chronic conditions and are prescribed more medications according to disease specific guidelines. Frail patients are twice as likely to be prescribed inappropriate medications and are more vulnerable to their harmful effects. Use of the STOPP/START criteria and the Medication Appropriateness Index (MAI) have been shown to improve patient outcomes,” she told the audience.

Pharmacy Resilience

Clare and her team examined the impact and cost effectiveness of pharmacist led WIDE Reviews. A total of 20 intervention and 20 control group patients were enrolled. Patient characteristics (age, sex and length of stay) were similar for both groups. 65% of STOPP and 62% of START criteria were addressed in the intervention group versus 12% and 5% respectively in the control group. In the intervention group 83 medications were stopped, 23 dose reduced and the total MAI score was reduced by 64%. Cost savings to the annual drug budget alone represented a 9:1 return on investment of hospital pharmacist time. “Pharmacists performing WIDE Reviews significantly improved medication appropriateness and realised compelling cost savings. A larger scale study of this innovative approach to medication review is planned,” she said. Cliona Hayden, Chief Pharmacist at Wexford General Hospital also presented on the ‘Assessment of nurses opinions on the introduction of a ward based pharmaceutical technician (WBPT) service. Her team found that this improves ward medication management.

Another interesting study presented during the day looked at ‘An exploration of pharmacy students’ resilience and the factors affecting it.’ This was presented by Eimear Ni Shaughnessy from the School of Pharmacy at Trinity College Dublin. “A high risk of burnout syndrome exists among practicing healthcare professionals (HCPs) with recent studies focusing on the risk and prevalence of burnout among students studying in the healthcare disciplines,” she noted,. “Many of these have demonstrated how the development of personal and professional resilience can be a mechanism of avoiding burnout both in student and practicing HCPs. HCP burnout also shows consistent negative relationships with quality and safety of patient care. The serious ramifications of burnout and its inverse correlation with resilience would suggest that resilience is a highly desirable if not essential trait for students embarking on an undergraduate degree in a healthcare profession such as pharmacy. In this study, the researchers aim to determine pharmacy students’ resilience levels and to investigate factors that affect their resilience.” Findings of this study indicate that there is potential for resilience levels of pharmacy students to be enhanced. Factors identified as having a positive impact on resilience should be targeted for the development and implementation of resilience enhancing interventions. As a leader in healthcare wholesaling, United Drug were proud to sponsor the conference dinner on the evening prior to the conference.

PHARMACYNEWSIRELAND.COM


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All Ireland Conference

Held in Ballymascanlon House Hotel in Dundalk and look forward to being part of the next IIOP All Ireland Pharmacy Conference which takes place in 2021. Captions 1. Mary Mockler, Regulatory Project Pharmacist, Pharmaceutical Society of Ireland and Amelia Smith, Medicines Management Programme 2. Paul Fahy, Business Development Officer, Pharmapod and Tara Kelly, Medicines Information Pharmacist, Irish Pharmacy Union 3. Catherine Shaw, School of Pharmacy, Queen’s University Belfast 4. Paul Gilvarry, PPharmacy Dean, NICPLD, Queen's University Belfast and Kate Mulvenna, Chief Pharmacist, HSE 5. Conference Organisers Dr Colin Adair, Postgraduate Pharmacy Dean, NICPLD and Dr Catriona Bradley, Executive Director, Irish institute of Pharmacy 6. Pat Watt, Director of Sales & Marketing United Drug, Cathy Harrison, Chief Pharmaceutical Officer, Department of Health Northern Ireland, Colin Adair, Postgraduate Pharmacy Dean, NICPLD, Queen's University Belfast and Kate Mulvenna, Chief Pharmacist, HSE

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7. Brendan Kerr, Registrar, Pharmaceutical Society Northern Ireland and Claire Fitzell, Professional Services Pharmacist, Irish Pharmacy Union 8. Brendan Kerr, Registrar, Pharmaceutical Society Northern Ireland 9. Sheelin McKeagney, Chair, Pharmacy Forum NI 10. Maeve Hynes, HSE Acute Hospitals Drug Management Programme and Niamh Dillon, Pharmacy Department, Royal Victoria Eye & Ear Hospital, Dublin 11. Johanne Barry, School of Pharmacy, Queen’s University, Paul Tighe, St Vincent’s University Hospital and Dr Catherine Duggan, CEO, FIP 12. Carole Parsons, Maurice Hall,, Rebecca Craig and Lezley Anne Hanna, School of Pharmacy, Queen’s University

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13. Fiona Hagan and Caoimhe Murphy, Pharmacy Students, UCC 14. Speakers Anita Lawther, Pharmacy Department, South Eastern Trust, Bronagh White, School of Pharmacy, University of Ulster, Clare Kinahan, Pharmacy Department, Portiuncula University Hospital, Cliona Hayden, Pharmacy Department, Wexford General Hospital, Professor Judith Strawbridge, RSCI and Susan Patterson, HSC Board 15. Speakers Matthew Lynch, School of Pharmacy, RCSI, Cicely Roche, Trinity College Dublin, Claire Kavanagh, Our Lady’s Hospice and Care Services and Sara Gardiner, School of Pharmacy Ulster University 16. Associate Professor Eimear O’Shaughnessy, Panoz Institute, Trinity College Dublin, Áine Barrett , PharmaFolder and Ciara Ni Dhubhlaing, Acting Chief Pharmacist, St Patrick’s University Hospital

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Pharmacy Resource for New Mums

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ew mothers are desperate for reassurance and advice, both during their pregnancy and in those vital early weeks with their newborn baby. This article gives a brief overview as to how community pharmacists and their teams can ensure that their pharmacy meets all their needs.

Through offering good customer service to a parent, pharmacists can develop customer loyalty, ensuring their pharmacy becomes the parent’s destination for the whole family’s healthcare. Pharmacists are vital because they can provide that added element of advice with a purchase that the customer can’t get from a supermarket. By engaging with the customer, pharmacists can also help support them with post-natal health-related issues and signpost to their GP or health visitor where appropriate. Growth areas for pregnancy health include incontinence pads, stretch-mark products and multivitamins, whilst in baby care, popular categories include nasal drops, cold remedies and nappy rash creams. Early Stages The pharmacy team can support any soon-to-be parents from early pregnancy – or even from the family planning stage – by dispelling any common myths well-meaning friends or relatives may have passed on. This ability to offer accurate and essential information will not only help them enjoy a healthy pregnancy, but will build a relationship of trust that

extends long past delivery and well into the childhood years. With people finding it increasingly difficult to see their GP, any additional support that pharmacy teams can offer, in terms of signposting the importance of vaccines, or offering advice on the use of OTC products during pregnancy or breastfeeding, is hugely important. It is important to focus on the following during any first contact with a woman in the early stages of pregnancy:  Folic acid supplementation  Food hygiene, including how to reduce the risk of food-acquired infection  Lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy. With gestational diabetes a risk during pregnancy, good eating practices are essential. Focusing on iron, folic acid and calcium constitutes an excellent starting point, supported by a balance of starch, protein, dairy and fibre, while avoiding too much fat. One of the biggest hurdles to

overcome is morning sickness which, contrary to its name, can actually occur at any time of day or simply be ongoing. Vomiting or a constant feeling of nausea are both common. For many women, this will begin to ease by the 12th to 14th week, although its severity and duration can vary. Provided sufferers are able to ingest sufficient levels of food and fluids, there should be no risk to the baby itself. However, in cases of constant vomiting or where dehydration is perceived to be a risk, women should seek urgent medical advice from a GP or midwife. Helping customers to manage the symptoms may be a matter of offering some simple dietary tips – such as preparing plainer, or even cold, food to avoid any aroma-based triggers, as well as the use of calming ingredients such as ginger. Supplements The current recommendation for folic acid, which reduces the risk of spinal cord problems like neural tube defects (NTD), is 400mcg per day – although higher doses may be prescribed by a GP for women considered to be in a high-risk category. These include:

 Women who have had a previous pregnancy affected by a NTD  Where a woman or her partner have such a defect or one is in the family  Medication is being taken for epilepsy  Women who are clinically obese  Women suffering from coeliac disease, insulin-dependent diabetes, sickle cell anaemia or thalassaemia, or those who abuse alcohol. Many pregnant women will suffer from heartburn. To treat heartburn, a common painful pregnancy ailment, both antacids and alginates are considered safe to use during pregnancy provided the recommended doses are adhered to. Pregnant women on iron supplements should be cautioned that antacids could prevent proper iron absorption, so should be taken at least two hours before or after the iron supplement. Feeding Infant feeding is a highly emotive and very personal topic. Any decision parents make on feeding their baby has to be right for them. What they need is reliable and relevant evidence-

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based information about both breastfeeding and bottle-feeding to enable them to make an informed choice, as well as access to ongoing support after the birth. Both WHO and the Government recommend exclusive breastfeeding for all babies until they reach six months, and continuing with breastfeeding alongside complementary foods for up to two years. Although ‘Breast is best’ has been the key message in extensive baby feeding campaigns, many women struggle with breastfeeding. Over the last few years there has been growth in specialist milks, such as soya, which are often pharmacy-only. More is being made of the different types of formulas available to relieve symptoms such as colic, reflux, lactose intolerance and constipation. These milks are generally not available in supermarkets. When new parents visit their community pharmacy, it is often because there is an issue. However, pharmacy teams should use open questions and not make assumptions. Ask designed questions such as, ‘How are you feeding your baby?’ rather than ‘Are you breastfeeding?’ or ‘Are you bottle-feeding?’ Knowing what is and is not normal for newborns, such as regular feeds and lack of sleep, is important when offering advice. Pharmacies should be able to supply useful products, such as nipple shields and breast pads, and mothers could be signposted to a breastfeeding café, peer

support group or their midwives. Some women decide to formula feed due to health pressures, convenience, specialised needs, the need to return to work quickly for financial reasons and for many other reasons. It is important they are given balanced information in a non-judgemental way. Colic and Nappy Rash Colic is one of the more stressful health issues for a parent to deal with. Colic is generally defined as repeated, excessive bouts of crying. According to the HSE, recent estimates suggest that one in five babies are affected by colic and babies of both sexes are equally affected. The symptoms of colic usually begin within the first few weeks of life but just because it is a common affliction does not make it any easier for parents who cope with it every day. When a parent presents in a pharmacy with a colicky baby there are a number of ways a pharmacist can advise to help ease the situation. Warm baths, keeping the baby upright after feeds, frequent winding, osteopathy or homeopathy may offer some solutions but it is also important to tell the parents that they should seek support if they are feeling under stress while dealing with their colicky baby. Some OTC medications can work to help soothe the baby but generally there are not many treatment options for the problem.

Nappy rash is one of the most common skin conditions in babies and it is also the most common skin problem in early childhood. Most children aged 0-3 years old develop nappy rash in some way and it is usually presents in babies from 6-8 months. Nappy rash can be caused by a number of factors including a combination of excess moisture, warmth, urine, faeces and friction in a baby’s nappy. It is a difficult environment for baby skin. The nappy rash creates an enclosed area around the bottom and this increases warmth, moisture and encourages the growth of micro-organisms that can cause infection. Chafing, due either to skin rubbing against the nappy, or from skin folds, can damage and irritate the skin and ongoing contact of the skin with urine, faeces or both, can lead to a formation of ammonia which can irritate a baby’s skin. There is also a common link made between nappy rash and teething, as well as the transition to solid foods. Pharmacists can ease a worried parent by telling them that most nappy rashes are mild and can be treated with a simple skin care routine. Most babies will not feel any pain or discomfort and it is very rare that a baby will contact a severe form of nappy rash where infection is involved. Teething Every child will have a different experience of teething, so new

parents might need to try a few different solutions until they find one that works for them.Typically commencing at around four months of age, cutting teeth can cause hot red cheeks, drooling, loss of appetite, irritation and an urge to chew. Herbal and medicated gels are available for infants, but parents can also try associated aids such as teething rings. Pharmacy Ready Stock products that will have real benefits for women, for example items that will help with stitches and pain after birth. Educating the pharmacy team on how ovulation kits and pregnancy tests work will ensure the whole team can provide appropriate advice. Fertility kits and ovulation kits should be merchandised next to pregnancy tests. As well as the usual folic acid, there are now preconceive vitamins for men and women, which could be dual sited alongside fertility and ovulation kits. Merchandising fixtures using category adjacencies and beacon branding will help customers navigate easily. The baby care category should be merchandised in an easily accessible area to allow parents with pushchairs access. Given enough space there is the potential to merchandise baby care as a ‘valley’ giving the effect of a baby area. Ensuring that merchandising makes it as simple as possible for customers to select products will drive sales, particularly as customers may not have much time.

Dealing with Colic Pharmacists play a unique role in the assistance of families coping with colic. They are easily accessible to parents and may often be the first healthcare professional to turn to for advice on an inconsolable infant.  Make them aware of the fact that colic occurs in both breastfed and formula-fed babies, and the cause is unknown  Reassure them that colic is temporary and is usually gone by the time the infant is 3 months old  Ask open-ended questions related to how the parents are coping Changes as simple as choosing the right baby bottle can help avoid the swallowing of air and thereby, put a stop to wind related colic in babies. There are several points of advice, including:  Advise parents that colic is not curable, but inform them of some popular soothing techniques that may help

There are many baby bottles on the market claiming to be ‘anti-colic’, yet it is important to recognise, that not all ‘anticolic’ bottles are the same and understand the physics behind the bottle mechanics.

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In conventional feeding bottles, negative pressure is generated both in the oral cavity and in the bottle, when fluid is removed by sucking. Consequently, the negative pressure retained inside the bottle causes the infant to suck excessively. Research highlights a vacuum is formed in most reusable feeding bottles, which are either nonventilated or under-ventilated through various configurations of holes and slits in the teat rim or actual teat. The non-vented bottle consists of a solid walled vessel with a teat held in place with a cap, thus does not permit any air entry and this results in the liquid being held within the feeding vessel by the vacuum, that is formed while sucking. As the teat collapses in response to the negative pressure in the

non-vented or under-vented bottles, the baby will break its seal at the teat and swallow air along with liquid into the stomach, which causes the windy colic symptoms. The collapsed teat and bubble induction into the feeding liquid are clear indications that a vacuum is present in the feeding bottle. Contrastingly, a 100% fully vented bottle has an open pathway for air leading from the threads between the bottle neck and the teat collar to an internal reservoir, that is in communication with ambient air. In fully vented bottles, the initial teat pressure is positive and the pressure remains positive, throughout the entire emptying of the bottle; subsequently, ensuring the baby takes in the feed without ingesting air.


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Online Resource for Mums A suite of free on-line resources for motherhood aimed at women, mothers and healthcare professionals has been launched by the School of Nursing and Midwifery at Trinity College. The resources will provide evidencebased information aimed at addressing women’s knowledge gaps, breaking the silence around embarrassing or sensitive health issues, and enabling women to self-assess and take action for their health. The resources have been developed from the findings of the Maternal health And Maternal Morbidity in Ireland (MAMMI) Study, an Irish longitudinal study which examined the health and health problems experienced by over 3,000 first-time mothers around Ireland, and are based on what women said they wished they had known. The findings suggest that although women experience a range of health issues in the postpartum period, the health of mothers is frequently overlooked or secondary to their baby’s health, because the main focus of care is on child-health issues. These health issues, which are often preventable and curable if recognised and treated early, negatively impact on women’s physical and mental health, preventing them from fully enjoying life and motherhood. Following birth, postpartum healthcare and information becomes almost exclusively child focussed; women say that they struggle to access reliable resources and trustworthy information regarding their own health and the health problems they might be experiencing. The new on-line resources are divided into three areas: • Women’s Health After Motherhood (WHAM) • Motherhood, Empowerment, Sustainable Self-help: Addressing Gaps in Education with Science (MESSAGES) • Towards Recovery After Childbirth, through Knowledge (ON-TRACK) The Women’s Health After Motherhood (WHAM) course, hosted on the FutureLearn platform, presents a diverse range of online resources, co-designed and developed with women who recently became mothers, and maternal health experts. You can find out more about the online resources here: https://www. futurelearn.com/courses/womenshealth-after-motherhood

Pharmacists Role in Psoriasis s newer treatments become more readily available, community pharmacists have an increasing opportunity in the management of psoriasis. It should also be a rewarding practice for pharmacists, as bringing support and relief to these patients has a major positive impact on their quality of life. World Psoriasis Day took place on October 29th, and the Irish Skin Foundation (ISF) joined with the International Federation of Psoriasis Associations (IFPA) and 55 members globally to raise awareness of psoriasis and the complex emotional toll of this common skin condition, estimated to affect 73,000 - 100,000 people in Ireland. Along with the physical burden of psoriasis, the often-visible nature of the disease means people living with the condition may have to cope with the reactions of others to the appearance of their skin. This can impact negatively on quality of life, self-esteem, social and personal relationships, which can then take an emotional, psychological and psychosocial toll on people with psoriasis. Psoriasis is a common, noncontagious, long-term, immunemediated inflammatory disease in which there is an increase in the rate at which skin cells are produced and shed from the skin. Psoriasis affects at least 100 million people worldwide, including upwards of 73,000 people in Ireland, suggesting a prevalence of close to 2% of the Irish population. It is estimated that

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around 9000 people in Ireland have severe psoriasis. Dr Eddie Murphy, Clinical Psychologist will join an expert psoriasis panel discussion entitled ‘Psoriasis on Your Mind?’ taking place on Saturday, 16 November in the Science Gallery, TCD, Dublin. Dr Murphy is part of the 'Ask How I Feel' campaign, which focuses on looking at psoriasis from the inside out and urges people not to suffer in silence, but to encourage people around you - friends, family and healthcare professionals to #AskHowIFeel. Psoriasis is a serious, chronic and non-communicable disease (NCDs) in itself, but there are a number of other conditions (called co-morbidities) that are associated with psoriasis such as cardiovascular disease, psoriatic arthritis, diabetes, metabolic syndrome and depression. Psoriasis may seem only skin deep, but it begins inside the body within the immune system. The red, scaly, flaky, and itchy patches occur when the skin cells grow too quickly as a result of inflammation caused by the body’s immune system.

Triggers for this abnormal immune reaction can include physical injuries or infections (in particular, a streptococcal throat infection), certain medicines, and emotional stress. Psoriasis varies in severity from person to person and can vary in severity in the same person at different times. Occasionally psoriasis can disappear without treatment but more usually, it is a chronic disease that requires treatment. Patches (also called plaques or lesions) can occur on various parts of the body, including the scalp, elbows, and or knees. Key Points: • It is a chronic, systemic, inflammatory skin disease. • It is related to the immune system – an autoimmune disease. • It may run in families (there are several different genes involved in psoriasis). • It is not curable, but treatments are available. • It is not contagious.


• It is sometimes associated with psoriatic arthritis. • It is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol and obesity. • It is associated with a slightly higher risk of cardiovascular disease (angina, heart attack and stroke). • There is a strong association between psoriasis and depression. Co-morbidities People who have psoriasis are at risk of developing psoriatic arthritis, which commonly affects the joints of the fingers, toes and spine. Psoriasis is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol, cardiovascular disease (angina, heart attack, stroke), and obesity. Symptoms Red, scaly patches (also called plaques or lesions) with sharply defined edges, that occur most commonly on both elbows, both knees, the scalp, under arms, under breasts, natal cleft (groove between the buttocks) and genitalia, or at the site of an injury • If the scales are gently scraped off, a number of small, bleeding points can be seen underneath • Nail changes – loosened, thickened or pitted nails (pits are small dents/ice pick like

depressions on the surface of the nails) Psoriatic Arthritis Symptoms • Joint pain, especially with redness, swelling, and tenderness • Pain in the heel(s) or tennis elbow • A finger or toe that was completely swollen (sausage shaped) and painful for no apparent reason • Morning stiffness/pain in the back that improves with movement Pregnancy and Psoriasis Over the last decade or so, research has provided greater insights about the course of psoriasis during pregnancy and the safety of newer treatments, particularly for moderate-to-severe psoriasis. This is an evolving area and the science is complex, so it is important pharmacy tams are educated and knowledgeable so as to be able to effectively advise sufferers when considering planning a pregnancy. Fifty percent of psoriasis patients are women and the majority of these are diagnosed with psoriasis during their reproductive years. With this in mind, if a woman is considering becoming pregnant, it is important she has a conversation with her consultant. Approximately 50% of women experience an improvement in

their psoriasis symptoms during pregnancy, while others report no change or a worsening of their condition. However, it is thought that good disease control during pregnancy may optimise the health of both the mother and the baby. Psoriasis treatments

trials. While research has provided greater insights about the safety profile of these newer treatments during pregnancy, most of the data comes from their use in pregnant patients with rheumatoid arthritis and inflammatory bowel disease, where there has been no increase in pregnancy complications.

Treatment can be divided into four main categories: Topical treatments: e.g. creams, ointments, lotions, gels, foam or mousse applied directly to the skin.

Will treatment change during pregnancy?

• Phototherapy: a form of artificial ultraviolet light, delivered in hospital dermatology departments.

• The type and severity of psoriasis

• Systemic treatments: medications taken in the form of tablet, liquid or injection that work throughout the body to control the psoriasis. • Biologic agents: targeted medicines used to inhibit part of the immune system that drive inflammation. These are mainly injections but some are now being developed in table form. In recent years, the new biologic agents have significantly broadened the range and efficacy of treatment options available, revolutionising the care of psoriasis patients and have become the ‘mainstay treatment’ for many with moderate to severe psoriasis. Experience with biologic agents during pregnancy remains limited because pregnant women are usually excluded from clinical

This will depend on a number of factors, some of which include:

• Current treatment • Recommendations by their GP • The patient’s choice Things to keep in mind: Conception If a person is on a treatment where pregnancy should be avoided, it is extremely important to use a reliable form of contraception. For example, according to the British Association of Dermatologists, men and women should take effective contraceptive precautions whilst taking methotrexate and for at least 3 months after stopping this drug. So, if planning on starting a family, it is very important for both males and females to discuss conception plans with the consultant supervising their care. Options should be discussed early on to alleviate any potential stress.

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Sound Advice – Ear Care in Pharmacy

T

here are a plethora of common ear complaints that people will present to their pharmacy with. Ear infections are a usual occurrence with most children experiencing at least one, whilst record numbers of the population are being diagnosed with hearing loss.

Given the importance of this category, the below article takes a brief look at some of the conditions you and your pharmacy team are likely to encounter and how you can help those affected. Hearing Loss In Ireland alone, over 300,000 Irish adults have a moderate or greater hearing loss, yet only one in five of these have ever sought treatment. Almost 250,000 Irish people have untreated hearing loss which is strongly associated with increased rates of depression, cognitive decline and loneliness. Hearing loss can be present from birth due to genetic or developmental abnormalities, or arise through trauma, disease or loud noise exposure during the lifetime of an individual. The degree of hearing impairment can vary from mild to profound and causes significant social and personal difficulties. Recent studies have indicated a connection between untreated hearing loss and dementia. There are two main types of hearing loss.

Sensorineural Hearing Loss: Sensitive hair cells inside the cochlea, or organ of hearing, are damaged, either naturally through ageing or prolonged noise exposure. Quite often a person suffering with this type of hearing loss will not recognise that they have a problem due to their hearing deteriorating over a very long period of time. Sensorineural hearing loss can also result from ototoxicity. Certain types of medication can have a toxic effect on the cochlea and vestibular system in the inner ear and result in hearing loss. Conductive Hearing Loss: When sounds are unable to pass from the outer ear to the inner ear, often as the result of a blockage, such as earwax or a build-up of fluid in the middle ear cavity a hearing loss will result. Head trauma with resulting ossicular chain dislocation, Otosclerosis, or excessive bone growth in the middle can also result in a conductive hearing loss. Sometimes both types of hearing loss occur at the same time, this is known as a mixed hearing loss.

This occurs when someone has a combination of sensorineural and conductive hearing loss. This results in a disruption to the transmission of sound through the outer and middle ear as well as damage to the hair cells in the inner ear. Hearing loss in children The total instances at school entry of unilateral (in one ear) and bilateral (in both ears) mild to profound hearing loss is thought to be of the order of 1 to 2 per 1,000; that means between 3,000 to 4,500 preschool and school age children in Ireland will have a permanent hearing impairment, with potential consequences for education, communication, literacy, social and emotional development, and later employability. The Health Service Executive now run the Newborn Hearing Screening Program to identify moderate, severe and profound hearing impairments in newborn babies. Newborns identified with a hearing difficulty have a better chance of developing speech and

language skills and of making the most of social and emotional interaction from an early age. Pharmacists can help to tackle the issue by spotting hearing problems, educating people about the symptoms and causes, and advising people about where to go for help. As well as discussing the dangers of exposure to loud noise, pharmacists can warn about trauma – for example, making sure that people buying items such as cotton buds know they should not be inserting them into their ears. Research suggests people do not seek help for hearing problems until 10 years after they start, meaning they may miss out on treatment or help. But pharmacists can pick up a great deal simply by observing their patients' behaviour. For example, you may notice that when you speak to them, they tend to look at your mouth in order to follow the conversation. Many people don’t even realise they are lip reading because of hearing problems.

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Outer Ear Ear Drum Cochlea

than for adults because of the risk of long-term effects. If it is affecting a child’s hearing, it can in turn delay their speech and language development. In all patients with persistent or recurrent glue ear, secondary care monitoring is often required, where surgical insertion of grommets to drain the fluid and restore air flow through the ear might be recommended. Importantly, pharmacists should be mindful that antihistamines and decongestants should not be recommended to patients with glue ear.

Middle Ear Ear Canal

With so many people living with hearing loss, pharmacists need to consider how best to optimise communication in their pharmacy to accommodate them. One option to support hearing aid users is a hearing loop system. This provides a magnetic, wireless signal that is picked up by hearing aids when they are on the right setting. A small microphone at the counter picks up spoken words, and the loop system amplifies it into the patient’s ear. Consultation rooms themselves can also help people with hearing loss to concentrate on what the pharmacist is saying, without distracting background noise. Clear signage enables people to know they can speak to the pharmacist in these areas. Otitis Media is an inflammation of the middle ear and is often associated with sore throats, colds or other respiratory issues where the infection spreads to the middle ear. It is very common in children. The patient can suffer from temporary hearing loss and pain or discomfort in their ear. Patients

Eustachian Tube

can avoid Otitis media by getting their annual flu vaccination. Otitis Media usually happens very quickly for a short duration. If the patient has had the symptoms for a few weeks or month it may be an acute ear infection and should visit their doctor. Antibiotics are usually prescribed as treatment. The pharmacy can offer pain relief with ear drops or antihistamines if the inflammation is causing discomfort. If customers are prescribed ear drops or use OTC products, it is important they are shown how to use them properly and reminded that ear drops should be discarded 28 days after opening. Otitis Media with effusion (OME) or glue ear is very common in young children. It is a build up of fluid and causes hearing loss in one or both ears. In some instances the condition can lead to an infection of the ear if it is not treated. Glue ear is caused by the eustachian tube not working effectively by neglecting to drain the ear of fluid. In young children, the case can be made for GP sooner

Otitis Externa is the inflammation of the skin lining the outer ear. This can be the cause of a trauma to the skin, an infection or a skin allergy. Symptoms include an itchy ear, a discharge from the ear canal and pain in moving the jaw. In some extreme cases, otitis externa can lead to a reduction in hearing. If the infection is severe an antibiotic may need to be prescribed. However a patient should be advised to avoid using cotton buds and treat the area with an ointment or ear drops. Also advise customers to keep their ears dry. This will help to stop bacteria from entering the ear canal. Tinnitus is a ringing or buzzing in the ears that comes from the inside of the body rather than an external source. In some cases it can be very severe and affect a person’s daily life. Occasionally a build up of earwax is the cause of tinnitus or it may occur because of a blow to the head or loud noises. Patients who work in noisy environments such as musicians or publicans would be susceptible to the condition which will present as a ringing or buzzing in the ear or occasionally a low frequency noise. Sinusitis is characterised by the inflammation of the lining of the paranasal sinuses. 80% of cases of sinusitis will resolve itself in 14 days. Symptoms of a sinus infection are a green or yellow

mucus discharge from the nose and severe facial pain around the cheeks, eyes or forehead. Sufferers should be advised to use nonsteroidal anti-inflammatory drugs (NSAID) or paracetamol to ease their pain from their headache, and systemic or topical decongestants to improve air circulation & mucus drainage. If someone has persistent sinusitis after 14 days they should be advised to visit their GP as this is a warning sign of chronic sinusitis and be the result of a bacterial infection or an allergy. Ear Wax - Earwax helps to protect, clean and lubricate the ears and usually falls out of the ears on its own. Some people are prone to excessive amounts of earwax, which can cause pain, itching and sometimes hearing loss. Excess earwax can often be treated with OTC eardrops to soften the wax so that it falls out more easily – and pharmacists are ideally placed to offer treatment advice before customers visit a GP. Customers will often see a pharmacist first, as this is easier and more accessible than making an appointment with a GP. Olive oil, sodium bicarbonate and OTC earwax products may help to loosen the wax and ease the symptoms. It is important to ask the right questions, however, to check that the customer has excess earwax, rather than anything more serious, and they should be referred to their GP if they have any pain in the ears or the hearing loss is substantial or continues. It is important that pharmacists ask a series of initial questions with the aim of confirming or eliminating wax as the cause of the problem, before considering whether it might be something else. Those questions would typically be aimed at eliciting whether the patient has any discharge, acute pain or hearing loss. If they don’t have discharge or pain, but it’s affecting their hearing, then the likelihood is it will be ear wax.

Pharmacy Continued Registration Pharmaceutical Society of Ireland Registrants who hold a Certificate of Registration expiring 31 December 2019 may apply online for continued registration for 2020 from the end of October 2019. Email reminders for pharmacists, pharmacies and pharmaceutical assistants will be sent during October, and applications can be made online, including secure payment. The registrant portal provides

the option to reset your log-in password and the continued registration helpdesk will be available for support from 1 November on 1850 774 734. Under the Pharmacy Act 2007, pharmacists and pharmaceutical assistants must oQbtain a Certificate of Registration. The Certificate will be received in the post by registrants 4-6 weeks after submitting the application and payment for continued registration.

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Since July 2016, the PSI sends email notices only to registrants as a reminder for their registration renewal. Registrants should ensure that the email address registered with the PSI is regularly checked. Correspondence details can be updated by logging into the online registration portal. You may need to check junk mail folders in case emails are misdirected. You must apply for your continued registration 30 days before your

current certificate expires or you will be required to pay a late fee. A process of cancellation of registration (removal from the Register of the Pharmacists and the Register of Pharmaceutical Assistants) will commence for registrants who have failed to make the necessary application for continued registration.


Case Study

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Medication Adherence in Pharmacy Determinants of intentions to monitor antihypertensive medication adherence in Irish community pharmacy: a factorial survey Authors: Paul Dillon, School of Pharmacy, RCSI, Ronald McDowell, HRB Centre for Primary Care Research, RCSI, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, Susan M. Smith, Department of General Practice and HRB Centre for Primary Care Research, RCSI, Paul Gallagher, School of Pharmacy, RCSI, Department of Pharmacy, National University of Singapore & Gráinne Cousins, School of Pharmacy, RCSI Background: Community pharmacy represents an important setting to identify patients who may benefit from an adherence intervention, however it remains unclear whether it would be feasible to monitor antihypertensive adherence within the workflow of community pharmacy. The aim of this study was to identify facilitators and barriers to monitoring antihypertensive medication adherence of older adults at the point of repeat dispensing. Methods: We undertook a factorial survey of Irish community pharmacists, guided by a conceptual model adapted from the Theory of Planned Behaviour (TPB). Respondents completed four sections, 1) five factorial

vignettes (clinical scenario of repeat dispensing, 2) a medication monitoring attitude measure, 3) subjective norms and self-efficacy questions, 4) demographic and workplace questions. Barriers and facilitators to adherence monitoring behaviour were identified in factorial vignette analysis using multivariate multilevel linear modelling, testing the effect of both contextual factors embedded within the vignettes (section 1), and respondent-level factors (sections 2–4) on likelihood to perform three adherence monitoring behaviours in response to the vignettes. Results: Survey invites (n = 1543) were sent via email and 258 completed online survey responses were received; twothirds of respondents were women,

and one-third were qualified pharmacists for at least 15 years. In factorial vignette analysis, pharmacists were more inclined to monitor antihypertensive medication adherence by examining refill-patterns from pharmacy records than asking patients questions about their adherence or medication beliefs. Pharmacists with more positive attitudes towards medication monitoring and normative beliefs that other pharmacists monitored adherence, were more likely to monitor adherence. Contextual factors also influenced pharmacists’ likelihood to perform the three adherence monitoring behaviours, including timepressures and the number of days late the patient collected their

repeat prescription. Pharmacists’ normative beliefs and the number of days late the patient collected their repeat prescription had the largest quantitative influence on responses. Conclusions: This survey identified that positive pharmacist attitudes and normative beliefs can facilitate adherence monitoring within the current workflow; however contextual timebarriers may prevent adherence monitoring. Future research should consider these findings when designing a pharmacist-led adherence intervention to be integrated within current pharmacy workflow.

News Rowa round-off 60th Celebrations September 2019 was an extremely special month for Rowa Pharmaceuticals Ltd., as they celebrated 60 years of business in Bantry, West Cork. On Saturday, the 21st of September, Rowa Pharmaceuticals Ltd., held a family day in the Westlodge Hotel, Bantry. The fabulous event was hosted by the company’s managing director Mrs Wagner-Halswick who invited staff, their families and former employees for a day of live music, dining and entertainment. The

family day was a special thank you for all the hard work done by staff both past and present. The pharmaceutical company based in Bantry has been a cornerstone of the community since 1959 and also marked the monumental milestone by inviting guests from over 55 countries to celebrate with them for a week of events in Bantry, giving them a flavour of West Cork with walking tours, dining out in local restaurants, trips to Mizen Head and more. On Saturday, the 28th of September, Rowa Pharmaceuticals Ltd., concluded their 60th year anniversary month in style with international guests at a gala dinner in Dromquinna Manor, Co. Kerry. Mr Joe Keane, Head of Operations for Rowa Pharmaceuticals Ltd. and Mrs Wagner-Halswick, Managing Director of Rowa Pharmaceuticals Ltd. Photography by Tony McElhinney

Mrs Neven El Aggar, Mrs Wagner- Halswick and Dr Ashraf Habashy Photography by Denis Connelly

Joe Keane, head of operations for Rowa Pharmaceuticals Ltd., said of the celebrations, “What an incredible month for the company and the gala dinner was a super event! Mrs. Wagner-Halswick has been our managing director since 1979 and even now, is still the driving force of the company!

Her ambition and work ethic is unmatched, at our gala event we had guests from over 55 countries which is a true testament to Mrs. Wagner-Halswick’s reputation as a business woman and the strong business relationships that she has developed over the years.”

PHARMACYNEWSIRELAND.COM


The options in Anorectal Conditions

M

any of those visiting their community pharmacy may be hesitant to discuss uncomfortable anorectal conditions such as pruritus ani, anal fissures, and haemorrhoids with their pharmacist.

An understanding of these conditions and how they are managed can help pharmacists and their teams to proactively bridge the communication gap and assist patients who may be experiencing discomfort. Haemorrhoids Haemorrhoids are one of the most common ailments known. More than half of people will develop haemorrhoids, usually after the age of 30. A HTA on referral thresholds for haemorrhoid procedures has shown that half the Irish population “experience symptomatic haemorrhoid disease at some point in their lives, with the peak incidence of symptomatic disease between the ages of 45 and 65 years.” Also known as piles, these are swellings that contain enlarged blood vessels that are found inside or around the bottom (the rectum and anus). Most haemorrhoids are mild and sometimes don’t even cause symptoms. When there are symptoms, these usually include: • bleeding after passing a stool (the blood will be bright red) • itchy bottom • a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool Symptoms may include rectal

bleeding resulting from irritation of internal haemorrhoids, with bleeding usually occurring immediately after defecation. Other symptoms may include itching, perianal discomfort, and soiling. Constipation, pregnancy, heavy lifting, or strenuous exercise may exacerbate these symptoms. Prolonged sitting, obesity, and low-fibre diets are other possible contributing factors. Supportive care strategies may include lifestyle changes, such as adopting a high-fibre diet, increasing fluid intake, avoiding straining during defecation, and using topical products for symptom relief. As haemorrhoidal tissues are inflamed, topical vasoconstrictors are commonly used to shrink blood vessels in the anorectal area and temporarily relieve swelling. Topical analgesics may also be used to relieve pain, itch, and irritation. Anal Fissures An anal fissure is a tear in the mucosa of the anal canal, just inside the anal margin. It is a common condition causing pain on defecation in adults and children. Most anal fissures respond well to conservative or topical management. In refractory cases surgery may be required. Anal fissure is known to be a common condition. There are no recent prevalence figures but

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it is believed to have a lifetime incidence of around 11%. It can occur at any age, including children. However, it is most common between the second and fourth decades. Primary anal fissures are less common in the elderly. The aetiology of primary anal fissures is not entirely clear. It is known they are associated with increased anal tone, although the cause of this is unknown. The subsequent relative ischaemia hinders the healing process. In children particularly, withholding of stool to avoid pain may worsen constipation and exacerbate the problem. Management options target reducing anal tone. Anal pain is experienced on defecation, traditionally described as feeling like passing shards of glass. Pain may persist for several hours after passing stool. There may be bleeding on passing stools. If present, it is seen as bright red blood on the stool or toilet paper. A thorough history should be taken to include: • Bowel habit - constipation, diarrhoea, recent change. • Associated symptoms abdominal pain, weight loss, rectal discharge. • Family history relating to inflammatory bowel disease and colorectal disease.

The management of primary anal fissures is generally nonoperative and includes increased dietary fibre, warm baths, topical ointments and botulinum toxin injections. If these treatments are ineffective then surgical intervention may be considered. Secondary anal fissures require further investigation. Patients with pruritus ani and anal fissures may benefit from the use of a topical analgesics for relief of anorectal pain and discomfort. Before recommending any of these products, pharmacists should ascertain the appropriateness of self-treatment and refer patients to seek medical care when warranted. Pharmacists should determine if the patient has any allergies or pre-existing medical conditions. It is imperative that patients adhere to the recommended directions for use of the selected product. Pharmacists can assist patients in the selection of the dosage form that best suits their needs. Pharmacists can also make recommendations of non-pharmacologic measures, including eating a well-balanced diet, ensuring adequate fluid intake, increasing dietary fibre, or the use of a fibre supplement and/ or stool softener. Pharmacists can advise patients to practice good personal hygiene, avoid lifting heavy objects or straining, and incorporate an exercise regimen into their daily routines.

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News More Measures called for in Asthma Care In response to Budget 2020 announcements by Minister for Health Simon Harris, the Asthma Society of Ireland has expressed dissatisfaction at the lack of substantive measures to tackle the financial burden of medications on people with asthma. The organisation has been calling over successive budgets for the cost of asthma medication to be urgently reduced. Ireland has the fourth highest prevalence of asthma worldwide with approximately 470,000 people affected (1 in 8 of population). Asthma is the commonest chronic disease in childhood and the most common respiratory condition here. Sarah O’Connor, CEO of the Asthma Society of Ireland, said, “The high costs of controller medication means many forgo taking it and rely instead on reliever inhalers when experiencing an attack, which is extremely dangerous. Reliever inhalers are often insufficient to combat severe asthma attacks. Overreliance on reliever medications can further exacerbate the condition, leading to higher rates of hospitalisation and even death. Ultimately, poor use of controller medication due to high costs is resulting in significant and wholly avoidable repercussions for both the patient and the State.” The Asthma Society also called on the Minister to establish a funding model for high-tech severe-asthma treatments in Budget 2020, which are needed by a small cohort of the population but which prove lifechanging for suitable patients. Ms O’Connnor continued, “For severe asthma patients, biologic medications can mean the difference between completely debilitating symptoms and frequent hospitalisation, or potentially leading a happy, healthy and full life. Yet, in Ireland, access to these medications is dependent on each hospital’s pharmacy budget so, for five hundred or so patients with severe asthma suitable for biologic treatment, it is not need that determines whether they receive this lifechanging medication, but where they live.”

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Pharmacy has vital role in vaccinations With the flu vaccination now available for this season, Boots Ireland has launched new research[ii] revealing 57% of people in Ireland have never been vaccinated against the flu and only 29% plan to get vaccinated for the 2019/2020 flu season. During the 2018/2019 flu season, 3,217 influenza hospitalised cases[iii] were reported in Ireland. While these were the most severe cases, getting a flu vaccination reduces the risk of getting the flu by up to 60%[iv] and helps prevent the spread of the virus. The Irish Pharmacy Union (IPU) has urged people to avail of the flu vaccine early in this year’s season. According to the IPU early vaccination will provide the best individual protection and can contribute to a nationwide reduction in flu levels. Speaking at the launch of the IPU’s annual campaign to encourage people to get an annual flu vaccine IPU Vice President Eoghan Hanly said, “Influenza (the flu) is a highly-infectious illness that can result in a very serious infection; tragically last year 74 people in Ireland died as the result of flu. In the Northern Hemisphere the flu season typically lasts from October to April. “The 2019/20 Seasonal Flu Vaccine is now available in pharmacies nationwide. This has been proven as the best protection against flu. It has also been shown that the most effective time to get the flu vaccine is before flu begins spreading in your community. Therefore early vaccination is highly recommended, particularly for those in at-risk groups.” HSE national guidelines strongly urges those in the at-risk groups to get the flu vaccination[v] as they are particularly vulnerable and have a greater chance of developing

complications from flu. At risk groups include those over the age of 65 years, pregnant women and people with long-term health conditions.[vi] While it is strongly recommended that people in these groups get the flu vaccination, Boots are supporting the HSE by encouraging the public to take preventative measures to stop the spread of flu by getting vaccinated. Of those who have previously availed of a flu vaccination, 66% go to their GP for the service, with one in five people (20%) availing of the service from a pharmacy. The vaccination is now available for those aged 10 years or older in selected Boots stores nationwide*, see Boots.ie for full list of stores. Speaking on the importance of getting vaccinated, Dr Kim Roberts, Ussher Assistant Professor of Virology and leader of the Influenza research group at Trinity College Dublin, said, “Getting the flu vaccination is the best preventive measure against influenza and the spread of the virus. With the service available in Boots stores across the country, it’s now more accessible than ever to get the flu vaccine and should be a priority for everyone to help prevent the spread of the virus. I have been availing of the service in Boots for years – it couldn’t be easier. The flu vaccine usually takes about two weeks to take effect, so it’s better to get the vaccination as early in the season as possible.” Of those who haven’t had a flu vaccination in the past, 10% stated cost was a main factor in their

decision, while 7% claimed it was a matter of how much time it took to organise. Many stores offer late night and weekend opening hours and the service can be booked online with walk-ins also welcome. The cost of the vaccination is ¤20** however is free of charge for those over 10 years old who are in the categories for whom vaccination is strongly recommended and have a Medical Card, Doctor Visit Card, HAA** Card or 2015A*** Card. Eoghan Hanly adds that, “Pharmacists have been safely delivering flu vaccines since 2011, in other countries they routinely offer a wider vaccination service and this is something that should be introduced in Ireland. We have been calling for the introduction of vaccines for meningococcal disease, tetanus and hepatitis A and B, as well as travel vaccines.” [ii] Research commissioned by Boots Ireland, and carried out by iReach, on a nationally represantive sample of 1,001 adults aged 18+. Field work was conducted in September 2019 [iii] Influenza Surveillance in Ireland - Weekly Report, https://www.hpsc. ie/a-z/respiratory/influenza/seasonalinfluenza/surveillance/influenzasurveillancereports/20182019season/Influenza_Surveillance_Report_Week%20 19&20%202019_20182019.pdf [iv] https://ecdc.europa.eu/sites/portal/ files/documents/influenza-why-do-Ineed-flu-vaccine-every-year-infographic.pdf [v] https://www.hse.ie/eng/health/ immunisation/pubinfo/flu-vaccination/ about-the-flu/ [vi] https://www.hse.ie/eng/health/ immunisation/pubinfo/flu-vaccination/ about-the-flu/

Pharmacy ‘Aware’ of Mental Health It is estimated that there are more than 450,000 people in Ireland living with depression, with around 45,000 diagnosed with bipolar disorder. Aware recently held their 2019 conference which looked to ‘The Future of Depression & Bipolar Disorder’ concentrating on novel approaches, further developments in existing therapies and additional means of understanding depression and bipolar disorder. Pictured is pharmacist, performance coach and speaker, Jack Kavanagh, at the conference which was held in University College Dublin. The event took place in the same week as World Mental Health Day, and brought together a wide range of mental health experts before an audience in excess of 800 people.

PHARMACYNEWSIRELAND.COM


Topic Team Training – Seasonal Ailments A community pharmacy environment that fosters teamwork ensured high levels of consumer satisfaction. This series of articles is designed for you to use as guide to assist your team in focusing on meeting ongoing CPD targets and to identify any training needs in order to keep the knowledge and skills of you and your team up to date. or even pain in the chest shortly after eating. Over-the-counter remedies can relieve the pain, but those getting regular bouts or experiencing other symptoms such as loss of weight, persistent vomiting, difficulty swallowing or blood in their vomit or stool, should be referred.

The below information, considerations and checklist provides support to enable you to run a team training session and identify opportunities for learning within the topic of Seasonal Ailments. It’s no coincidence that more people get ill over the holiday period than any other time of year. Parties, late nights, bad weather, over-indulgence in food and drink, not to mention concerns about the bank balance, all take their toll on people’s bodies. This issue’s Team Training is designed to help pharmacists and their teams to prepare for the rush of festive ailments – and boost your seasonal sales in the process. Cold/Flu: Adults in general suffer from cold approximately two to four times annually while children can contract the virus three to eight times as their immune systems aren’t as developed.

Distinctive symptoms means that people often diagnose and treat themselves through a combination of self-care and OTC products, without needing to go to the doctor. If there is no improvement then an appointment with a doctor should be arranged. The flu is the big brother to the common cold and will generally have similar symptoms, but they will be more intense. Other groups are at-risk of harmful or even life-threatening complications from the flu, particularly those with compromised or developing immune systems, including pregnant women, the elderly, and young children. Decongestants, antihistamines and pain relievers might offer some relief from symptoms. Indigestion: The holidays aren’t the holidays without an overload of food. Indigestion can cause heartburn, nausea and discomfort

Consider:  Am I/my team familiar with the current lifestyle tips on dealing with the cold/flu such as drinking plenty of fluids and avoiding infecting others?  Am I/my team aware of those at-risk of flu and who should be referred?  Is the team confident in advising on indigestion remedies?  Am I/my team aware of recommended alcohol guidelines?  Are the team confident in recognising the signs and symptoms of SAD and other mental health disorders that should be referred?

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Alcohol Consumption: The festive season often means endless parties, catching up with old friends, eating and drinking. Research has found people drink much more than the annual monthly average during December. Regularly drinking above the daily unit guidelines during Christmas can cause temporary effects, such as headaches, sickness, diarrhoea and may also negatively affect mood, weight and sleep. Frequently consuming alcohol can also lead to liver damage. Advise on drinking responsibly, staying within the safe daily unit guidelines, to drink water or soft drinks between each alcoholic drink and to eat a filling meal before alcohol consumption. Sore Throat: Sore throats are nearly always the result of a viral infection which means antibiotics

won’t be of any use. There is usually no need to seek medical help, unless an individual is getting them very regularly and are taking a long time to recover, which may imply a weakened immune system. One of the easiest home remedies is to gargle warm salty water and take paracetamol to help relieve the pain. Over the counter medications such as throat lozenges will not cure the illness, but they can help with painful symptoms. SAD: Seasonal Affective Disorder has only recently been recognised as a genuine condition, characterised by ongoing feelings of depression during the winter months, irritability, lethargy and a craving for carbohydrates. Levels of serotonin, which affect moods, appetite and sleep, are thought to be lowered by the shorter sunlight hours, and this stops the hypothalamus from working properly. Advise sufferers to make a point of getting as much natural sunlight as they can. If this isn’t possible, light therapy boxes can simulate exposure to sunlight and help raise seretonin levels. Those who are feeling really low should be referred.

Key Points: Check your pharmacy team are aware and understand the following key points:  The importance in ensuring people have adequate supply of prescription medication for the holiday season  Educate the pharmacy team on the recommended daily alcohol intake for both men and women  Lifestyle and hygiene tips and advice on reducing infection  The different types of OTC medications available for sore throat and cough and their indications  Those who must be referred to the pharmacist such as those with regular indigestion accompanied by additional symptoms

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


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‘Snow’ Joke - Skin Care in Winter

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inter plays havoc with skin, especially for customers with conditions such as eczema, rosacea and psoriasis. There’s plenty of advice that pharmacy teams can offer customers so that their skin doesn’t suffer at this time of year. It is important to ensure that all pharmacy staff are well educated about the variety of different skin conditions prevalent in winter.

The below article takes a look at how winter conditions affect the skin, how pharmacists and their teams can build a successful winter skin category and will offers advice on common conditions such as eczema, flare-ups, dry and chapped lips, rosacea and dry skin and hands. Study Findings A study which was published in the British Journal of Dermatology provides some information that may help explain why many people experience eczema and dry skin in the winter. In tests of skin on 80 adults, the levels of breakdown products of filaggrin, a protein that helps maintain the skin's barrier function changed between winter and summer on the cheeks and hands. Changes were also seen regarding the texture of corneocytes, cells in the outermost part of the skin's epidermis.

“This study shows clearly that the skin barrier is affected by climatic and seasonal changes. Both children and adults suffer from red cheeks in the winter in northern latitudes and some may even develop more permanent skin conditions such as atopic eczema and rosacea,” said senior author Dr Jacob Thyssen, of the University of Copenhagen, in Denmark. “By the use of high magnification we show that the skin cells suffer from shrinkage and therefore change their surface. The clinical message to individuals are that they should protect their skin with emollients in the winter and sunscreen in the summer.” Pharmacists need to highlight to customers that winter weather can exacerbate existing conditions such as eczema or psoriasis. Alongside moisturising and treating dry skin elements, they may need support and treatment for flare-ups.

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Dry Skin If the skin’s water content drops below 10%, the enzymes responsible for corneocyte desquamation no longer function properly. The corneocytes shrink

reducing levels of NMF and the lipid lamellae appears broken (analogous to crumbling mortar in an old brick wall). These will create breaches in the skin’s barrier, allowing for greater water loss.


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David McMahon, Chief Executive Officer, Irish Skin Foundation

Clinically, xerotic skin appears rough and flaky, with white patches (which represent adherent corneocytes due to reduced desquamation) that is both uncomfortable and pruritic. Dry skin is commonly seen on the lower legs, the trunk, forearms, hands and face. The feet are normally less prone to dryness, being protected by socks and tights, but dryness can be problem for those who walk barefoot or wear sandals. Left untreated, xerotic skin becomes red, dull and rough, and ultimately starts to crack. These cracks deteriorate over time and can bleed, providing an entry portal for irritants and bacteria that can lead to infections. To prevent dry skin, customers should be advised to maintain skin hydration through adequate fluid intake, avoid hygiene products that dry out the skin, reduce fullbody bathing to every other day, and avoid long, hot showers. To treat dry skin, there are several suggestions pharmacists can offer. Patients can apply oil-based emollients (eg, petrolatum and mineral oil) after bathing, or they may use colloidal oatmeal or bath oil while bathing to enhance skin hydration. Humectants, such as glycerin, draw water into the skin. More serious cases of dry skin may require a urea- or lactic acid containing product. Managing Eczema The words eczema (which comes from the Greek word meaning ‘to boil’) and dermatitis (meaning inflammation of the skin) are often used interchangeably to describe several conditions that cause the skin to become dry, itchy, inflamed or irritated. There are a number of different types of eczema but the term is most often used to refer to atopic eczema (also called atopic dermatitis).

The word atopic refers to hypersensitivity reactions to something in the environment. Atopic eczema is a very common, non-contagious, chronic (long-term) inflammatory skin condition. While the exact cause is not known, certain factors are thought to be important in its development, these include an inherited (genetic) predisposition to have a weakened skin barrier, as well as altered inflammatory and allergy responses. Atopic eczema most frequently begins in infancy but may also develop for the first time in adulthood. It affects approximately 1 in 5 children and 1 in 12 adults in Ireland. For most children affected, the disease is mild. However, often those who have seemingly outgrown the condition will continue to have life-long sensitive skin and may have recurrences of eczema following long symptom-free spells. Atopic eczema can run in families and frequently occurs alongside other atopic conditions, including hay fever and asthma. Symptoms include red, dry, itchy skin, which can sometimes weep, become blistered, crusted and thickened. However, the appearance of eczema and the locations of the body affected can vary greatly depending on the age of the person affected. The main symptom is an intense itch. Scratching only provides temporary relief, and leads to more itching and scratching (the itch-scratch cycle), which can worsen eczema and make the skin more vulnerable to infection. Scratching in response to itch can cause some of the changes seen on the skin in eczema. The main aim is to improve symptoms and achieve longterm control. In atopic eczema,

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the skin’s protective barrier is weakened which allows moisture to be lost, and irritants and allergens to pass through the skin more easily. Some common everyday substances e.g. soap, contribute to the weakening of the skin’s barrier and should be avoided. The Irish Skin Foundation’s ‘Living with Atopic Eczema’ survey, which over 450 people living with eczema or caring for someone with eczema responded to between September 2018 – April 2019 showed that the cost of eczema treatments and doctor’s appointments needed to manage the condition can be a significant financial burden. The survey revealed that 42% of carers of children and 49% of adults reported cutting back on household expenses due to the cost of managing atopic eczema. The figures suggest that one quarter of these consumers spend at least ¤2,300 annually on doctor’s fees, over-the-counter management products and prescription treatments. The findings also show the pronounced negative impacts that atopic eczema can have on quality of life, including sleep disruption, absences from school, as well as participation in exercise and social activities. A major symptom of atopic eczema is intense itch, which is commonly reported to disrupt sleep, with findings revealing that the overwhelming majority of children (86%) and adults (84%) living with the condition experience ongoing sleep disturbance. The ISF’s, David McMahon says, “The disruption and stress that moderate and severe atopic eczema can cause is very clear from the findings of our recent survey. And while we know that the family impact of atopic eczema can be profound, we were

“Our work with families impacted by eczema, particularly at this time of the year as the school term starts back, focuses on supporting people to re-establish care routines that will strengthen the skin barrier. This is quite important in advance of the weather cooling and central heating being turned on again in the autumn, both of which can be a challenge for vulnerable skin and can lead to flares” David McMahon, Chief Executive Officer, Irish Skin Foundation

surprised how disturbed sleep, lost school days and potentially, productivity features so strongly. “Our work with families impacted by eczema, particularly at this time of the year as the school term starts back, focuses on supporting people to re-establish care routines that will strengthen the skin barrier. This is quite important in advance of the weather cooling and central heating being turned on again in the autumn, both of which can be a challenge for vulnerable skin and can lead to flares.” Rosacea Gusty winds during the winter and the dry air in overheated rooms cause the skin of patients with rosacea to become more sensitive. Rosacea is defined as a chronic, relapsing, inflammatory condition that affects the central portion of facial skin. More frequently seen in fair-skinned individuals of Celtic or Northern European heritage, rosacea occurs more commonly in women (although men tend to experience more severe disease) and in those between 30 and 50 years of age. A system for classifying rosacea defines four sub-types although, in practice, aspects of each subtype will be present to varying degrees in the same patient. Irrespective of the sub-type, a


diagnosis of rosacea is made in patients having one or more of the following primary features:

Chapped Lips Chapped lips can occur in any season of the year, although they are particularly common during the winter months. Chapped lips can be painful, embarrassing, and uncomfortable. They may sometimes cause difficulty in talking, eating, and drinking. Understanding the causes, treatments, and prevention can help pharmacy teams advise sufferers on how to reduce or avoid the occurrence of chapped lips.

• Flushing (transient erythema) • Non-transient erythema • Papules and pustules • Telangiectasia (visible blood vessels). Currently available treatments for rosacea are directed at managing sub-type 2 (papulopustular rosacea). Mild to moderate disease, defined as only a small number of papules and pustules, is normally managed with topical antibiotic agents such as metronidazole or azelaic acid. Other agents that have been used include topical clindamycin, tretinoin cream and benzoyl peroxide. The use of scarves or ski masks may help outdoors in cold winds. Although hot soups and drinks are tempting in the colder weather, these should be avoided or at least left to cool off before drinking, particularly if certain foods are a known trigger. It is important that patients are aware of the potential triggers for rosacea and try to avoid these wherever possible. It is useful for patients to keep a diary to help identify and therefore minimise exposure to potential triggers. All patients should use a high factor, broad spectrum sunscreen every day and those with very dry skin should be advised to experiment with hypoallergenic emollients to help relieve the dryness.

The skin on the lips is much thinner and more delicate than that on other parts of the body. The lips are also exposed to the elements, including the sun and cold, dry air, making them prone to dryness, cracking, flaking, and peeling. wish to consider using a heavier petroleum-based emollient during the winter months to prevent moisture loss. Humectants such as glycerine and hyaluronic acid added into some moisturisers help to draw water molecules from the external environment to the skin surface. Gentle exfoliating in winter using products that contain natural polishers, such as colloidal oatmeal, can have a hugely beneficial effect. On a day-to- day level, one of the most overlooked areas, especially for men, is proper handcare. The main thing about winter skincare is taking steps to prevent dry skin as this is a key issue during the season and can exacerbate existing skin conditions.

Managing the Category

Some of the best winter skin displays often feature elements of winter weather. Putting out an eye-level selection of winter hero products to address this issue often converts into sales.

Encouraging customers to rethink their winter skincare routine will help. Patients with dry skin need to be diligent with more frequent applications of moisturiser throughout the day. They may also

Diversity of brands and formats is also important. Creams are easier to use and absorb better for daily use, while ointments have higher efficacy and are more popular for night use. The two formats can

The lips lack oil glands and so cannot produce their own moisture, but natural moisturisers can help. Whilst the winter conditions most often cause chapped lips, there are other causes such as:  Smoking  Dehydration  Repeatedly licking the lips  Skin disorders such as eczema  Allergic reactions to certain skin care products or cosmetics  Use of certain medications such as anti-acne products Those with chapped lips may experience dryness, redness, tenderness and sensitivity, cracking, splitting, or peeling and pain. A variety of OTC products are available for treating or preventing chapped lips. These products typically contain ingredients that assist in healing, such as skin protectants, moisturisers, pain relievers, and sunscreens.

be sold together for day and night use. Retailers, wholesalers, distributors and brands should be working together to ensure pharmacists and staff have both the knowledge and materials they need to be able to educate their customers on being prepared for winter.

Furthermore, healthy winter skin could be a great topic for a community pharmacy that’s moving towards healthy living status, with eye-catching posters in store encouraging customers to start conversations with the pharmacy team.

News New Role for Barbara Excel Recruitment are delighted to announce the launch of their new specialist Pharmacy recruitment division and welcome the fantastic Barbara Kelly to the team. Excel Recruitment have successfully recruited for major pharmacy retail brands and local, community pharmacies for over 17 years. This new division is a natural progression and will see them specialise further in recruiting locum, contract and permanent Pharmacists of all levels, Pharmacy Technicians and more nationwide. If you have any Pharmacy recruitment requirements or are a pharmacy professional considering a new job, get in touch with Barbara today at barbara@excelrecruitment.com or call 087-7379636.

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News

Landmark decision in HIV prevention A new public access programme for Pre-exposure prophylaxis, PrEP was announced last month (October), signalling a landmark decision in preventative healthcare and the reduction of HIV infections in Ireland. Taoiseach Leo Varadkar, Minister for Health Simon Harris and Minister for Health Promotion Catherine Byrne announced that a HIV PrEP programme will begin from 4 November 2019. The new programme starting in November means that those who attend an approved service and are found to be at substantial risk for HIV and meet the clinical eligibility criteria will be eligible for PrEP free of charge, dispensed through community pharmacies. The decision to provide a public access programme comes in the aftermath of HSE research, published prior to the announcement, which found a high awareness of PrEP at 86% [iii] amongst men who have sex with men in Ireland. This figure is a substantially higher figure than most European countries. Despite a greater awareness of PrEP, only 4%[iv] of those surveyed confirmed they were using PrEP. But 49% of those surveyed also said they were likely to use PrEP if it was available and affordable. The findings suggest that today’s public access programme will meet an unmet demand. A formal PrEP programme in place, as previously recommended by the Health Information and Quality Authority, would allow for a safe, effective and cost-saving environment. The programme will roll out in 2020 and was announced by Minister for Health Simon Harris. The announcement has been welcomed by Teva Pharmaceuticals Ireland, the

company who first introduced PrEP to community pharmacies in Ireland in December 2017. Director of Generics with Teva, Paul Neill said, “The introduction of a PrEP programme represents a landmark decision in reducing new HIV infections in Ireland, by making the drug more available and affordable. “Up to this point, access to PrEP for Irish patients has been restricted and based on their capacity to pay. Today’s announcement will hopefully end that inequality. Access to PrEP will now be based on need rather than financial means. “The decision is also an important statement on the value of preventative healthcare versus after-the-fact treatment. At a time of stretched health budgets, when our health services have so many competing priorities, medicines such as PrEP can make a huge contribution to keeping people healthy and in reducing healthcare costs. “Further work is now needed to increase education and awareness of PrEP, to ensure that patients have a better understanding of the healthcare regime which must support PrEP, usage such as regular sexual health testing. Teva will also work to expand awareness and knowledge on PrEP. “Teva, as Ireland’s largest generic medicines company, strongly supports making medicines more affordable and accessible. That today’s decision, underpins these objectives, is particularly welcome.”

In December 2017, Teva launched a generic version of the medication (Emtricitabine/Tenofovir disoproxil Teva). The entry of a generic into the Irish market lead to a more affordable price for PrEP, it also expanded patient access by making it available through community pharmacy for the first time, where it is available subject to a doctor’s prescription. However, PrEP up until now has been available only to private patients, excluding patients reliant on GMS or Drug Payments Schemes. Today’s decision will now change that. PrEP has been shown to significantly reduce the risk of HIV infection through sex, particularly for those deemed at risk, such as gay and bisexual men, and transgender women, but also for heterosexual men and women. PrEP was first launched in the United States in 2012 and since then has been made available in multiple healthcare jurisdictions across the globe as part of wider national and municipal HIV prevention strategies. The medication works to prevent HIV from establishing infection inside the body[v]. [iii] EMIS-2017 Ireland Reports: The European MSM Internet Survey 2017 (EMIS-2017) http://gayhealthnetwork. ie/research/ [iv] EMIS-2017 Ireland Reports: The European MSM Internet Survey 2017 (EMIS-2017) http://gayhealthnetwork. ie/research/ [v] PrEP, Centres for Disease Control and Prevention, https://www.cdc.gov/ hiv/basics/prep.html

New Pharmacy Appointments Adrian Dunne Pharmacy Group recently welcomed two new appointments. The new starts completed their induction in the group office last month. The team are happy to have on board, pictured Ciara Nolan, Pharmacy Technican, Lucan Lisa Kenny, Group Relief Pharmacist and Eloisa Troisi, also Group Relief Pharmacist.

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Over 80% experience Back Pain For many, back pain can be both debilitating and frustrating, with the cause often unclear. In a recent study commissioned by Elastoplast involving 1,607 Irish adults, researchers found that 89% have experienced back pain, with a third experiencing it on a weekly basis. As the number of people experiencing back pain is constantly increasing, it is important that people are aware of the most effective ways to treat it. There are many misconceptions around treating back pain, such as the idea that staying in bed and not moving will help. However, contrary to what one might think, research has found that exercise can be one of the most effective ways of treating back pain. Elastoplast Spiral Heat patches are the perfect product to relieve pain and keep you moving and active. While the highest proportion of the population to experience back pain are those aged 55+, the lifestyles of those under 25 leave them susceptible as well. Research shows that 51% of under 25s spend 7-9 hours seated per day, which can put immense strain on their backs. In order to avoid back pain now and in the future, it is recommended that young people increase their daily activity and relieve any current issues with the help of Elastoplast Spiral Heat Patches. Elastoplast Spiral Heat Patches are the first heat patch designed to be extra discreet. It is an effective, targeted, long-lasting product that provides 12 hours of constant warmth and stays in place throughout the day. The innovative Elastoplast Spiral Heat Patches can be used on the neck, shoulders and back to provide targeted relief where needed from aches, strains and pains, while ensuring comfort is not compromised.


O

Breaking the silence on Osteoporosis steoporosis 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. Community pharmacists can help prevent osteoporosis by recommending that patients exercise, avoid smoking and excessive alcohol intake, and have an adequate intake of vitamin D and calcium. Pharmacists can also help identify patients at risk of osteoporosis, such as those taking glucocorticoids long-term. World Osteoporosis Day (WOD), took place last month (October 20th) marking a yearlong campaign dedicated to raising global awareness of the prevention, diagnosis and treatment of osteoporosis. WOD aims to make osteoporosis and fracture prevention a global health priority by reaching out to health-care professionals, the media, policy makers, patients, and the public at large. In 2019 the campaign featured “THAT’S

OSTEOPOROSIS” as a headline, and, for the first time highlighted emotionally impactful visuals and stories of real people living with osteoporosis in all regions of the world.

These include:

The campaign also emphasised the direct link between osteoporosis and broken bones, which have a serious, life-changing impact in terms of pain, disability, lost independence and inability to carry out tasks of everyday life.

• Sight, hearing or cognitive impairment

Impact of Falls As people get older, they may fall more often. While falls can obviously result in physical injury that can be serious such as a fracture or head injury, they can also have psychological effects, such as a fear of falling itself. This loss of confidence can then lead to a self-restricted reduction in physical activity and social interactions. Falls are costly to the individual and to society because they lead to additional GP visits, ambulance call-outs, A&E attendances, hospital stays and increased social care costs. As the number of older people in society increases, the impact of falls is likely to grow. Falls are not a normal part of ageing and there are many causes.

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• Side-effects of medicines • Impaired postural stability linked to diseases (such as arthritis, stroke and Parkinson’s disease)

• Poor mobility, balance and coordination due to inactivity. Environmental factors include: • A lack of, or poorly positioned, hand rails

Bone is a living tissue that is constantly being removed and replaced. Bones need normal sex hormones, calcium, vitamin D, adequate calories, proteins and appropriate weight bearing/ strengthening exercise to keep them healthy. As people get older, more bone is naturally lost than is replaced, but those with osteoporosis lose more bone than people who do not have this disease. Osteoporosis causes bones to become fragile and therefore they break easily, for

• Uneven or slippery flooring • Poorly fitted rugs and mats • Poor lighting • Poorly fitting footwear. Often a combination of these factors leads to falls, so a multifactorial risk assessment (including medication reviews and home assessment) is needed to identify the risks. Consequently, there is a variety of possible solutions (e.g. disease and medicines review, physical alterations in the home, cataract surgery and improved activity). Prevalence of Osteoporosis Only 15% of people in Ireland are actually diagnosed with bone loss, leaving 280,000 undiagnosed and facing losing their independence.

Medications that can increase the risk of falling  Blood Pressure medicines  Antihistamines  Antidepressants  Parkinson’s Disease medicines  Anti-psychotics  Benzodiazepines  Decongestants  Opioids  Muscle relaxers  Sleep medicines  Urinary antichollinergics


flushes and provided there are no other contraindications. Monoclonal Antibody Denosumab is a monoclonal antibody which binds to RANK Ligand, inhibiting the maturation of osteoclasts, therefore protecting the bone from degradation. Bisphosphonates which are also known as antiresorptive medications are non-hormonal drugs which help maintain bone density and prevent further bone loss. Parathyroid Hormone – (PTH) is a bone forming agent, that stimulates the formation of new bone. Role of the Pharmacist There are several key questions community pharmacists and their teams can ask customers and important advice to be offered for those visiting the pharmacy.

example through a minor bump or fall. A broken bone because of a trip or fall from a standing position, should be considered osteoporosis, unless proven otherwise.

Osteoporosis Treatment

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.

• Cause/s of the osteoporosis

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.

Taking the recommended daily amount of calcium, vitamin D and appropriate weight bearing exercise, are essential to help to prevent osteopenia/osteoporosis and also the treatment for those with osteopenia/osteoporosis, along with the appropriate medication.

Broken bones can be prevented in most cases, and is a treatable disease in most people. Early diagnosis is essential for the best results. A DXA scan of the spine and hips is the gold standard for diagnosing osteoporosis and is highly recommended for those at risk. Osteopenia is the early stages of osteoporosis, however research shows that more people break bones in the moderate to marked osteopenia range than the osteoporosis range. Signs of Osteoporosis Usually the first sign of Osteoporosis is a fragility (low trauma) fracture, for example a broken bone due to a trip and fall from a standing position or less. 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.

The treatment selected for each individual person is usually based on the following: • Risk of fracture or re-fracture

• Age • DXA scan results of the spine and hips • Medical history

Calcium and Vitamin D supplements These can help to provide building blocks for healthy bone production. There is a major problem worldwide of low levels of Vitamin D, particularly in postmenopausal women. In Ireland 74% of adults and 88% of primary school children, take less than half of the recommended daily amounts of vitamin D. Vitamin D is not only essential for bone health, but is also important for muscle function and balance. A deficiency of vitamin D can cause rickets in children and osteomalacia in adults. Unfortunately, Ireland does not have the weather for people to get their vitamin D from the sun throughout the year. Vitamin D is essential for the absorption of calcium. Milks supplemented by vitamin D, fortified yogurts and oily fish are very easy ways for people to get their daily amounts.

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Pharmacists can offer supplements like chewable tablets, which provide patients with both calcium and vitamin D. HRT – Estrogen/Hormone Therapy There are multiple brands available. There are oestrogen replacement for women going through the menopause which help to maintain bone density and reduce fracture rates for the time they are on the treatment. Estrogen therapy and estrogen with progesterone hormone therapy are approved for the prevention of osteoporosis in postmenopausal women provided there are no contraindications. They are usually recommended for postmenopausal symptoms to help improve the person’s quality of life. They may also be prescribed for premenopausal women who have amenorrhea and low levels of oestrogen. Selective Estrogen Receptor Modulators (SERMs) SERMs work in a similar way to oestrogen on bone, by preventing bone loss in postmenopausal women who do not have hot

Pharmacists should find out if all the causes of their bone loss have been found and addressed. For 99% of people who contact the Irish Osteoporosis Society, their causes of bone loss have been assumed not investigated. Ask them if they are actually taking their medication, as well as the daily amounts of calcium and vitamin D. 70% of osteoporotic patients stop taking their treatment within one year. Are they getting enough calcium and vitamin D through food, therefore do they need a supplement, for example? You need to check if they have symptoms of gluten and wheat sensitivity as they may not be absorbing their treatments. The Irish Osteoporosis Society recommend that people get DXA scans every two years maximum. This is to ensure they are improving and if they are declining it is caught quickly. If a person declines, it usually means that the causes of bone loss were not found and addressed OR they have been put on another treatment that causes bone loss OR developed a condition which causes bone loss OR their cortisol levels may be high due to stress from a divorce, spouse ill etc.

Risk Factors for Osteoporosis Modifiable

Non Modifiable

Older Age

Smoking

Female Gender

Inadequate calcium intake

White/Asian Race

Inadequate vitamin D

Low peak bone mass

Low body weight (BMI < 21KG/M2

Family history of Osteoporosis

Estrogen deficiency

Personal history of fracture

Hypogonadism

Low body mass index

Chronic glucocorticoid therapy


News HPRA Annual Report The Health Products Regulatory Authority (HPRA) has published its 2018 annual report which details its key activities and progress across an extensive range of work programmes. According to Dr Lorraine Nolan, Chief Executive, during 2018 all parts of the organisation contributed to the delivery of a sizeable programme of work. There was significant progress across a number of key strategic projects and areas of focus and Dr Nolan is confident that these developments will enable the HPRA to continue to deliver on its public health remit. “In what was an incredibly busy year, we engaged extensively with stakeholders to focus on our preparedness for Brexit and to help us to effectively manage the potential impact on health product supply and availability. Given the central role of UK regulators within the European network over many years, this has been a difficult and complex task on many levels. “We continue to be busy at EU level working closely with regulatory counterparts through a wide range of committees and working groups at the European Medicine Agencies, the Heads of Medicines Agencies and the Competent Authorities for Medical Devices. “Once again 2018 saw us continue our work to stem the flow of counterfeit and falsified medicines and medical devices into Ireland and to protect the health of those who may use these products. During the year, working with our partners in An Garda Síochána and Revenue’s Customs Service, we detained almost 620,000 dosage units coming into Ireland. Looking forward, according to Dr Nolan, the HPRA is keen to continue addressing the challenges of and adapting to the ever evolving environment in which they operate. “We will continue to prioritise and advance regulation to best serve the Irish public and to further enhance how we work as an organisation. In particular, we must continually keep pace with the rapidly evolving pharmaceutical, medical device and cosmetic sectors so as to protect and enhance the health of the people and animals benefiting from the breadth of products we regulate.”

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Curley’s Celebrate 85 Years Curley’s totalhealth Pharmacy in Ballyhaunis recently celebrated 85 years of serving their local community in their family pharmacy. The pharmacy has been run by three generations of the Curley family. “We would like to thank all our loyal customers for all their support throughout the years,” said the pharmacy team.

Rosaleen and Roisin Curley

The pharmacy opened their doors to Midwest Radio who broadcast live from the shop and customers were able to enjoy special offers, spot prizes and goodie bags, as well as double points on all purchases.

Ned Curley and Roisin Curley with pharmacy staff member Mary and Rosaleen Curley

Mundipharma welcomes Matthew Mundipharma Pharmaceuticals Limited have announced the appointment of Matthew Homent to the position of Ireland Country Manager, a position he has held on an interim basis since April 2019. Matthew joins Mundipharma Pharmaceuticals Limited from Napp Pharmaceuticals Limited in the UK, where he was Director of Commercial Operations. During his time at Napp, Matthew was integral in setting up a marketleading portfolio of branded generic medicines providing muchneeded innovative, high-quality and cost-effective medicines to the NHS. Matthew has been with the Mundipharma network for over

20 years, moving to Napp in 2003, where he progressed through various procurement and commercial roles before becoming Director of Commercial Operations in 2015. Commenting on his appointment, Matthew said, “I am delighted, and it is a great privilege, to have the opportunity to lead Mundipharma in Ireland at a particularly exciting time for the company. As a business, we are committed to move medicine forward in

Ireland by bringing innovative and cost-effective medicines to our customers, the healthcare professionals, who are helping patients every day to manage their long-term conditions and lead better lives. I am extremely excited for the future of Mundipharma and look forward to working closely with an incredibly talented and ambitious team, who are equally committed to move medicine forward in Ireland.”

Clonmel Healthcare’s expansion of OTC portfolio Clonmel Healthcare, a subsidiary of STADA Arzneimittel AG are continuing with an expansion of their OTC Portfolio. They have now acquired the following brands from GSK Consumer Healthcare -Oilatum, Savlon and Eurex. Martin Gallagher, Director of Marketing and Business Development said, “In the past few months we have worked together very closely with the seller in order to ensure a smooth transition in distribution and in order to ensure the same high level of customer care to which our customers are used to.

“In the meantime we will maintain business as usual. From the 1st of November customers should please continue to place orders, return products and make payments for these brands with their local wholesaler. In the weeks and months ahead, we will provide customers with details regarding plans for the future and

timing of proposed changes in the management of the Oilatum, Savlon and Eurex brands. “We value our customers, and would like to assure them that both companies are committed to facilitating a smooth transition.”

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Advertorial

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The huge benefits of fish oils are widely reported, but there is a new product on the market which is making waves - the world's 1st omega blend designed for a healthy microbiome. 1: Help the Microbiome Flourish 2: Create the perfect Omega Blend 3: Produce a sustainable and Eco-Restorative Product In addition to its powerful anti-inflammatory and brain-boosting benefits, DPA fish oil absorbs faster than EPA and is often mercuryand toxin-free, making it one of h cleanest, healthiest fish oils that can be bought. Helping to Support the Microbiome Aqua Biome™ is the world's first fish oil with DPA, the "missing omega" that other fish oils don't know about. This crucial omega can be converted to either DHA or EPA by your body in an instant. The Microbiome is the microbial environment of bacteria within our gut. It's responsible for nearly every aspect of total body wellness, directly influencing everything from energy levels, to weight loss, to digestion, and more. To truly help your microbiome flourish, diversity is key. Studies show that a higher intake of Omegas EPA, DHA, and now DPA are critical for promoting microbial diversity.

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oil has been found to play a major role in imparting health benefits that have previously always been attributed to EPA and DHA. However research has shown that DPA is absorbed into the bloodstream and red blood cell lipids 22% better than EPA and DHA, meaning the body may be able to absorb more of its benefits. Fish oils rich in DPA can also act as a reservoir to help the body retain its omega-3 fatty acids. A two-week study in Copenhagen showed that omega-3 levels increased in the bloodstreams of the participants’ by 63% who had taken supplements rich in DPA in addition to EPA and DHA. This compares to just a 41% improvement in the participants who took supplements with only EPA and DHA.

Fun Fact: DPA is orginally found in a mothers breastmilk and has has been shown to improve sleep in newborns. Created for Holistic Health We set out to design a completely new type of omega product, made from wild-caught and sustainably-sourced anchoveta and based on these 3 tenets:

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News

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Women more at risk than Men of Stroke On World Stroke Day (Tuesday 29 October 2019) the Irish Heart Foundation was urging women in particular to be aware of the warning signs of stroke as the latest statistics show that women are far more likely to die from their stroke than men. While overall stroke deaths have fallen significantly more among women than men during the past decade, mainly due to major improvements to hospital stroke services, women are still at an increased risk of dying from stroke than men. According to the latest figures from the Central Statistics Office (CSO), since 2010 when the HSE’s National Stroke Programme was established, the number of stroke deaths has fallen by more than 18 per cent, from 2,053 to 1,680 last year – a total of 373 fewer deaths a year. Deaths among women were down by 323 and men by just 50. However, in 2018 in Ireland 935 women died from stroke which was more than 25% higher than the 745 deaths recorded in men. “It is not clear why stroke deaths

have fallen at a much higher rate among women than men,” said Head of Advocacy at the Irish Heart Foundation, Chris Macey. “It may be in part due to the fact that women are more likely to act on health campaigns for conditions such as high blood pressure and atrial fibrillation. “However, we do know that as many as 5,000 stroke sufferers every year are failing to get to hospital within the time window to benefit from potentially lifesaving clot busting treatment. “At least one in six of us will have a stroke at some time in our lives, so if you are not affected yourself it’s virtually certain that at least one of your loved ones will be. Therefore, it’s vital that everyone knows the act FAST signs. But given their considerably higher risk we are urging women in

particular make a special effort on World Stroke Day to familiarise themselves with these warning signs.” The F.A.S.T. acronym stands for: • Face – has their face fallen on one side? • Arms – can they raise both arms and keep them there? • Speech – is their speech slurred? • Time – time to call 112 or 999 if you see any one of these signs. “The high numbers not getting to hospital in time is all the more shocking when you consider that by knowing the warning signs, people can have a huge influence on their outcome after stroke,” said Mr Macey. “The average stroke destroys roughly two million brain cells every minute,

so the quicker you get to hospital after a stroke, literally the more of your brain can be saved.” Mr Macey added that the advent of thrombectomy, a clot retrieval treatment that restores the blood supply to a stroke patient’s brain, provided an even more compelling reason to act FAST. “Global evidence shows that this is the most effective treatment yet developed to treat stroke. It reduces deaths by half and the rate of permanent severe disability among stroke patients by almost as much. “Getting to hospital in time to receive thrombectomy or clotbusting thrombolysis treatment can literally mean the difference between walking out of hospital after a few days or death or being dependent for the rest of your life. But only if you act FAST.”

Date for your Diary The Irish Pharmaceutical Healthcare Association (IPHA), which represents the originator pharmaceutical industry, will hold the 'Innovate for Life' conference in Croke Park Conference Venue on Thursday, November 21st, 2019. The event, the 26th IPHA annual conference, will gather some 300 industry, policy, research and patient leaders to share their insights on improving standards of care through medicines innovation. The conference opens at 8.30am and closes at 4.30pm. Registration is from 8am. Speakers will include IPHA President, Mr Aidan Lynch and Mr Paul Reid, Director General with the HSE.

Customers First at Lynch’s Customers are what matter in 2019, especially to Lynch’s Totalhealth Pharmacy in Kells who have been shortlisted as a finalist in the Meath Business & Tourism Awards within the Best Customer Service category. Also shortlisted for Best in Retail are Farrell’s Pharmacy. The Customer Service Category had the greatest number of entries closely followed by Best New Business. “This is a great sign that Meath people are brave, passionate and innovative,” says Mary McGuigan Group Commercial Manager, Celtic Media Group who has been involved with the awards since they began 10 years ago.

Lynch’s totalhealth Pharmacy owner and Pharmacist Neil Sokay with pharmacy staff

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Life Awards

Honouring the Incredible - Life Pharmacy Awards Life Pharmacy has held its first awards ceremony to recognise the outstanding achievements of pharmacy teams and staff across the group.Teams from as far as Donegal travelled to Dublin to attend the event at the Clayton Hotel in Liffey Valley. Chairman of the Life Pharmacy Group, Ger Coffey, opened the event by describing the “incredible” stories that were put forward during the nomination process. “You have provided answers when there has been uncertainty and given people direction when they were lost,” he said. Two pharmacies were double winners, with Smyth’s Life Pharmacy in Dundalk taking both the Best in Sales and Loyalty for Life awardswhile Flynn’s Life Pharmacy in Ennis, Clare won the Pharmacy Team of the Year and VMS and Wellness Growth awards.

Other winners included Ward’s Life Pharmacy in St Johnston, Donegal for Best in Marketing; Armstrong’s Life Pharmacy in Arklow, Wicklow for Brand Standards;Brennan’s Life Pharmacy in Donabate, Dublin for Health Services and Murtagh’s Life Pharmacy in Ballinagh, Cavan for OTC Team of the Year. The individual awards saw Lesley McCarthy from Byrne’s Life Pharmacy in Ballsbridge, Dublin named Front of Counter Assistant of the Year with Sarah O’Riordan from Fogarty’s Life Pharmacy in Kilmallock, Limerick winning the Diarmuid O’Donovan Special Recognition Award.

The Life Pharmacy Awards ceremony was hosted by satirist and impressionist Oliver Callan

Sinead Quinn and Michael Guiney of Quinn's Life Pharmacy in Ballina with Paddy Colleran (centre) of Colleran's Life Pharmacy in Charlestown.

Sarah O’Riordan receives the Diarmuid O’Donovan Special Recognition Award

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Ger Coffey (right), Chairman of Life Pharmacy with partner Jackie and nephew Robert

Eugene McEntegart receives the Loyalty for Life Award on behalf of the team at Smyth’s Life Pharmacy in Dublin


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Jane Brennan and her team receive the Health Services Award from Michael McGreal of GSK Ethical

Life Pharmacy Territory Managers (left to right) Orlagh Dunne, Elaine Bright Jensen and Emmalouise Kelly

Connor Ward, winner of the Best in Marketing award, with his wife Jennifer (left) and Territory Manager Elaine (right)

Diarmuid O'Donovan Special Recognition Award winner Sarah O'Riordan (centre) from Fogarty's Life Pharmacy with team and sponsor

Laura Armstrong and her team from Armstrong's Life Pharmacy who together won the Brand Standards Award with Oliver Callan and sponsor

Johnny and Catherine Flynn, Flynnâ&#x20AC;&#x2122;s Life Pharmacy, winner of the Pharmacy Team of the Year and VMS Wellness Growth Award

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Charity

Scope Charity Golf Event Scope, in partnership with Childvision weathered the storm – Lorenzo - to host a fun, light-hearted charity golf event at Druid’s Glen Golf Resort on 3rd October. With 15 teams braving the weather to take on the Championship course, there was an air of healthy competition as they each took to a sponsored tee for a shotgun start and a 4-person rumble. After the final putt was played, the guests retired for a well deserved drink, dinner and award ceremony. Tom Freyne, Managing Director for Scope opened the ceremony with a huge appreciation for everyone that braved the elements for such a worthy cause. He explained the charity partnership with Childvision and Scope’s hope for making a difference to some of the families and children affected by sight loss. Brian Allen, CEO from Childvision explained the amazing work they do. Childvision is the only place in Ireland totally dedicated to the education and therapy needs of blind and multi-disabled children. Over 150 years old, ChildVision has helped thousands of children with sight loss and other profound disabilities bravely overcome their

obstacles and grow up to reach their full potential. With children from birth right up to 23 years old, the teams in Childvision include speech and language therapists, occupational therapists, teachers, nurses, braille specialists, social care workers, pet and equine therapists. https://childvision.ie/site/ A huge thank you to all the teams  Name of companies that played – Venn Life Sciences, United Drug, Dutec, Amgen, JJ Jewellers, Child Vision & Scope

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 Winners, 2nd & 3rd place Winners: Tony Richardson, Kealan Moran, Clive Whealan, Harry Byrne 2nd Place: Alan White, Hugh Johnson, Mike Sweeney, Tom Sayers 3rd Place: – Sean Conway, Brian Nolan, Noel O’ Connor, Philip Hehir  Longest Drive – Brian Nolan  Closest to the Pin – Mike Sweeney

3 1. First place - Venn Life 2. Second Place - Dutec 3. Third Place - Dutec

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Sponsors Thank You  Irish Pharmacy News  Wilson Creative  Venn Life Sciences  Primecourt  OSSM  PR360  Dutec  DMC Distribution  DC Media  Clanwilliam Health  John Good Shipping  Bellestone Associates  Healthy Workforce Ireland

News Budget 2020 – Not Enough The Irish Cancer Society has welcomed the Government’s announcement that the price of cigarettes will increase by a further 50 cent. This will be the fifth continuous increase at this rate, and will mean the price of a pack of cigarettes will rise to €13.50. However the Irish Heart Foundation has said the measures do not do enough to drive down smoking rates and tackle childhood obesity. Evidence shows that the most effective way to reduce demand for cigarettes is through taxation. Therefore, the Irish Heart Foundation recommended that tax on 20 cigarettes at the most popular price category should increase annually on a pro-rata

basis so that the overall cost of a pack reaches ¤20 by 2025. Commenting Mr Chris Macey Head of Advocacy at the Irish Heart Foundation said, “The Irish Heart Foundation welcomes the continuing policy of annual price hikes on cigarettes which have spearheaded an historic reduction in smoking rates particularly among young people in Ireland. “But much more needs to be

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done to drive down smoking to the Tobacco Free Ireland target of 5%, which equates to 200,000 smokers by 2025. And the failure to announce more significant tax increases in tandem with much greater investment in quit services brings into question the Government’s commitment to even trying to achieve one of its flagship national health policies. “The number of smokers in Ireland has fallen by 80,000 over

the last three years, but we need further reductions of 100,000 every year up to 2025 to meet the Government target. We believe that increasing the price of a pack of cigarettes to ¤20 by then, in addition to an immediate quadrupling of investment in quit services to at least ¤50 million a year are essential to achieving such a sizeable reduction in smoking rates.”


COPD - THE SIGNS Chronic cough Ongoing wheeze Pressure in your chest

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