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October 2019 Volume 11  Issue 10 PHARMACYNEWSIRELAND.COM


In this issue: NEWS: Calls made for pharmacy chronic disease service Page 6


REPORT: Pharmacist shortages at crisis point Page 12




Pharmacy Code of Conduct launched Page 19



FEATURE: Women’s Health: Pause for Thought Page 20



BENYLIN NON DROWSY DRY COUGHS: Syrup Composition: Dextromethorphan hydrobromide 7.5mg/5ml. Each 5 ml of Benylin Non Drowsy for Dry Coughs Syrup also contains: Sorbitol solution (70%) E420: 325mg, Sucrose 1625mg, Glucose 2380mg, Sodium 4.4mg, Ethanol (96% v/v) 0.311ml. Pharmaceutical form: Syrup. A clear amber coloured syrup with a characteristic smell of peaches. Indications: BENYLIN Non Drowsy for Dry Coughs is indicated for the relief of non-productive irritating cough. Dosage: Adults and children 12 years and over: Oral. 15mg (10 ml syrup) 3-4 times a day. maximum daily dose: 40 ml syrup. Children under 12 years: This product is contraindicated in children under the age of 12 years. Hepatic dysfunction: Due to the extensive hepatic metabolism of dextromethorphan, caution should be exercised in the presence of hepatic impairment. Contraindications: This product is contraindicated in individuals with known hypersensitivity to dextromethorphan or to any of the excipients. Dextromethorphan should not be used in patients taking monoamine oxidase inhibitors (MAOIs), or within 14 days of stopping MAOI treatment (see section 4.5). There is a risk of serotonin syndrome with the concomitant use of dextromethorphan and MAOIs and the concomitant use of these medications may cause a rise in blood pressure and hypertensive crisis. This product is contraindicated in patients taking serotonin reuptake inhibitors (SSRIs). Dextromethorphan, should not be given to patients in, or at risk of developing respiratory failure. Benylin Non-Drowsy Dry Coughs, Syrup is contraindicated for use in children under 12 years of age. Special warnings and special precautions for use: Patients with the following conditions should not use this product, unless directed by a physician: acute or chronic asthma, a persistent or chronic cough such as occurs with chronic bronchitis or emphysema, or where cough is accompanied by excessive secretions. Cases of dextromethorphan abuse have been reported.. Caution is particularly recommended for adolescents and young adults as well as in patients with a history of drug abuse or psychoactive substances. There is no evidence of drug dependence at therapeutic doses. Use of dextromethorphan with alcohol or other CNS depressants may increase the effects on the CNS and cause toxicity in relatively smaller doses. While taking this product, patients should be advised to avoid alcoholic drinks and consult a healthcare professional prior to taking with central nervous system depressants. Dextromethorphan is metabolised by hepatic cytochrome P450 2D6. The activity of this enzyme is genetically determined. About 10% of the general population are poor metabolisers of CYP2D6. Poor metabolisers and patients with concomitant use of CYP2D6 inhibitors may experience exaggerated and/or prolonged effects of dextromethorphan. Caution should therefore be exercised in patients who are slow metabolizers of CYP2D6 or use CYP2D6 inhibitors. This product should be used with caution in atopic children due to histamine release. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this product. This medicinal product contains 6 vol% ethanol (alcohol), i.e. up to 240 mg per 5ml, equivalent to 6 ml beer, 2.5 ml wine per 5 ml. This can be harmful for those suffering from alcoholism. To be taken into account in pregnant or breast-feeding women, children and high-risk groups such as patients with liver disease or epilepsy. Patients who are taking other medication including cough and cold medicines and / or who are under the care of a physician, should consult their doctor / pharmacist before taking this product. Undesirable effects: Adverse drug reactions (ADRs) identified during post-marketing experience with Dextromethorphan are included below. The frequencies are provided according to the following convention: Very common ≥1/10, Common ≥1/100 and < 1/10, Uncommon ≥1/1,000 and <1/100, Rare ≥1/10,000, <1/1,000, Very rare <1/10,000, Not known (cannot be estimated from the available data). Psychiatric Disorders - Rare - Confusional state. Not known – Agitation, Insomnia, Nervous System Disorders: Not known – Dizziness, Psychomotor hyperactivity, Seizure. Somnolence. Respiratory, Thoracic and Mediastinal Disorders: Rare – Bronchoconstriction, Dyspnoea Gastrointestinal Disorders: Not known - Abdominal pain, Diarrhoea, Nausea, Vomiting. Skin and Subcutaneous Tissue Disorders: Not known - Angioedema Pruritus, Rash, Urticaria. PA Number: PA 330/25/1. MAH: Johnson & Johnson (Ireland) Ltd. Airton Road, Tallaght, Dublin 24, Ireland Date of revision of text: September 2018. Product not subject to medical prescription. Full prescribing information available upon request

TEAM TRAINING: Fish Oils Page 48


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Childhood Vaccinations Part 2 Page 44

Courage, risk and reward Page 68

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Page 6: McCabes Pharmacist Emmet hailed a Hero

A shortage of community pharmacists in Ireland is on the verge of crisis point, and could become a ‘critical’ problem, it has been claimed. Many are identifying that the burden of excessive bureaucracy and unnecessary regulation is becoming a major frustration, particularly for those entering the profession. The team at totalhealth Pharmacy Group have recognised the issues around this and have launched an innovative new offering. You can read more about this and the wider shortages problem on page 12.

Page 8: Re-branding for Bradley’s Pharmacy Page 12: Pharmacist shortages at crisis point


Page 16: Helping Hands abound at Hugh’s House

In lead news this issue, Brexit is fast approaching. Plenty will be hoping the Halloween deadline won’t bring any nasty surprises. The British government’s Yellowhammer report warned that a 40-60% fall in the amount of traffic getting through the channel ports would inevitably pose major risks for medicine supply. But Irish industry sources are more sanguine.

Brenson Lawlor Box Advert Apr 2019.pdf 1 10/04/2019 Pharmacists have been concerned about the availability of

Page 37: The impact of Brexit on Medicines Supply

medicines post-Brexit. Irish Pharmacy Union spokesman Jim Curran says they have been assured that “everything that can be done is being done to plan for and prevent any potential problems that could crop up as a result of Brexit, and to put solutions in place.”

Page 42: Migraine and the Pharmacist

Turn to page 37 for our full report on the potential disruption to medicines supply.

Are You Thinking of Selling Your Pharmacy? Page 50: CarePlus look to the Future at Annual Conference


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

The Minister for Health Simon Harris TD has established a new Vaccine Alliance, aimed at boosting the uptake of childhood vaccines and reducing vaccine hesitancy. The Alliance will include healthcare professionals, policy makers, patient advocates, students, and representatives from groups most affected by vaccine hesitancy. Our Second Part of David Reilly’s Educational looking at childhood vaccinations is a very timely article and can be found on page 44.

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

Bradley’s Pharmacy Group was bought over by Uniphar and in this issue we detail how Allcare has unveiled 17 newly-rebranded pharmacies from the Bradley’s portfolio, with events in Dublin, Louth, Meath, Wicklow, Monaghan and Kerry.

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

JPA Brenson Lawlor12has over 30 years’ experien advising pharmacy owners and will help you to maximise your return. Our features for this issue cover Irish Heart Month (September), the Menopause and Upper GI Conditions, amongst others. Our October issue is also bringing our readers the first offering in our IRISH PHARMACY new Business CPD section, giving you yet more opportunities to NEWS Lawlor Box Advert Apr 2019.pdf Brenson 1 10/04/2019 11:18 contribute to your CPD portfolio.

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

Irish Pharmacy News is circulated to all independent, multiple Pharmacists and academics in Ireland.

CONTRIBUTORS David Reilly Niall Byrne

DESIGN DIRECTOR Ian Stoddart Design

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.

I hope you enjoy the issue.


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Telephone Jason Bradshaw or Padraic onof 01-6689760 Are YouFerguson Thinking Selling Your Pharmacy? Contact Us Today for a Free Consultation jason@brensonlawlor.ie JPA Brenson Lawlor has over 30 years’ experience advising Telephone Jason Bradshaw or pharmacy owners and will help padraic@brensonlawlor.ie Padraic Ferguson on 01-6689760 C








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Emmet emulates a Pharmacy Hero Northwood Pharmacy’s Emmet McCann has been labelled a hero, after saving the life of a young girl suffering from anaphylactic shock. McCabes Pharmacist Emmet McCann

have to do CPR on her. I gave her a shot of adrenaline and it didn't really do anything. Then I gave her a second and it seemed to work until the ambulance arrived. “I then heard that she required two more in the ambulance but from what I've heard she seems to be good now.” Emmett, who is originally from Co Armagh and has only been working in Dublin for three months added, “Her daughter, who lives in Brussels sent me a message to thank me which was really nice. “I just want to remind anyone who has allergies the importance of carrying an Epipen.”

He had to give her two shots of adrenaline before the ambulance arrived, where she required two more on her way to Beaumont Hospital.

She came in suffering from anaphylactic shock, she was really struggling to breathe. I could see the rash on her neck so I knew she had an allergy.”

Emmett reflects, “It was quite a stressful and scary situation.

Emmet, also a trained doctor, knew what to do. “I thought I'd

Sharen McCabe, Managing Director of McCabes Pharmacy Group commented, “A perfect example of the extensive training, competency, and professionalism of Irish pharmacists. We could not be prouder of how Emmet McCann dealt with this situation. Continuous professional development is always at the heart of everything we do.”

Pharmacists propose chronic disease service A collaborative approach to chronic disease management could save lives in Ireland, it has been claimed. Speaking out on World Pharmacist Day, Pharmacist Caitriona O’Riordan said that the "evidence of the benefits of the community pharmacy sector is clear, but sadly the ambitions of Government are not.” Explaining the proposal for a chronic disease management services Ms O'Riordan said, “Many people in Ireland live with the reality of chronic illnesses. The effective management of these can have a profound impact on people's health. Doing so in an efficient and convenient manner can also significantly improve quality of life and reduce the stress of such conditions. The clinical benefits of pharmacy involvement in chronic disease management are compelling and we have long advocated for a collaborative approach between community pharmacists, GPs and practice nurses.” Citing the example of hypertension Ms O’Riordan said, “Over ¤1.36 billion could be saved by the state

over thirty years if a pharmacy-based blood pressure management service was rolled out. More importantly this would avoid over 70,000 cardiovascular events.” The Irish Pharmacy Union (IPU) has said that a collaborative approach is needed. IPU Executive Committee member Ms O'Riordan added, “Earlier this month a study by Imperial College London published in the Lancet highlighted that Ireland has among the highest levels of high blood pressure in the developed world, but very worryingly we also have among the lowest diagnosis rates. These are warning signs we cannot afford to ignore any more.” Providing an example of where the


expansion of pharmacy services has been successfully delivered in Ireland Ms O'Riordan said, “Since Irish pharmacists first started vaccinating in 2011, flu vaccine deliveries have increased overall by 48%. Pharmacists now represent 15% of all flu vaccinations, with a 99% public satisfaction rate. We now want to deliver similar result in other areas of patient care. “There are currently over 1,900 community pharmacies nationwide ready to play their part in making Sláintecare a success. However, in spite of many promises there is little evidence the Government is taking the simple steps necessary to empower pharmacists to do more and help save patients' lives. This needs to change.”

Pharmacy Excellence The Pharmaceutical Society of Ireland (PSI) is pursuing excellence. In a statement the society says, “The PSI recognises the importance of quality in our work, both in terms of how we carry out our functions as well as how we formulate our strategies and how we interact with our stakeholders. With this in mind, we began our journey to achieve recognition under the European Foundation for Quality Management (EFQM). “We believe that the public has the right to expect, and to receive, a high standard of care from pharmacists, and to know that pharmacies are operated to high standards. We believe that the public should always be able to trust pharmacists and pharmacies to deliver this standard of care. “As part of our ongoing development, and in seeking to provide continued assurance in an evolving healthcare, regulatory and public sphere, we committed to adopt the EFQM Excellence Model as the framework for quality development within the PSI, so we too can be held accountable for our work.” The EFQM Excellence Model is a non-prescriptive framework, created by a team of experts from industry and academia, that can be used to gain a holistic view of any organisation. Since its inception, the EFQM Excellence Model has been a blueprint for EFQM members and organisations to develop a culture of excellence, drive innovation, and improve results. Excellent organisations achieve and sustain outstanding levels of performance that meet or exceed the expectations of all their stakeholders. The journey to recognition began in late 2016 when the PSI decided to explore achieving recognition under the EFQM Excellence Model. During 2017 and 2018 they did significant work in looking at the EFQM Model and assessing the organisation against the EFQM criteria. “This assessment allowed us to take a step back and critically look at how we function as an organisation.”

News Over ¤2bn capital investment for Health Taoiseach Leo Varadkar, Minister for Health Simon Harris and Minister for Finance & Public Expenditure and Reform Paschal Donohoe TD have announced the publication of the Health Service Executive’s Capital Plan. This Capital Plan provides for the spending of just over ¤2 billion on health capital projects from 2019 to 2021 including: • Over ¤1 billion on Government priorities – new Children’s Hospital, National Rehabilitation Hospital, National Forensic Mental Health facility in Portrane and Radiation Oncology facilities in Cork, Galway and Dublin; • ¤265m over the three years to replace / refurbish residences for older people and people with a disability; • ¤300m to maintain and upgrade facilities, equipment and ambulances • Over ¤335m for a wide range capital projects at individual hospital and primary/community facilities to provide modern health accommodation and equipment to improve and expand service provision. • Progressing three new hospitals. Taoiseach Leo Varadkar said, “Under Project 2040, we are doubling investment in healthcare infrastructure and equipment from ¤5 billion in the last ten year period to more than ¤10bn in this one. “This Plan sets out how we will spend more than ¤2 billion between now and 2021 on new hospitals, better local health facilities in your community and hundreds of much needed extra hospital beds. “This investment comes at a time of positive progress in our health service, despite the considerable challenges we still face. Waiting times for operations and procedures at long last are going down. By the end of this year, the number of hospital beds will be back above 11,000 for the first time since 2009. By investing in better facilities, newer equipment and more bricks and mortar, we are building a health service to provide you with the care you need, when you need it.”


Pharmacy-based screening ‘could save lives’ Pharmacy-based population health checks for hypertension would save lives according the Irish Pharmacy Union (IPU). Based on a very successful pilot in 2018 the IPU is now calling for a national roll out which would assist in the prevention, detection and management of suspected hypertension. A study by Imperial College London published in the Lancet earlier this month highlighted that Ireland has a particular problem with high blood pressure. IPU Secretary General Darragh O’Loughlin said, “We now know that Ireland has among the highest levels of high blood pressure in the developed world, but very worryingly we also have among the lowest diagnosis rates. “High blood pressure is the leading cause of stroke and heart attack; it is an important warning sign from the body that cannot be ignored. This study is a similar warning sign and should encourage the Government to take urgent action.

“A pilot undertaken by the IPU found that a pharmacy-based screening service to detect people at risk of hypertension would have significant benefits. Across 68 community pharmacies nationwide over 1,100 people over the age of 50 were checked during a twomonth period. 27% were identified as having high blood pressure and 5% had an irregular pulse. “99% of participants stated they were happy to have taken part in the pilot. This pilot has shown yet again the range of services that could be provided in community pharmacies. It is one of a range of common-sense proposals that have been submitted to the Department of Health, but sadly

all too often these are ignored. We are urging the Department to not ignore the long-term impacts of undiagnosed hypertension and roll out nationwide screening without delay.” The Imperial College study of 12 high-income countries found that Irish men ranked second for prevalence of hypertension, at 56%. Only Finland, at 59%, was worse. Just 56% of Irish women had been tested for hypertension compared to 86% in the US and 87% in Germany. The corresponding figure for Irish men was 46%, well below the highest figure of 84% for Canada.

A Pharmacy ‘First’ for Autism CarePlus Pharmacy has been named Ireland’s first “autism-friendly” accredited Pharmacy. John Keane, who owns and operates four CarePlus Pharmacies has spearheaded the initiative which has gained widespread recognition from his peers across the Pharmacy Franchise Network. Keane's CarePlus Pharmacy team with Adam Harris from autism charity, AsIAm and John and Robert Keane, Pharmacists and Owners

The accreditation was awarded by AsIAm, Ireland's national Autism charity and advocacy organisation, and is official recognition of becoming an autism-friendly premises. Obtaining this accreditation is a combination of staff training and of meeting the stringent standards set by AsIAm. As a result, the three Keanes CarePlus Pharmacies in Mullingar and one in Enfield are now more friendly to people on the autism spectrum. All four locations have staff on hand to meet any additional needs. In addition, each store is equipped with a safe space and fidget boxes that can be availed of if required.

AsIAm and caring for those on the autism spectrum. This is an important initiative for us to integrate our Pharmacies further into our local communities and we hope to launch similar initiatives in conjunction with other CarePlus Pharmacies nationally.”

John said, “We are delighted to be named Ireland’s first autism friendly pharmacy and we are looking forward to working with

Founder and CEO of AsIAm, Adam Harris added, "Over the last number of months we’ve been working with the Keane group to

bring them towards our autism friendly accreditation. That’s involved us reviewing the business, how it operates, identifying how there might be challenges in the environment for autistic people and working with the staff to rectify these and provide supports and staff training. We’re delighted to accredit these pharmacies as the first autism friendly ones in the country - and we hope that others will follow suit.”




Bradley’s Pharmacy re-branded Allcare has marked the official unveilingof 17 newly-rebranded pharmacies it acquired from Bradley’s with six days of special celebrations held across Ireland. The Allcare Pharmacy team cut the ribbon on their newly rebranded Blanchardstown store

prize raffles, face painting and a range of special offers. “The name has changed but we’re very happy to say the faces have stayed the same,” said Teresa Sheridan, Pharmacist at Allcare Pharmacy Blanchardstown, one of the pharmacies that welcomed customers to their new-look store. “We will continue to maintain a high level of service and value together with great new extras like the Allcare Rewards card.” Allcare purchased the Bradley’s portfolio of pharmacies last year after the group entered examinership. Since then, Allcare has invested significantly in the Bradley’s pharmacies including a complete renovation of its flagship store in Blanchardstown.

Inside the new-look Allcare Pharmacy in Blanchardstown Thousands of new and regular customers and patients attended the events in Dublin, Louth, Meath, Wicklow, Monaghan and Kerry.

The new look stores were introduced to the public with 20% off all front of shop products, free makeup consultations and applications,

This follows on from several investments in the brand this year including the launch of a cuttingedge e-learning platform, the sponsorship of The Ray D’Arcy Show on RTÉ Radio 1 and joining with Glanbia to partner on the group’s pharmacy in Campile. Following its acquisition of Bradley’s, Allcare Pharmacy has grown further as the largest Irish-owned pharmacy group with 92 pharmacies across Ireland.

Pharmacy welcomes Headache self-care funding Pharmacists from across Ireland have welcomed the announcement that the ‘Towards Selfcare in Headache’ project has been funded under the Sláintecare Integration Fund. The successful applicants to the €20 million Fund were announced on 16 September. The ‘Towards Selfcare in Headache’ project was submitted by the National Clinical Programme for Neurology (NCPN). The NCPN, in partnership with the Irish Pharmacy Union (IPU) and the Migraine Association of Ireland (MAI), will deliver this innovative approach to headache self-management. The programme will include educational sessions for pharmacists by the IPU, MAI and NCP Neurology.

Patrick Little, CEO of The Migraine Association, in welcoming the announcement said, “Patient self-management and patient education is a key component of the services we offer. Migraine is very specific to each person, so it is imperative that patients learn more about their condition and develop their own selfmanagement plan.” Mr. Little also highlights the importance of the community pharmacist in migraine management, indicating that many migraineurs are self-medicating without the advice of their local


pharmacist, leading to an increase in medication overuse headache in the migraine community. He further explained that, “The situation is compounded by the fact that presently Irish GPs only receive 4 hours training in headache at undergraduate level. There is sometimes a knowledge gap there and callers to our information line often highlight this problem. The GP educational sessions, proposed as part of this project, will go a long way to improving patient outcomes at a primary care level.”

Warning issued on overprescribing The Medical Council is actively working with the HSE, Pharmaceutical Society of Ireland, the Department of Health and the medical profession to take action on the issue of overprescribing of benzodiazepines. The Council has now issued advice to all doctors prescribing benzodiazepines, z-drugs and Pregabalin to follow best practice guidelines and to only prescribe benzodiazepines or similar drugs when absolutely required. If necessary, in order to protect the public, the Medical Council will take disciplinary action against medical practitioners in relation to the over-prescribing of benzodiazepines, z-drugs and Pregabalin, they said. Benzodiazepines are a group of medicines that can be prescribed for short periods to help with sleeping problems, or to help with episodes of severe anxiety. They are not for long-term use and can be dangerous when a patient develops an overreliance or a dependency on these drugs. The President of the Medical Council, Dr Rita Doyle, said, “The impact of inappropriate prescribing of benzodiazepines, z-drugs, Pregabalin and other controlled drugs is having a significant impact on patient safety and wellbeing. “While benzodiazepines may have a role in the treatment of a patient on a time-limited basis, caution and strict monitoring are required when they are prescribed. Patients who become dependent upon benzodiazepines should be referred to the appropriate drug treatment services and provided with appropriate supports. “As a Council, we acknowledge and appreciate the challenges faced by practitioners, the difficulties some practices are experiencing in terms of benzodiazepine and z-drug usage, and the demands from some patients for this and similar types of medication. “If a doctor is facing challenges in prescribing these medications, I would strongly encourage them, as a matter of priority, to engage with the HSE Addiction Services for support and guidance.”



Drone Delivery – The next step for medicines? Staunton's Allcare Pharmacy in Galway was a key partner in the world’s first delivery of diabetes medication onboard a drone. Pauline Staunton Forde from Staunton's Allcare Pharmacy with the drone that carried diabetes medication to the Aran Islands crop

“We’ve been supporting our patients on the Aran Islands for over 25 years and this advance in technology is a big step towards strengthening our ability to provide even greater care.”

The Salthill pharmacy dispensed the insulin and glucagon which flew 21 kilometres from Connemara Airport to Inis Mór in the Aran Islands onboard the drone nicknamed “Seagull.” The delivery, which took just over 15 minutes, was organised by NUIG and supported by the Irish Aviation Authority. Staunton’s has been serving the Aran Islands for more than

two decades and maintains a strong relationship with Dr Marion Broderick, the only GP on the island. “In an emergency, we can’t afford to allow weather disruptions or inconvenient timetables to prevent our deliveries from reaching those who need them,” says Pauline Staunton Forde, owner and superintendent pharmacist at Staunton’s Allcare Pharmacy.

The #DiabetesDrone project was organised by Professor Derek O’Keeffe, Professor of Medical Device Technology at NUI Galway and a Consultant Physician at Galway University Hospitals. It was initiated out of concern for patients in remote communities who are vulnerable during severe weather events. Deliveries to the island usually take place on non-commercial flights but these can be restricted by external factors. The use of a drone also eliminates the risk to human life during the transportation process. The return flight was also put to good use with Dr Broderick placing a blood sample onboard for testing on the mainland.

Irish Pharmacists support FIP Congress Community pharmacists from across Ireland were out in force at the end of last month (September), attending International Pharmaceutical Federation (FIP) World Pharmacy Congress in Abu Dhabi. Pictured are the Pharmapod team of Leonoroa O’Brien, Founder and CEO with Rory O'Donnell, Chairperson, totalhealth Pharmacy Group and colleagues from the Irish Pharmacy Union, Darragh O'Loughlin and Darragh Connolly. Decreasing the gaps in pharmaceutical science, practice and education between different regions of the world is among the aims of a new FIP strategy announced by FIP president Dominique Jordan in Abu Dhabi, UAE.

The Pharmapod team Leonoroa O’Brien, Founder and CEO, Rory O'Donnell, Chairperson, totalhealth Pharmacy Group and colleagues from the Irish Pharmacy Union, Darragh O'Loughlin and Darragh Connolly


Speaking at the opening ceremony of the 79th World Congress of Pharmacy and Pharmaceutical Sciences , he said that the intended outcomes of this strategy include that everyone has access to medicines. The FIP president said, “The 21st century will be the century of pharmacists.”

Diabetes and Obesity Link Scientists from the School of Medicine, Trinity College Dublin, have, for the first time, discovered a family of proteins that are associated with lower blood sugar levels among obese patients with type 2 diabetes. The study showed that patients with type 2 diabetes who have high levels of the protein, IL36 cytokines, were found to have lower blood sugar levels, implying that those proteins are associated with better control of the patient's blood sugar levels and their disease. IL-36 cytokines are members of a larger family of proteins known as the interleukin-1 family which have emerged as central players in the development of obesity related disease. Researchers have linked the protective effects of these proteins with their ability to alter the make-up of the intestinal microbiome. Obesity causes an increased level of fatty acids and inflammation leading to insulin resistance. When the body is resistant to the insulin it produces it causes a high build-up of glucose or blood sugar, ultimately leading to type 2 diabetes. Obesity is now recognised as a global pandemic and has been definitively linked to a wide range of diseases including metabolic disorders such as diabetes, stroke and many types of cancer. The World Health Organisation state that global levels of obesity have more than doubled since 1980. In Ireland, according to the Healthy Ireland survey, 854,165 adults over 40 in the Republic of Ireland are at increased risk of developing (or have) type 2 diabetes. The economic burden of diabetes on the Irish health care system is becoming a major challenge for the government. The Trinity research team believe that there is an urgent need to achieve a greater understanding of the mechanisms associated with obesity related diseases.

Report: Script needed to cure Pharmacist shortage crisis C

alls have been made across Ireland for the Minister of Health to address serious shortages of community pharmacists, before the situation reaches crisis point.

The problem is not limited to just Ireland, it would seem. A huge drop in the number of pharmacists registering with the General Pharmaceutical Council since Brexit has led to concerns of significant staff shortages in the future. Brexit could lead to a major nationwide shortage of pharmacists available for work, the Chief Executive of the organisation that represents multiple high street and supermarket pharmacies has warned. Malcolm Harrison, who leads the Company Chemists’ Association (CCA), said the number of pharmacists from the European Economic Area (EEA) registering with the General Pharmaceutical Council (GPhC) to practise in the UK had fallen by 80% since the Brexit vote, and he warned that owing to this, alongside other factors, shortages could become “more of a problem.”

A report for the GPhC Council, published in June 2017 identified a significant fall in the number of pharmacist registrations from the EEA which it said potentially reflects the impact of Brexit. At the time of the Brexit vote, at the end of June 2016, there were 3,445 pharmacists from the EEA on the GPhC register. Assisted Purchasing John Arnold is Managing Director with totalhealth Pharmacy Group. The Group has a strong continuity of front-of-shop staff and therefore they experience small numbers of turnover in this field. However, John adds, “Where we see the industry struggling is within the professional capacity, obtaining and retaining good, community pharmacists. The numbers entering retail community pharmacy has considerably reduced.”


John notes there are several reasons for this; from increasing paperwork and bureaucracy to an inability for those entering the profession in obtaining finance to purchase their own pharmacy. And this is a factor which totalhealth has decided to tackle head-on as a Group. “We have decided to establish PAPS – the Pharmacy Assisted Purchasing Scheme, to enable the future generation of the profession to purchase existing businesses to help them get across that threshold. This will be of huge benefit,” John adds. “We believe that if we are able to assist the transition of pharmacies to the next generation, we will be greatly helping the profession to grow.” Marketing and Communications Manager Naomi O’Farrell says, “Consistently we see signposting towards retail pharmacy as being

the consumer’s first point of call for their health and medication needs, as well as offering additional services. But there are consequences to that, such as added pressure, added workload, increasing paperwork and so on. “We need to ensure the profession is a desirable one for the next generation to join, and crucially, we need to ensure our staff are equipped with the right tools to effectively provide their services. Red Tape and Bureaucracy In May of this year, the Irish Pharmacy Union highlighted the issue at their annual conference in Galway saying that a shortage of community pharmacists could become a ‘critical’ problem. They identified that the burden of excessive bureaucracy and unnecessary regulation was a major frustration, particularly for younger pharmacists.

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John Arnold, Managing Director, totalhealth Pharmacy Group

of pharmacists state that they are required to spend too much time on paperwork, which means time away from our patients. Almost half of pharmacists now believe the sector is over-regulated which is creating constant pressure. “Ireland produces some of the most qualified pharmacists in the world”, according to Ms O’ Loughlin, “and yet our system is content to consign them to a career of administration. Expert healthcare professionals are being hamstrung by meaningless paperwork and excessive bureaucracy.”

“We need to ensure the profession is a desirable one for the next generation to join, and crucially, we need to ensure our staff are equipped with the right tools to effectively provide their services” - Naomi O’Farrell Sheila O’ Loughlin, Pharmacist and member of the IPU Employee Pharmacy Committee (EPC), outlined some of the main findings of a new Behaviour & Attitudes report commissioned by the IPU, Perspectives of Community Pharmacy. “The report found that excessive red tape, bureaucracy and administration is one of the biggest drawbacks to a career in community pharmacy. The research shows that this is making it difficult to attract new graduates into the community pharmacy sector and to retain pharmacists in their current roles. “The areas identified as the biggest concerns include the additional burden of dealing with the HSE PCRS and its attendant paperwork and the pressure of ensuring compliance with regulatory guidelines. “We all recognise the importance of checks and balances, and safety is something a pharmacist would never compromise. However, 98% Naomi O’Farrell, Marketing and Communications Manager, totalhealth Pharmacy Group


The impact upon the profession is becoming profound Ms O’Loughlin continued. “Fewer and fewer pharmacists now say they would recommend community pharmacy to a student today. We are therefore calling on the Regulators, particularly the HSE PCRS and Pharmaceutical Society of Ireland (PSI), to work with us to review and reduce the level of unnecessary bureaucracy foisted on community pharmacists. “Doing so will signal a commitment to would-be community pharmacists, that their role does matter as a key professional in the healthcare service and not just a quasi-administrative role, which involves frustrating hours chasing paperwork and complying with unnecessary bureaucracy”, she concluded. Running Short News reported by the Belfast Telegraph last month said Northern Ireland is short of 320 community pharmacists to provide a safe service, it has been warned. Community pharmacists, who run High Street chemists, have reported working up to 100 hours a week as chronic underfunding of the service drives it to crisis point. A Department of Health scheme aimed at helping to reduce the strain on overworked GPs is also being blamed for pushing the community pharmacy service to breaking point. About 400 pharmacists have left the service in the last two years - around 170 of them to take up posts working in GP practices as part of the practice-based pharmacist scheme. Earlier, the Department of Health announced it will invest a further £2.19m to support the roll-out of the scheme, as part of an overall £26.7m package to help family doctors. At the same time, however, community pharmacist fees have reduced by about 30% despite the

fact their workload has increased by 40% over the past nine years. Community Pharmacy NI (CPNI), the body that represents high street pharmacists, has launched a stinging attack on health officials for pressing ahead with its practice-based pharmacy scheme while community pharmacy plunges deeper into crisis. While the pharmacists working in GP practices advise family doctors on the best treatment for patients, it is community pharmacists who actually dispense medication to the public. Around 123,000 people, or 9% of the NI population, visit community pharmacists every day, according to the CPNI report. This equates to 37 million visits each year, compared to 12 million visits to GP surgeries. Gerard Greene, CPNI Chief Executive, said: "The findings in the CPNI workforce report are damning but what I find even more worrying is the Department's willingness to continue the roll-out of the practice-based pharmacist scheme when we have asked that it should be deferred until the community pharmacy workforce crisis is resolved. "Obviously, any new money for the health service is good news and nearly £27m is a significant investment, but the department must urgently make

the same investment in community pharmacy to stabilise the sector and to ensure that safe services can continue to be provided." Mr Greene was speaking out as CPNI released the findings of its damning community pharmacy workforce survey. It has revealed that 83% of community pharmacies have lost pharmacists in the last two years and 94% of contractors have experienced difficulty finding a locum (See Side Panel). Joe McAleer, a pharmacist based in Enniskillen, called on the Department of Health to act immediately, saying, “If the Department does not invest properly in community-based services, then we won’t achieve the much needed transformation in healthcare. “We understand there is pressure right across the health and social care sector, however community pharmacy is essential in reducing the need for unnecessary visits to GP practices, out-of-hours services and hospitals. We are a front-line service and people rely on us for immediate and accessible advice in their local areas. “We know that the Department is aware of the pressures that are mounting and it is now time the Department acted to reverse the huge damage that is being done to our network,” he said.

Locum Cover Over the past four years, the locum market has seen a steady rise in rates. Research examining locum pharmacists’ engagement with providing locum services was carried out by Clarity Locums, who provide locum services in both the Republic of Ireland and across the UK, may provide some insight into the reasons for this. ‘The rates appear to be rising steadily yearly since the beginning of 2015 due to the improving economy,’ states the report. ‘There is also a pattern whereby prices during the summer tend to be higher, perhaps due to lower levels of supply. Naturally enough in a market determined by supply and demand, fewer locums are available in the summer while the demand doesn’t fall, in fact rising in many cases. ‘Outside of the general upward trend in rates that we have all observed, there are a number of other underlying trends that directly affect the rate at which locums book days. There are steps that pharmacies can take to contain locum rates,

including proactive resource planning. There are situations, however, where exceptional and sudden need arises. Locum rates in these circumstances tend to be higher, but also tend to shape perceptions of the market. ‘This perpetuates the view that the locum market is in crisis and there is a chronic shortage of locums and increases the likelihood locums will wait for longer to book days in the hope this apparent crisis may result in an increase in the rate offered. ‘In reality, if there is a crisis it is nowhere near as acute as it seems. Clarity will be implementing a suggested rate feature that will allow you to meet the market rate sooner, more effectively. ‘No doubt, there are wider socio-cultural factors affecting the way locum pharmacists tend to provide their services including the growing feminization of the profession, that the pharmacist cohort available for locuming is becoming younger together with their perceptions around job satisfaction and work life balance.’

News Budget 2020: Pharmacists demand FEMPI Reversal At their Budget 2020 briefing, the Irish Pharmacy Union (IPU) called for a reversal to the savage FEMPI fee cuts imposed on pharmacies since the recession. 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. Earlier this year, the Government committed to the reversal of FEMPI cuts for GPs, but pharmacists are still waiting for delivery on promises made to them. Secretary General of the IPU Darragh O'Loughlin said, “Our members 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, and we are sick of being treated like the Cinderella of the health system. “With 2,200 IPU members working in 1,900 pharmacies in every town and city in the country, pharmacists are the first port of call for patients in the Irish health service. Pharmacies need to be properly resourced to provide the level of service that patients require. While our members have doubled down on health service delivery over the years, in the face of an increasingly difficult environment, the time has now come for renewed investment

in pharmacy services and to deliver on clear commitments in the Programme for Government. “The failure by Government to do anything meaningful for pharmacy in Budget 2020 risks doing structural damage to the whole profession. Already, community pharmacy is no longer regarded as an attractive career option for young pharmacists, which will have a knock-on impact on the sustainability of the services we provide.”

Mr O'Loughlin concluded, “The health system needs to be fit for purpose and pharmacy is an essential part of it; FEMPI cuts must be unwound in Budget 2020 to address the decade-long underfunding of the service.”




Pharmacy industry continues to support Hugh’s House ‘Heroes’ The teams from Real World Analytics and Ferring Pharmaceuticals recently gave up their time to volunteer at Hugh’s House. Rebecca, Nicole, Lauren, Conall, Simon and William from Real World Analytics visited to do their yearly BBQ for Hugh’s House families whilst Ferring Pharmaceuticals team assisted with various jobs for the day. Last month’s issue of Irish Pharmacy News carried details of the team from Star Medical who also volunteered their services whilst team member Gary followed this up by recently running the Waterford Marathon, fundraising to gather some vital funds for the charity.

The charity, set up by Stacks Pharmacy Group owner Ade Stack, relies completely on the efforts of volunteers to provide their services and funding. Hugh’s House tries to make life a little more manageable and comfortable for the families coping with the stress of having a very sick child. All volunteers help by spending the day cooking, cleaning, and ironing for the current families staying at the house. They also take part in gardening, painting and general

Hugh’s House provides accommodation 365 days a year to the families of children who are long-term in-patients of Temple Street, Holles Street, the Coombe and Rotunda Hospitals in Ireland.

DIY tasks to help keep the house well-maintained. Mention must also go to the efforts of McLernon Computers' very own Helen Taylor, who has been making amazing monkey bears for all the babies and children. In other news, the team at Hugh’s House were celebrating themselves last month, as they won the Family Hero Award at the Hidden Hearing Hero award ceremony in Dublin.

The team received the most nominations ever in the history of the awards. Hidden Hearing, which spearheaded the introduction of hearing tests to the high street, created the awards in 2011 to honour ordinary people who do extraordinary things. The Awards also saw Hidden Hearing donate ¤2,000 to the charity.




1 1 One for you, one for me – Simon and Conall enjoying the fruits of their cooking and doing trojan work on the BBQ 2 Until next year! Laura, Conall, Simon, Rebecca, Nicole and William from RWA 3 Real World Analytics’ William finds his inner child 4 The RWA helpers with the amazing Maria of Hugh’s House 5 Ferring Pharmaceuticals were delighted to give their support to the Hugh’s House team 6 Gary Lydon, Star Medical 7 The bears created by McLernon Computers’ Helen Taylor bring huge joy




flutiform® k-haler® (fluticasone propionate/formoterol fumarate) 50 μg/5 μg and 125 μg /5 μg pressurised inhalation suspension. Prescribing Information Republic of Ireland. Please read the Summary of Product Characteristics (SPC) before prescribing. Presentation Pressurised inhalation suspension, in a breath-actuated pressurised aerosol inhaler. Indications Regular treatment of asthma where the use of a combination product (inhaled corticosteroid [ICS] and long-acting β2-agonist [LABA]) is appropriate: (i) for patients not adequately controlled with ICS and ‘as required’ inhaled short-acting β2-agonist (SABA) (ii) for patients already adequately controlled on both an ICS and a LABA. For adults and adolescents aged 12 years and above. Dosage and administration for inhalation use. Patients should be shown how to use the inhaler correctly by a healthcare professional. Patients should be given the strength of flutiform k-haler containing the appropriate fluticasone propionate dose for their disease severity (50 μg/5 μg per actuation is not appropriate in patients with severe asthma). The appropriate strength should be taken as two inhalations, twice daily (normally morning and evening) and used every day, even when asymptomatic. flutiform k-haler is not recommended in children under 12 years. Prescribers should be aware that in asthmatics, fluticasone propionate is as effective as some other inhaled steroids when administered at approximately half the total daily microgram dose. Patients should be assessed regularly and once asthma is controlled, treatment should be reviewed and stepped down to the lowest effective dose, or an ICS alone. ICSs alone are first line treatment for most patients. flutiform k-haler is not intended for initial treatment of mild asthma. For patients with severe asthma the ICS therapy should be established before prescribing a fixed-dose combination product. Patients on flutiform k-haler must not use an additional LABA. An inhaled SABA should be taken for immediate relief of asthma symptoms arising between doses. Patients should be advised to contact their prescriber when flutiform k-haler dose counter is getting near zero. Contraindications Hypersensitivity to the active substances or to any of the excipients. Precautions and warnings flutiform k-haler should not be used as the first asthma treatment, to treat acute asthma symptoms or for prophylaxis of exercise-induced asthma. It should not be initiated during an exacerbation, during significantly worsening or acutely deteriorating asthma, and should not be stopped abruptly. If a patient experiences serious asthma-related adverse events or exacerbations, they should continue treatment and seek medical advice. Patients should be reviewed as soon as possible if there is any indication of deteriorating asthma control. In case of sudden and progressive deterioration, seek urgent medical assessment. Caution in patients with: pulmonary tuberculosis; quiescent tuberculosis; fungal, viral or other infections of the airway; thyrotoxicosis; phaeochromocytoma; diabetes mellitus (consider additional blood sugar controls); uncorrected hypokalaemia; predisposition to low levels of serum potassium; impaired adrenal function (monitor HPA axis function regularly); hypertrophic obstructive cardiomyopathy; idiopathic subvalvular aortic stenosis; severe hypertension; aneurysm or other severe cardiovascular disorders; unstable or acute severe asthma and other conditions when the likelihood for hypokalaemia adverse effects is increased. There is risk of potentially serious hypokalaemia with high doses of β2-agonists or concomitant treatment with β2-agonists and drugs that can induce or potentiate a hypokalaemic effect. Monitoring of serum potassium levels is recommended during these circumstances. Formoterol may induce prolongation of the QTc interval. Caution must be observed when treating patients with existing prolongation of QTc interval. flutiform k-haler should be discontinued immediately if there is evidence of paradoxical bronchospasm. Visual disturbance may be reported with corticosteroid use. Systemic effects with an ICS may occur, particularly at high doses for prolonged periods or when combined with potent CYP3A4 inhibitors, but are less likely than with oral corticosteroids. Possible systemic effects include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density and cataract glaucoma. Children may also experience anxiety, sleep disorders and behavioural changes. Increased exposure can be expected in patients with severe hepatic impairment. Prolonged treatment with high doses of corticosteroids may result in adrenal suppression and acute adrenal crisis, particularly in children and adolescents or potentially as a result of trauma, surgery, infection or rapid dose reduction. flutiform k-haler contains a negligible amount of ethanol that does not pose risk to patients. Interactions Co-treatment with CYP3A inhibitors (e.g. ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nelfinavir, saquinavir, ketoconazole, telithromycin, cobicistat) should be avoided unless the benefit outweighs the increased risk of systemic side-effects. Caution is advised with concomitant use of non-potassium sparing diuretics (e.g. loop or thiazide), xanthine derivatives, glucocorticosteroids, L-Dopa, L-thyroxine, oxytocin, alcohol or other adrenergic drugs, including anaesthesia with halogenated hydrocarbons and digitalis glycosides, β-adrenergic drugs, known to prolong the QTc interval, such as tricyclic antidepressants or MAOIs (and for two weeks following their discontinuation), antipsychotics (including phenothiazines), quinidine, disopyramide, procainamide, antihistamines, furazolidone and procarbazine. flutiform k-haler should not normally be used with β-blockers including those that are used as eye drops to treat glaucoma. Under certain circumstances, e.g. as prophylaxis after myocardial infarction, cardioselective β-blockers could be considered with caution. Pregnancy and lactation flutiform k-haler is not recommended during pregnancy unless the benefits to the mother outweigh risks to the foetus. A risk to the breastfeeding infant cannot be excluded. Side-effects Uncommon (<1/100) but potentially serious: hyperglycaemia, agitation, depression, aggression, behavioural changes (predominantly in children), vision blurred, vertigo, palpitations, ventricular extrasystoles, angina pectoris, tachycardia, hypertension, dyspnoea, peripheral oedema. Please consult the SPC a full list of side-effects and those reported for the individual molecules. Legal category POM Package quantities One inhaler (120 actuations) Marketing Authorisation numbers PA 1688/013/004-005 Marketing Authorisation holder Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Ireland. Tel: +353 (0)1 2063800. For medical information enquiries, please contact medicalinformation@mundipharma.ie. ® FLUTIFORM is a registered trademark of Jagotec AG, and is used under licence. ® K-HALER is a registered trade mark of Mundipharma AG. © 2018 Napp Pharmaceuticals Limited. UK/FLUT-K-18036a(1). Date of Preparation July 2019. Adverse events should be reported to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra. ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on drugsafetyireland@mundipharma.ie or by phone on 01 2063800 (1800 991830 outside office hours) References: 1. https://www.medicines.ie/medicines/flutiform-k-haler-50-microgram 5-microgram-125-microgram-5-microgram-peractuation-pressurised-inhalation suspension--34603/ last accessed September 2019. 2. Bell D et al. J Aerosol Med Pulm Drug Deliv 2017; 30:425–34.

IRE/FLK-19015 Date of Item September 2019

Intelligently designed. Simple to use.1,2

The first and only ICS/LABA delivered in a breath-actuated aerosol inhaler.



Double celebration for Hogan’s Life Pharmacy Hogan’s Life Pharmacy in Limerick has celebrated a landmark year in its history with its official relaunch and opening day, as a member of the Life Pharmacy network. To mark the occasion, the familyrun pharmacy held a special day of events for customers and patients including special offers, face painting, prize raffles and refreshments. Limerick’s Live95FM Roadshow was also present at the event.

A host of new features and enhancements have been added to the Medicines. ie website and dashboard. Medicines.ie is Ireland's most popular source of accurate and reliable medicines information. The features include better search suggestions, more filtering options, advanced searching and a choice of display categories which significantly enhance the usability of the site. Such features have increased the visibility and accessibility of accurate, reliable, regulatory authority approved medicines information online for both healthcare professionals and the public.

Established by Pat Hogan in September 1940, the pharmacy is now owned by his daughters Elenora Hogan and Marie McConn. The sisters pride themselves on the continued care and advice they provide to the second, third and fourth generations of customers originally served by their father.

The site, available online and mobile, boasts a sleek design, offers an intuitive user interface and most importantly acts as a vital source of up to date, trusted medicines information.

The day was also a double celebration with the pharmacy recently joining the Life Pharmacy network. Currently employing six staff, the pharmacy originally occupied 45 Upper William Street, moving one door down to number 46 in 2005.

In addition, pharmaceutical companies who upload and update their medicines information for public display now have an enhanced backend dashboard with improved system usability.

Elenora Hogan and Marie McConn owners of Hogan's Pharmacy in Limerick

Staff from Hogan's Life Pharmacy cut the ribbon with the members of the Life support team

Hickeys celebrate 20,000 App order Just last month, Hickey’s Pharmacy Group celebrated their 20,000th App order! The Hickey’s Pharmacy App provides a convenient and easy way to pre-order prescriptions. In just a few simple steps customers are able to order their prescription and it will be ready to collect from their local Hickey’s Pharmacy within 1 hour (during store opening hours). Jamie-Lee in the Hickey’s Phibsboro store was delighted to present Jenny with a hamper to celebrate this milestone.


Medicines Update

Key features added to the website include improved filtering for advanced searching, better search suggestions, enhanced result sorting, crosslinking from the medicine results page to the pertinent medicine tab and flexible display of medicines information through sorting and filtering tools. Key features added to the dashboard include news and FAQ pages plus a new self-service Package Leaflet (PIL) & Educational Material submission process. The newly updated website can be viewed at www.medicine.ie New Approaches A two-day international cancer conference took place last month at the Trinity Translational Medicine Institute (TTMI), which saw global leaders in their fields and a new generation of researchers explore ‘advances and future directions in personalised medicine.’ This approach to patient care allows doctors to select the treatments most likely to help patients based on a genetic understanding of their disease. The ‘International Cancer Conference’, now in its 11th year, is an important legacy of the Northern Ireland peace process.



New Code of Conduct - Supporting pharmacists Niall Byrne, Registrar/Chief Officer PSI - The Pharmacy Regulator, gives Irish Pharmacy News readers an overview of the PSI's new Code of Conduct that is supporting pharmacists in their crucial role as healthcare providers. Public trust in healthcare professionals is a fundamental element in the provision of safe and effective healthcare. In marking the publication of the revised Code of Conduct for pharmacists, we have an important opportunity for pharmacists, and the PSI, to reflect on the rationale for a code of conduct and ethics, and to take the time to reflect on the significant role that pharmacists, as healthcare professionals, play in our society and our healthcare system. Traditionally, pharmacists, along with medical doctors, have enjoyed high levels of public trust, but in an era of changed expectations, with people generally more informed, engaged and more questioning of traditional authority and expertise, no healthcare professional can take this trust for granted. It is only by demonstrating a high standard of professionalism that always puts the patient first, that pharmacists can continue to generate public confidence in their profession and in their role as medicines experts, who always work to support public health and individual wellbeing. The launch of the revised Code was held on World Pharmacists Day, 25 September; a global marker of the vital role pharmacists play in ensuring the rational, safe and appropriate use of medicines and in providing accessible healthcare advice and services. The revised professional principles, standards and ethics in this new Code of Conduct for pharmacists in Ireland, focuses particularly on how professionalism and care are at the heart of a patient-centred approach, whatever area of the profession a pharmacist is working within. The Code serves as a reminder of the responsibility that comes with being a healthcare professional and of the frequent challenges presented in day-today professional practice. While the Code sets the standard against which pharmacists are held to account, its principlesbased approach is intended to promote the exercise of a broad breadth of professional judgement by pharmacists as autonomous healthcare professionals. The Code, very deliberately, places the patient first and sets out clear criteria for acting professionally and for communicating effectively, thereby enabling enhanced

patient-centric care. The Code creates a positive framework for professional practice, within which the health, wellbeing, care and safety of patients is the key priority. It also sets out clearly the expectations of the regulator as regards the high standards expected of pharmacists and is intended to promote excellence within the profession of pharmacy in Ireland. The new Code outlines seven key principles: 1. Put the patient first 2. Act professionally 3. Communicate effectively 4. Work with others 5. Show leadership 6. Maintain competence 7. Be open and honest This revised and updated Code is the outcome of a detailed review of the pre-existing Code. Thanks are due to everyone who participated in our extensive process of review and consultation which took place over a two-year period. Registered pharmacists, as well as many others, generously shared a wealth of thoughts and reflections on the ethics, and the practicalities, of pharmacy practice.

their patients within a modern, and evolving, pharmacy profession.

events around the country during September and October.

As an organisation, the PSI is committed to working with pharmacists in the interests of patients and the public. There is an onus too on the regulator to support pharmacists by putting in place a fair, balanced and proportionate system of regulation which works to assure the public that pharmacists, and pharmacies, are deserving of the trust of the public.

By meeting as many pharmacists as possible face-to-face, we hope to encourage deeper discussion and engagement around the important principles in the Code while also providing opportunities for pharmacists to meet with their fellow pharmacists, as well as with staff from the PSI.

We aim to deliver support and create understanding around the core themes in the revised Code of Conduct. To this end, we are hosting a series of information

For further information and to download a copy of the Code of Conduct - Professional Principles, Standards and Ethics for Pharmacists we encourage pharmacists and others to visit our website www.psi.ie

It is clear from this process that there is a desire among both professionals and the wider public that healthcare is ethically-led and that healthcare professionals are seen to always act in the interests of patients. We have worked hard to ensure that these expectations are clearly reflected in the revised Code. Our aim in publishing the Code is that it supports pharmacists now, and into the future, to provide the best possible health outcomes for

Niall Byrne, Registrar, Chief Officer, PSI


Pause for Thought:

Women’s Health


y virtue of their patient access, community pharmacists can provide front-line health education and screenings to female patients. Pharmacists can identify women at increased risk for various diseases and help in early detection of disease.

Managing Menopause The intensity, duration, and type of symptoms a woman experiences during menopause depends on a variety of factors. Pharmacists are in a position to identify appropriate strategies to reduce or manage the most bothersome symptoms. Many women experience uncomfortable symptoms as they approach menopause. The hallmark symptom is the hot flash (also called the hot flush). This sudden feeling of intense warmth in your face and chest is followed by skin redness (flushing) and heavy sweating. Then it ends with a cold, clammy feeling. Some women may also have fast heartbeats (palpitations), a feeling of pressure in the head, dizziness, faintness, or weakness. A hot flash usually lasts from 1 to 5 minutes. Approximately 80% of women suffer from hot flashes before, during, and after menopause. Hot flashes usually occur for 2 to 5 years before they

taper off, but can last longer. Some women may never have a hot flash and some may have them for many years. What is Happening? Most women have their final menstrual period at about age 50 or 51. It can be said that a woman has reached menopause when she has not had a menstrual period for 12 months in a row. Ovulation stops and they will no longer be able to become pregnant. Physiology of menopause Menopause is a natural process driven by changes in the balance of sex hormones as a woman ages. Menopause is an inevitable event for all women as each ovary is stocked with a finite number of oocytes. These egg reserves gradually diminish with age until, at about 50 years old, the supply eventually becomes exhausted. The major hormonal and biological changes that mark the onset of menopause begin during the


so-called perimenopausal phase. Perimenopause literally translates as the time around menopause and is used to describe the transition period leading into true menopause, often associated with cycle irregularities and characteristic symptoms of early menopause. It can begin as early as 10 years before a woman’s last menstrual period. There are three key biological changes that occur during perimenopause: • Ovarian follicular activity begins to fail and egg production tapers off • Levels of oestrogen, progesterone and other female sex hormones start to drop • Levels of follicle-stimulating hormone (FSH), normally involved in stimulating a ripe egg follicle to develop in the ovary, start to fluctuate dramatically as the ovaries and pituitary gland in the brain become locked into a negative feedback loop.

Bothersome Symptoms Many people call menopause the “change of life.” As women start to enter menopause in their mid 40s, they may begin to notice hot flashes and other changes in their body. As estrogen levels fall, every woman experiences different symptoms. Some lucky women have no symptoms whatsoever, but others have troublesome symptoms. Some things that seem to make symptoms more severe include family history, having started their periods at a young age, smoking, poor diet, a higher body mass index (BMI) than is ideal, lack of exercise, and ethnic heritgage (African American women seem to have more hot flashes than others). The most common symptoms of menopause are: • Bladder problems • Hot flashes • Mood swings

of breast cancer and cardiovascular disease. The cancer risks of taking HRT The Women’s Health Initiative (2002), a sizeable randomised controlled trial, and the Million Women Study (2003), a multicentre, population-based prospective cohort study of one million women aged 50 and over, raised concerns about the safety of HRT. Cancer Research UK scientists, who ran the Million Women Study, found strong evidence that HRT can cause breast, womb and ovarian cancer. The risks are that two more women will get breast cancer and one more will get ovarian cancer if 1,000 women take HRT at the age of 50 for five years. Avoiding HRT could prevent 1,700 cancers a year. However, NICE says that: • The baseline risk of breast cancer for women around menopausal age in the UK varies from one woman to another • Oestrogen-only HRT is associated with little or no change in the risk of breast cancer

• Night sweats • Severe tiredness • Sleep problems • Stiff painful joints • Vaginal dryness These symptoms may disappear within a few months, but sometimes they can persist for several years after the last menstrual period. As women age, they are at increased risk of developing other health conditions—this is natural. It’s at this time of life that some women develop heart disease, dryer skin, and lack of interest in sex. These problems can be related to low estrogen levels. Low estrogen after menopause can also cause faster bone loss and increase the risk of developing osteoporosis (“brittle bones”). Dealing with Symptoms The best approach to reducing menopause symptoms is to look at the individuals lifestyle and make simple changes. Many women note that certain things bring on hot flashes, or make them worse. These are

called “triggers.” Advise them to pay attention to what is happening before and during these hot flashes. Once they identify things that cause or contribute to them, they can avoid them. Some may find that hot drinks, hot or spicy foods, alcohol, caffeine, cigarette smoking, stress, hot weather, or a warm room may trigger a hot flash. Exercise regularly. Exercise reduces stress, decreases the risk for heart disease and diabetes, helps to preserve bones, and can help get a better night’s sleep. Those who are overweight, should try to shed a few pounds. Lighter women seem to have fewer symptoms. Stay as cool as they can. Dress in layers so that they can remove clothing quickly to cool off. Use a fan or air conditioner to keep the air around them cool. Hormone Replacement Therapy Hormone replacement therapy (HRT) was once viewed as the panacea for many of the symptoms associated with the menopause. However, prescriptions for HRT almost halved following the publication of two studies that linked the treatment to an increased risk


• HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer • Any increased risk reduces after stopping HRT. The heart disease risks of taking HRT Prolonged lack of oestrogen puts post menopausal women at increased risk of osteoporosis The Women’s Health Initiative study reported a 29% increase in heart attacks and a 41% increase in strokes among HRT users. However, NICE says this association between HRT and cardiovascular disease has since been disputed and the results show that the risk varies in accordance with individual factors. The new guidance recommends that women with cardiovascular risk factors should not be excluded automatically from taking HRT as it does not increase cardiovascular disease risk when started in women under 60 years of age, and it does not affect the risk of dying from cardiovascular disease. Pharmacy support Increasing population longevity means that the average woman living in the UK today will now spend around a third of her life in a postmenopausal state. Female customers therefore need support and advice from the pharmacy,

both to manage the difficult transition into menopause and to optimise health and wellbeing as a postmenopausal woman. Hormone replacement therapy (HRT) is the cornerstone of pharmacological treatment of menopause symptoms. The BNF makes the following observations on HRT use: For the treatment of menopausal symptoms, the benefits of shortterm HRT outweigh the risks in the majority of women, especially those aged under 60 years. The minimum effective dose of HRT should be used for the shortest duration, and treatment reviewed at least annually. Experience of treating women over 65 years of age with HRT is limited. Most HRT preparations contain small doses of oestrogen or drugs with oestrogenic properties, which effectively alleviate vasomotor symptoms and reduce the risk of osteoporosis when taken in either the peri- or postmenopausal period. Oestrogen is typically combined with progestogen in women with an intact uterus in order to reduce the risk of endometrial cancer. Common side effects of HRT include breast tenderness or enlargement, nausea, headache and bleeding. HRT is also proven to increase the risk of venous thromboembolism and stroke, as well as endometrial, breast and ovarian cancer. Tibolone is a synthetic hormone alternative to HRT, combining oestrogenic and progestogenic activity with weak androgenic activity, which is administered in a tablet formulation. Its side effects are similar to HRT and it is contraindicated in patients with a history of cardiovascular or cerebrovascular disease, uninvestigated vaginal bleeding and porphyria. Clonidine can be used to reduce menopausal flushing in women unable to take oestrogen-based therapy. However, due to its central action, it is linked to side effects that patients may find unacceptable, including postural hypotension, dry mouth, dizziness and sedation. Clonidine interacts with methylphenidate and mirtazepine and may also show drug-drug interactions with other classes of drug, including beta-blockers and tricyclic antidepressants. The choice of HRT for an individual woman should hinge on an overall balance of indication, risk and convenience. A range of HRT formulations are available, including creams and gels, tablets


GP R *GPrXdata – from July 2014 to June 2015 – UK coverage


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Relieve. Rejuvenate. Rekindle. Replens.

(oral or pessary), transdermal patches and implants. A woman with a uterus normally requires oestrogen with cyclical progestogen for the last 12 to 14 days of the cycle, or continuous administration of an oestrogen and a progestogen (or a compound that combines oestrogenic and progestogenic activity). Continuous

combined HRT preparations or tibolone are not suitable for use in the perimenopause or within 12 months of the last menstrual period due to the risk of irregular bleeding. Oestrogen-based HRT alone is suitable for continuous use in women without a uterus. Most women will require at least two

to three years of HRT treatment for effective relief of menopauseassociated vasomotor symptoms, and topical vaginal oestrogen may be required long-term. Alternative treatments to HRT should be considered, and are preferred, where osteoporosis is the chief concern. The British Menopause Society recommends

several agents for the prevention and treatment of osteoporosis in menopausal women, including bisphosphonates. A variety of vaginal lubricants and bioadhesive moisturisers are also available that can help ease symptoms of vaginal discomfort and dryness; many of these can be purchased over the counter.

Women’s Health Taskforce Last month saw the establishment, and first meeting, of a new Women's Health Taskforce. The Taskforce will be led by the Secretary General of the Department of Health Jim Breslin and Peggy Maguire, the Director General of the European Institute for Women's Health in partnership with the National Women's Council of Ireland. National Women’s Council of Ireland Director Orla O’Connor

cardiac health, women's physical activity and wellbeing, women's neurological health particularly in later life, women's mental health, maternal health and others. At its first meeting, the Taskforce agreed as its first action to lead a large-scale consultation with women in Ireland to hear their experiences of and solutions for the health system. The Taskforce will also examine a wide range of issues impacting women's health outcomes in Ireland and to work on these on a phased, prioritised basis. Topics under consideration include: disadvantage and its impact on health outcomes, women's

Jim Breslin, Secretary General of the Department of Health commented, "This Department wants to lead the way. We have such a strong foundation to build on: Healthy Ireland, the Maternity Strategy, the National Strategy for Women and Girls, the Sexual Health Strategy, the introduction of termination of pregnancy services and our recent work to improve sexual assault services. “Sláintecare puts the use of evidence and citizen engagement at the heart of the health reform

process. Within the Taskforce I'm particularly delighted that we have Peggy Maguire - a European leader on women's health - as Co-Chair and the National Women's Council of Ireland as active partners, building on the recent work we have undertaken together.” In support of the first meeting, the National Women's Council of Ireland today published an evidence base on women's health which synthesises the available data. Director, Orla O'Connor, who is a lead partner in the Taskforce welcomed its establishment saying "the National Women's Council of Ireland has made the case for strong, concerted action on Women's Health and we welcome the response from the Department and the support from the Minister. It will be crucial that as a new Taskforce we show the leadership on women's health that women in Ireland have been looking for.”

The Taskforce is an opportunity to:  act on the evidence of gender inequality in health and improve health outcomes;  meet women's expectations for the care and services they receive;  meet the commitments in the National Strategy for Women and Girls;  demonstrate the Department's capacity to collaborate internally and outwardly with women, professionals, academics and others to develop effective policies and importantly;  respond to Recommendation 2 of the Report of the Scoping Inquiry into CervicalCheck by Dr. Gabriel Scally that “The Minister for Health should give consideration to how women's health issues can be given more consistent, expert and committed attention within the health system and the Department of Health.”

News Building Healthier Communities The Community Foundation for Ireland (CFI), in partnership with the Medtronic Foundation, have released a new step-by-step guide for community-based organisations to use philanthropic funding to build better health outcomes across Ireland. The new framework, "Building Healthy Communities: Strategic Partnership from Concept to Delivery", has been created following the successful conclusion of the third phase of the ¤1 million Medtronic Healthy Communities Fund which awarded grants to support vital projects undertaken by its four national partners, the Irish

Cancer Society, the Irish Heart Foundation, Siel Bleu and the Marie Keating Foundation, over the last four years. The ¤1 million Fund's projects have had a nationwide impact since 2015, helping 12,600 endusers, 146 upskilled trainers and 134 local partner organisations, as well as supporting healthier


lifestyles, expanding access to healthcare for the underserved and tackling health inequalities. Collectively, the four national partners are working to reduce and manage non-communicable diseases in communities from pre-school age through to older people. Non-communicable diseases are estimated to

account for 91% of all deaths in Ireland. The partners were funded to address health challenges in respect of such diseases, including cancers (the Irish Cancer Society and the Marie Keating Foundation), cardiovascular diseases (Irish Heart Foundation) and chronic respiratory disease (Siel Bleu).

“ Revive Active is how I take care of me, so I can take

care of everyone else. I simply wouldn’t be without it. Made in Ireland. Made for me. ” - Sharon Tuthill from Cork

Revive Active is a super supplement with 26 active ingredients working in synergy providing adults with a daily dose of vitamins, minerals and amino acids in one convenient daily sachet. Made in Ireland, Revive Active was created for busy hectic lives, and is the easy way to put back what life takes out.


MindYourBack is a national campaign to help you manage and prevent back pain by following 5 simple S.T.E.P.S.

BACK PAIN – THE PROBLEM Lower back pain is the leading cause of disability worldwide, affecting an estimated 540 million people at any one time1. Back pain was also the most commonly reported chronic health condition in the first Irish Health Survey by the Central Statistics Office. More than one in three of the population said they had a long-standing health issue and almost one in five reported chronic back pain2.

professionals are recommended to switch from the old advice of rest and painkillers to the latest thinking – that the first line of treatment should be education and advice to sufferers to keep active and at work wherever possible1.


The Mentholatum Company, maker of the iconic Deep Heat and Deep Freeze brands of topical analgesics, has drawn on its decades of expertise in muscle and joint pain to create Mind Your Back, a one-stop shop to help back pain sufferers relieve their discomfort and help prevent further problems.

First line treatment of back pain has changed and healthcare

Throughout October and November, the campaign is


raising its profile on Facebook, Instagram and YouTube using educational content from GP Dr Dawn Harper. This will be boosted by a new consumer PR campaign highlighting the impact of sedentary lifestyles and health and back problems caused by sitting too long and developing poor sitting posture. The content targets adults over 35 in occupational professions and will also include parenting, health and wellbeing interests. Backs were designed to move and Mind Your Back comprises five simple steps S.T.E.P.S. to a stronger, healthier back with Stretching, Therapy, Exercise, Posture and Strengthening. It’s as straightforward as this:

• Stretch – five easy to follow stretches to help ease tight back muscles and keep you mobile* • Therapy – when life gets in the way and you can’t fit in all the S.T.E.P.S. use hot or cold therapy to ease aches and pains, or try a topical NSAID for inflammatory back pain • Exercise – go for a walk, a swim or a cycle ride, just start slowly and build up gradually*. Back care is a marathon, not a sprint! • Posture – could you draw a straight line between your ear, shoulder and hip when sitting or ear, shoulder, hip, knee and ankle when standing? No? Then it’s time to work on posture

• Strengthen – five more exercises, this time to strengthen core muscles and help prevent back pain*. A strong core means a stronger back. The exercises can be done anywhere at any time, no need for special equipment or expensive clothing. More details and videos demonstrating the exercises are at http://mindyourbackeire.com/ THERAPY – HOT, COLD OR ANTI-INFLAMMATORY There are bound to be times when you can’t fit a walk, swim or bike ride into a busy day and when even finding a few minutes to stretch can be a problem. That’s when Therapy can help keep you going. Topical analgesics deliver targeted, penetrating pain relief, with hot, cold and antiinflammatory products to help manage back pain: • Heat helps to soothe muscular aches and pains including stiffness and tight muscles • Cooling therapy for muscles and joints is well established and recommended by sports physiotherapists and health professionals. It works fast to ease sharp, shooting pains as well as muscular back pain in pregnancy** • Anti-inflammatory products provide penetrating pain relief for inflammatory back pain The Mentholatum Company’s Deep Heat and Deep Freeze ranges offer a range of formats to suit different lifestyles and different needs. The Deep Heat range includes traditional, medicated Deep Heat rubs and spray, and also drug-free options: • Deep Heat Pain Relief Heat Patches, which are activated by the air when they are opened. They heat up within five minutes and provide penetrating warmth and pain relief for up to 16 hours. The heat increases blood flow to the affected area, bringing oxygen and nutrients to aid the healing process

• Deep Heat Muscle Massage Roll-On Lotion offers drug-free heat therapy plus the benefits of massage in a convenient, modern roll-on format to ease tight, knotted muscles. It can be used before exercise to help loosen and soften muscles to help them move more easily and afterwards to ease stiffness. It also helps after exercise to Rehab soft tissue, with massage helping the realign the muscle fibres and break down adhesions and scar tissue. It can be used whenever needed to release knots in shoulders and backs. The Deep Freeze range offers patches, gel, spray and Deep

Freeze Pain Relief Glide-on Gel, providing fast relief for sharp, shooting back pain or back pain in pregnancy: • Deep Freeze Pain Relief Glideon Gel delivers scientifically proven fast-acting, cooling, soothing pain relief for sharp, shooting back pain. The fast-acting cooling sensations last for up to an hour, with penetrating cooling providing longer-lasting relief. • Deep Freeze Pain Relief Cold Patch works like ice to cool the affected area for up to three hours and gives fast-acting relief from sprains, strains, minor sports injuries, tense, tired or sore muscles and joints.

• Deep Freeze Pain Relief Cold Gel delivers effective, scientifically proven cooling. The cooling gel works swiftly, like ice, to bring soothing, cooling pain relief to the affected or swollen area. • Deep Heat Pain Relief Cold Spray can be used during or immediately after exercise to deliver an instant burst of cooling relief for sprains, strains, muscle and joint pain.

1 https://warwick.ac.uk/ newsandevents/pressreleases/ warwick_contributes_to/ 2 https://www.irishtimes.com/ news/health/back-pain-mostcommonly-reported-chronichealth-condition-1.2870170 *Always check with your GP before starting any new exercise programme, especially if you have not been active for a while. Take it slowly, making sure you follow the exercises correctly and stop immediately if you feel sudden, sharp or severe pain. **When experiencing new pain or symptoms in pregnancy always consult your midwife.


Rubbing out Pain Pharmacy Management in Topical Analgesics


he management of pain places a huge burden on health resources, with the number of patients seeking help for chronic pain increasing due to Ireland’s ageing population.

Pharmacists are experts in medicines and are the most accessible community healthcare professional for many individuals. Pharmacists already offer (in addition to their core dispensing role) competencies and services relevant to the needs of people living with and receiving treatments for pain. Around 80% of the public already say that acute pain is a symptom/condition they would consult their pharmacist about. Over the counter (OTC) analgesics containing codeine or dihydrocodeine in combination with other analgesics, such as paracetamol or ibuprofen, are intended for short-term use (no longer than three days) to minimise dependence and addiction. Concerns that codeine

or dihydrocodeine containing analgesics are being taken regularly should be discussed with the patient and the patient should be encouraged to seek medical advice and access appropriate services.

The biggest problem areas are the lower back, knee, back, shoulder and hip. But it can also involve living with pain in the foot, abdomen, head or ankle. Three in 10 said persistent pain had a severe impact on their sleep.

Pain in Ireland

"Social factors such as isolation, exclusion and loneliness can greatly exacerbate many of the problems associated with chronic pain,” says physiotherapist Niall Halliday, Chair of the society's Pain Management Group. “Changes in people's relationships with their family, friends, work colleagues and with other social groups can have serious impact on their pain.”

One in seven people has endured living with pain for more than a decade, a new survey has recently revealed. As many as one in four has suffered pain for at least six years, the findings from the Irish Society of Chartered Physiotherapists show. They warned that this is worrying and far too high given that "the longer a person has pain the more difficult it is to manage and more costly to treat.”

Types of Pain • Acute or short-term pain usually has a sudden onset

and a clearly identifiable cause, such as sustaining a burn while cooking, and lasts no longer than a few days. While unpleasant, it often serves a useful purpose in triggering reparative action, eg taking a baking tray out of the oven with bare hands causes pain that results in the individual dropping the tray, thereby minimising further damage. Addressing the cause usually resolves the problem, eg taking heat out of the burned area by applying a towel soaked in cold water. • Recurrent or intermittent pain is acute pain that comes and goes, for example, toothache. Again, addressing the issue usually eases the pain, though the exact cause may be difficult


WHO Analgesic Ladder: adults Step 3 Step 2 Step up if pain persists or increases

Step 1 Non-opioid

Weak opioid

Step up if pain persists or increases

Moderate Pain +/- non-opioid +/- adjuvant

Mild Pain +/- adjuvant

Strong opioid Severe Pain +/- non-opioid +/- adjuvant

Consider prophylactic laxatives to avoid constipation Non-opioids

ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin

Weak opioids

codeine, tramadol, or low-dose morphine

Strong opioids

morphine, fentanyl, oxycodone, hydromorphone, buprenorphine


antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid

Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life ("dose by the clock"); do not wait for pain to recur Adapted by Treat the Pain from World Health Organisation http://www.who.int/cancer/palliative/painladder/en/ (accessed 7 November 2013)

to pinpoint and some conditions – period pain, for instance – require regular management, though usually not for long on each occurrence. • Chronic pain differs from recurrent pain in that it is unrelenting, though there will be times when it feels more severe than others, and it lasts three months or longer. The cause is usually a long-term condition such as arthritis, though it may be less specific, for example a painful back. Chronic pain can have a huge effect on quality of life, causing problems with mobility, dexterity, sleep and concentration. It often results in the sufferer changing how they live in order to cope. This, in turn, can have a huge bearing on emotional wellbeing, causing anxiety, helplessness and depression. Approaches to Management In terms of management, a good approach is the ‘analgesic ladder’ advocated by the World Health Organisation. Originally developed to help improve the management of cancer pain, the stepwise tactic is equally applicable to many painful conditions:

• Step 1 (mild pain): non-opioid, eg aspirin, paracetamol or an NSAID, with an adjuvant if appropriate. If the pain persists or worsens, move to step 2. • Step 2 (mild to moderate pain): weak opioid, eg codeine, with or without a non-opioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 1. If it persists or worsens, move to step 3. • Step 3 (moderate to severe pain): strong opioid, eg morphine, with or without a non-opioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 2. Treatment Options Various formulations and dosage forms are available for the selftreatment of pain, and pharmacists can help patients choose the one that meets their needs. Helping customers choose the right topical analgesic for their individual needs is key if they are to gain optimum benefit. Topical analgesics are recommended for targeted relief


where pain is localised to a small area. This may also help with adherence. Improved adherence may also depend on the site of pain. For superficial joints with easy access, such as the hand, adherence may be easier than for larger, deeper joints, such as the hip. Patient confusion regarding the wide array of topical products and formats available can also hinder usage. Consumers want help and reassurance when it comes to self-treating. For the treatment and management of musculoskeletal injuries and disorders, many patients commonly use nonprescription topical analgesics. Available in several different formulations, including gels, ointments, creams, lotions, sprays, and patches, and as single entity or combination formulations, these products may have local analgesic, anesthetic, antipruritic and/or counterirritant effects. Topical OTC treatments broadly divide into those with active ingredients and those that are drug-free. OTC options are suitable for treating acute musculoskeletal problems, such as soft tissue injuries (e.g. sprains,

which are an injury to the ligament, or strains – an injury to the muscle fibres). OTC treatments can also be used in chronic conditions such as persistent back pain and osteoarthritis (OA). NSAIDs, such as ibuprofen and diclofenac, act by inhibiting the cyclo-oxygenase enzyme to reduce prostaglandin production. These are usually available as gels, creams or sprays, but the amount of NSAID found in plasma is usually less than 5%. Rubefacients (also known as counterirritants) cause the blood vessels to dilate and redden and irritate sensory nerve endings to alter or offset pain in the underlying muscles or joints served by the same nerves.Counterirritants are often used for the treatment of acute musculoskeletal injuries, such as simple backache, arthritis pain, strains, bruises, and sprains. In addition, these agents are also often used as adjuncts in the treatment of chronic musculoskeletal disorders. Unlike other external analgesics, with counterirritants, pain relief results more from nerve stimulation than depression.

Reminder of Precautions to avoid Photosensitivity Reactions with Fastum Gel (ketoprofen gel) A. Menarini Pharmaceuticals Ireland Ltd. wish to remind healthcare professionals of the necessary precautions to avoid the risk of photosensitivity reactions with Fastum Gel. The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) undertook a safety review of topical ketoprofencontaining medicines in 2010 and recommended that doctors should strictly follow the contraindications when prescribing topical ketoprofen. CHMP also recommended that doctors and pharmacists should inform patients on how to use these medicines appropriately to prevent the occurrence of serious skin photosensitivity reactions. A series of risk minimisation measures for Fastum Gel was agreed with the Health Products Regulatory Authority. The Summary of Product Characteristics and the Patient Information Leaflet were updated accordingly and may be found on www.medicines.ie and www.hpra.ie. Patients should be reminded to wash their hands thoroughly after application of the product and to protect treated areas from sunlight by wearing clothing. They should avoid exposing the treated areas to sunlight, even if cloudy, or UVA from sunbeds or solarium during use and for 2 weeks after discontinuation. In addition they should be advised to avoid using Fastum Gel under occlusive bandages and to discontinue Fastum Gel immediately and contact their doctor should any skin reaction develop, including cutaneous reactions after co-application of octocrylene-containing products. A copy of the patient educational leaflet is available from A. Menarini on 01 284 6744 or 1800 283045 or is available at www.hpra.ie A. Menarini would like to remind healthcare professionals that any suspected adverse reactions associated with the use of Fastum Gel should be reported to the Health Products Regulatory Authority at www.hpra.ie or by calling 01 676 4971. Adverse reactions can also be reported to A. Menarini’s Pharmacovigilance Department on 01 284 6744.

Counterirritants can be further categorised into 4 subgroups and can be used alone or in conjunction with oral analgesics when appropriate and warranted. It is important to be able to advise on which type of product to use to relieve different types of pain and the key differences between products. It is also important that customers are aware that, while often seen as innocuous, topical preparations can still produce systemic side-effects. Pharmacy Advice Factors that may be considered when selecting an OTC topical analgesic include dosage form,

cost, ease of use, odour, and the patient’s medical history, including possible allergies. Patients who are taking anticoagulation therapy should be cautioned not to use topical products that contain salicylates (aspirin, methyl salicylate, and trolamine salicylate), as concomitant use has been associated with prolonged prothrombin time. Patients should be counselled on the proper use of these products, which include using them as directed and only applying topical products to intact skin. Hands should always be washed after applying topical products and before touching the eyes or mucous membranes.

Tight bandages or occlusive dressing should not be applied to skin treated with counterirritants. Patients should also be cautioned not to use heating devices while using topical counterirritants. If a patient experiences excessive redness or blistering of the skin, the product should be discontinued. Key Learning Points • Pharmacists can advise patients about their medicines and can help improve safety, efficacy and adherence in medicines use. • Pharmacists should ensure that analgesics available ‘over the counter’ (OTC) containing codeine or dihydrocodeine

are only used for acute pain of short duration (less than three days). • Pharmacists must ensure that the prescribed dose of medication is appropriate for an individual patient and that dose increases are proportionate to the current dose • Pharmacists are able to support monitoring of effectiveness and tolerability of opioids by carrying out Medicine Use Reviews • By taking a proactive approach, pharmacists may highlight excessive/unusual doses and potential drug interactions and can request a review by the primary prescriber.

News Uniphar help Pharmacy tackle key challenges

Brian Cronin Ryans Pharmacy Brian Mangan Business Development Manager at Uniphar and Ger Leo Kielys Pharmacy Ballyfermot

Brian Mangan Business Development Manager at Uniphar with Rosie Conway Smith from Conways Pharmacy Ashbourne


Brian Mangan Business Development Manager with Donna McQuaid from McQuads Pharmacy

The event was an opportunity for Uniphar and pharmacists to exchange experience and knowledge

The latest event in Uniphar’s expert-led Future Proof Your Profit series took place in Navan last month. Attendees were provided with guidance on how to overcome challenges and get ahead by maximising the potential of key areas including commercial, retail, marketing, dispensary, regulatory and HR. They also received a detailed overview of the current state of play in Irish pharmacy and what they could expect coming down the tracks. The event encouraged the exchange of knowledge between Uniphar and community pharmacy by holding roundtable discussions with questions then directed to Uniphar’s panel of experts. The next event in the Future Proof Your Profit series is currently scheduled for Dublin in November.

News Survival Guide for Asthma in Children September is one of the riskiest times of the year for people with asthma, especially children. Community pharmacists will see an increase in asthma sufferers visiting the store for advice on their medications and inhaler use, while doctors will see a significant spike in hospital visits and admissions of children with asthma, as a result of what is known as the 'September Asthma Peak'. This year, the Asthma Society of Ireland recommended that parents of children who have asthma to use its September Survival Guide to ensure their children do not end up in hospital.


World Pharmacist Day! Wednesday 25th September marked World Pharmacist Day for 2019, with the theme of “Safe and effective medicines for all. The theme aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors. The Federation of International Pharmacy (FIP) member organisations and others around the globe use World Pharmacists Day to highlight the value of the pharmacy profession to stakeholders, and to celebrate pharmacy. 2019 marks the tenth year since the annual World Pharmacists Day was first designated by the FIP

Council in Istanbul. The Day took place as FIP held their Annual Congress in Abu Dhabi. “Studies show that a significant number of patients are harmed during health care, resulting in permanent injury, increased length of stay in healthcare facilities, or even death. Medication errors are a contributing factor to this and pharmacists have a vital role in curtailing this global health challenge,” says FIP President Dominique Jordan. “Pharmacists use their broad knowledge and unique expertise

to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, co-ordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm”, Mr Jordan added. Pharmacists, Pharmacy Groups and industry took to their social media to acknowledge the day:

Asthma Consultant, Dr Muhammed Tariq, says, “Every September I see a notable increase in the number of children admitted with respiratory conditions. In the past 24 hours, one third of the children admitted to my hospital were admitted with respiratory problems caused by viral infections at this time of the year, it is very common in September. The September Asthma Peak is caused mainly by viral infections and is particularly dangerous for children with asthma who have slipped out of their asthma management routine over the summer months.” Get the basics right: • Use the inhaler technique videos on asthma.ie to help children take their inhaler properly • Make sure the child carries their reliever inhaler (usually blue) at all times • Check that they take their medication every day with a fridge planner • Leave a spare reliever inhaler in the school, with their name clearly labelled Advice for Pharmacists: • Ensure children’s asthma is reviewed by their GP every September • Update the child’s Asthma Action Plan. If they do not have one, put one in place • Ensure children with asthma have received the flu vaccine

Mari Mina Pharmacy Celebrations The pharmacy team at Mari Mina Pharmacy in Lismore, Waterford celebrated World Pharmacist Day in-store. Pictured are pharmacists Dr Bernard Leddy, Mary Morrissey and Leanne Bumster. All of the staff enjoyed taking part in this great acknowledgment of the vital work carried out by community pharmacists every day.




Pharmacy-based MAS in Spotlight Minister for Health Simon Harris has said there will be further consultations on a pharmacy-based minor ailment scheme before the end of the year. Sinn Féin Spokesperson for Health, Louise O’Reilly TD

“The Programme for a Partnership Government contains a commitment to expand the role of community pharmacy in managing patient health, and this is an issue I intend to progress,” said Minister Harris. He was responding to a question posed by Sinn Féin Spokesperson for Health, Louise O’Reilly who asked in a Dáil debate, “when the pharmacy-based minor ailment service will be rolled out to provide medical card holders with advice and appropriate treatment for minor ailments without the need to visit a general practitioner, as is commonplace in Northern Ireland, Scotland and Wales.”

“Work has been done in recent years on wider healthcare roles for pharmacies, including the Pharmaceutical Society of Ireland’s Future Pharmacy report, concerning 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 community

pharmacy. Important new services, in influenza vaccination and emergency contraception, have already been introduced. “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 met with the Irish Pharmacy Union (IPU) earlier this year and I attended their conference in Galway and these and other issues were discussed in both forums. It is my intention that there will be further consultation with the IPU before the end of the year.”

Deputy O’Reilly had also earlier asked the Minister when pharmacists will be permitted to provide oral contraception to women without prescription in line with his commitment to improve access to contraception and plans being considered by his Department. “A Working Group was established in April 2019 to consider the range of policy, regulatory and legislative issues arising in relation to improving access to contraception. As part of its deliberations and engagement with stakeholders, the Group has considered the potential role of pharmacists in providing oral contraception to women without prescription,” he said. “The Group is continuing its deliberations and intends to report to the Minister shortly.”

Educating Pharmacists on Dispensing A new CBD capsule, which has clinically proven bioavailability, provides a reliable dose and is GMP manufactured, is now nationally available in pharmacy in Ireland. In July of this year, Minister for Health Simon Harris TD signed legislation which will allow for the operation of the Medical Cannabis Access Programme on a pilot basis for five years. The Programme will facilitate access to cannabis-based products for medical use in line with legislation. This new law meant pharmacists are now also able to dispense cannabis for medical use to patients. 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 Gelpell® capsules deliver a consistent 10mg dose of CBD each time a capsule is taken. 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 times higher than that of standard CBD oils, representing a significant advancement over the current CBD oils and capsules found on shelves in many stores today. 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.” Pharmacists are able to dispense Cannabis for Medical Use to patients as set out in the legislation, on foot of a valid prescription, once suppliers make

the specified controlled drugs available on the Irish market. Pharmacists should also refer to the Clinical Guidelines prepared by the Expert Reference Group, available on the Department of Health website. The offences and penalties for unauthorised supply and possession of controlled substances remain unchanged. Satipharm CBD Gelpell® capsules are manufactured under Good Manufacturing Practice (GMP). The GMP certification ensures the highest quality and safety standards.

Extension of FMD Use and Learn The Falsified Medicines Directive safety feature requirements came into effect on 9th February 2019. During this time, the system in Ireland has been in ‘use and learn’ phase to ensure the continuity of safe supply of medicines to patients while all parties gained a better understanding of the new system. The National Safety Features Oversight Group comprising the 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) has been closely monitoring progress since go live on 9th February. Taking all factors into account, the group has decided that the use and learn period will be further extended to allow additional time


for the system to stabilise and to ensure that everyone is ready when it becomes mandatory to investigate and close out all alerts before supplying the packs. The use and learn period will end on a phased basis from 31 January 2020.

In the meantime, pharmacies, hospitals, wholesalers and manufacturers/MAHs are asked to continue following the instructions given to them when the use and learn period was last extended in May.

Contains nicotine

“I quit smoking for her” Fergus O’Shea

Help smokers quit with an


combination* from


*Provides significant improvements in quit rates vs patch alone. Stead LF et al. 2012 Nicotine replacement therapy for smoking cessation, Cochrane Library.




NiQuitin CLEAR 24 hrs transdermal patches are indicated for the relief of nicotine withdrawal symptoms including cravings as an aid to smoking cessation. Indicated in adults and adolescents aged 12 years and over. NiQuitin patches should be applied once a day, at the same time each day and preferably soon after waking and worn continuously for 24 hours. Apply a patch to non-hairy clean dry skin surface, a new skin site should be used every day. Therapy should usually begin with NiQuitin 21 mg/24 hrs and reduced according to the following dosing schedule: Step 1 NiQuitin Clear 21 mg/24 hrs transdermal patches first 6 weeks. Step 2 NiQuitin Clear 14 mg/24 hrs transdermal patches next 2 weeks. Step 3 NiQuitin Clear 7 mg/24 hrs transdermal patches last 2 weeks. Light smokers (e.g. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (14 mg) for 6 weeks and decrease the dose to NiQuitin 7 mg/24 hrs for the final 2 weeks. Contraindications: Non-smokers, hypersensitivity, children under 12 years and occasional smokers. Precaution: Supervise use if hospitalised for MI, severe dysrhythmia or CVA, if haemodynamically unstable. Use with caution in patients with active oesophagitis, oral and pharyngeal inflammation, gastritis, peptic ulcers, GI disturbances, susceptible to angioedema, urticaria, renal/hepatic impairment, hyperthyroidism, diabeties, phaeochromocytoma, seizures & epilepsy. Discontinue if severe persistent skin rash. Pregnancy and lactation: Oral formats preferable to patches unless nauseous. Remove patches at bedtime. Side effects: Transient rash, itching, burning, tingling, numbness, swelling, localised pain urticaria, hypersensitivity reactions. headache, dizziness, tremor, sleep disorders, nervousness, palpitations, tachycardia, dyspnoea, pharyngitis, cough, nausea, vomiting dyspepsia, upper abdominal pain, diarrhoea, constipation, dry mouth, sweating, dermatitis, photosensitivity, arthralgia, myalgia, asthenia, malaise, influenza-type illness, fatigue, seizures and anaphylaxis. Legal classification: GSL: PA 1186/18/4, PA 1186/18/5 & PA 1186/18/6. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. http://www.medicines. ie/medicine/12136/SPC/NiQuitin+CLEAR+7+mg+24+hours++transdermal+patch/ http://www.medicines.ie/medicine/12137/SPC/NiQuitin+CLEAR+14+mg+24+hours+transdermal+patch/ http://www. medicines.ie/medicine/12138/SPC/NiQuitin+CLEAR+21+mg+24+hours+transdermal+patch/ NiQuitin Mini 1.5mg/4mg Mint Lozenges are used for the treatment of tobacco dependence by relief of nicotine withdrawal symptoms and cravings. Indicated in adults and adolescents aged 12 years and over. NiQuitin Mini 1.5 mg are suitable for those who smoke who smoke 20 cigarettes or less a day. NiQuitin Mini 4 mg are suitable for smokers who smoke more than 20 cigarettes a day. Place a lozenge in the mouth whenever there is an urge to smoke, allow to dissolve completely. Do not chew or swallow whole. Abrupt cessation: Use a lozenge whenever there is an urge to smoke, maximum of 15 lozenges a day. Continue for up to 6 weeks, then gradually reduce lozenge use. Gradual cessation: Use lozenges whenever there is an urge to smoke in order to reduce the number of cigarettes smoked for up to 6 weeks, followed by abrupt cessation. Adolescents (12-17 years): Only with advice from a healthcare professional. Contraindications: Hypersensitivity to nicotine or any of the excipients, children under the age of 12 years and non-smokers. Precaution: Supervised use in dependent smokers with a recent myocardial infarction, unstable or worsening angina pectoris including Prinzmetal’s angina, severe cardiac arrhythmias, uncontrolled hypertensions or recent cerebrovascular accident. Use with caution in those with; stable cardiovascular diseases, diabetes mellitus, susceptiblity to angioedema & urticaria renal/hepatic impairment, phaeochromocytoma & uncontrolled hyperthyroidism, GI disease & seizures. Side effects: Nausea, mouth/throat and tongue irritation, irritability, anxiety, sleep disorders, dizziness, headaches, cough, sore throat, dyspnoea, vomiting, diarrhoea, GI discomfort, flatulence, hiccups, heartburn, dyspepsia, nervousness, depression, palpitation, rash, angioedema, pruritus, erythema, hyperhidrosis, fatigue, malaise chest pain, anaphylactic reactions, hypersensitivity, tremor, dysgeusia, paresthesia mouth, seizures & epilepsy, dysphagia, eructation, salivary hypersecretion, pharyngitis. http://www.medicines.ie/medicine/14493/SPC/NiQuitin+Mini+1.5mg+mint+lozenges/#PRODUCTINFO http://www.medicines.ie/medicine/14492/SPC/NiQuitin+Mini+4mg+mint+lozenges/ Legal classification: GSL: PA 1186/18/11 & PA 1186/18/12. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

Brexit Report


Concerns over No-Deal Brexit for Medicines Supply

With Brexit imminent, and UK prime minister Boris Johnson determined that the country leaves the EU, deal or no deal, Irish businesses in every sector of the economy are facing into an uncertain future.

So what would a no-deal Brexit mean for the pharmaceutical sector? Ireland's pharmaceutical industry has said there are always two to three months' supply of medicines in the system and these stocks will help absorb any short-term delays that could arise from a disorderly Brexit. Access to medicines has been one of the highest priority concerns for doctors, pharmacists and the Government, given the often critical nature of these products for patients. The British government’s Yellowhammer report warned that a 40-60% fall in the amount of traffic getting through the channel ports would inevitably pose major risks for medicine supply. But Irish industry sources are more sanguine. Pharmacists have been concerned about the availability of medicines post-Brexit. Irish Pharmacy Union spokesman Jim Curran says they

have been assured that “everything that can be done is being done to plan for and prevent any potential problems that could crop up as a result of Brexit, and to put solutions in place.” “Most importantly, we have been told that there are several months’ supplies of medicines in the supply chain in Ireland, which will prevent any immediate interruption to supply in the aftermath of the UK’s withdrawal,” he said. The main concern in the immediate term relates to medicines with a short shelf life, such as those relying on refrigerated supply chains. The Irish Pharmaceutical Healthcare Association (IPHA), which represents the big, researchdriven drug companies here, says the HSE has been working with the Irish medicines regulator and the industry to put contingency plans in place. Risks of Disruption Bernard Malle, Director of Communications and Advocacy

with IPHA says, “Patients are understandably worried about whether they will still be able to get their medicines after Brexit. The risk of disruption to medicines supply can never be fully discounted - but it can be managed. For over two years, biopharmaceutical companies have been working on how medicines supplies can be managed after Brexit, whether deal or no deal. Ireland's exposure to Brexit is big.

routing transport away from the UK. There is always two to three months’ supply of medicines in the system. These stocks will help to absorb any short-term delays that could arise. There is no need for hospitals, pharmacists or patients to order extra quantities of medicines, or for doctors to issue extra prescriptions. That would risk disrupting existing stock levels.”

“About 4,000 medicines are marketed in Ireland. Of these, between 60% and 70% come from, or pass through, the UK. So, planning for every scenario, in partnership with the State, was the responsible thing to do. Brexit will disrupt how medicines are moved around the supply chain - but we don’t expect it to affect the availability of the medicines patients need or impinge on continuity of care.

An HSE statement said, “We are working with the Department of Health, the Health Products Regulatory Authority (HPRA) and industry to reduce and deal with any risk to the supply of medicines.

“The industry has invested in making complex logistical and supply chain arrangements, including in some cases re-

Stakeholder Event

“There is no need for patients, pharmacists or hospitals to order extra medicines. This could disrupt stocks and reduce the supply of medicines for other patients. “Medicines shortages are happening more often worldwide. This has nothing to do with Brexit. In 2018, the HPRA launched the Medicine Shortages Framework.



Brexit Report

This is to manage and deal with shortages or potential shortages. This will reduce the effects on patients. “There are about 4,000 medicines marketed in Ireland. A number of them come from, or travel through, the UK. Companies have been reviewing these arrangements to try and avoid delays in supply. They are also considering other supply routes, if needed. “We have not identified any major issues with the availability of specific products. We will be working with the HPRA to identify alternative products if specific issues are identified.” Minister for Health Simon Harris TD just last month hosted the third key Brexit stakeholder event at the Department of Health for representatives from the pharmaceutical and medtech industries, the Pharmaceutical Society of Ireland, the Irish Pharmaceutical Union, the Hospital Pharmacists Association of Ireland and the Irish Medication Safety Network. The Minister, Secretary General of the Department of Health, the HPRA, and the HSE provided detailed updates on Brexit planning at Government level. Industry and representative groups gave updates on their preparedness for Brexit, and any issues they are facing. Speaking at the event, Minister Harris said, "I know that a significant amount of work and investment has already been made by the medicines and medical device industry in preparing for Brexit and I would like to take this opportunity to acknowledge that work and to thank you, and the members of your organisations, for the huge efforts that you have made to prepare for life after Brexit. “As Minister for Health, my priorities in planning for Brexit are to ensure the protection of public health, continuity in the provision of health services and to avoid or mitigate changes that would have a negative impact for patients. Ministerial Planning “Brexit means change, as outlined in July's Contingency Action Plan Update which outlines the extensive work taking place across Government, but throughout our preparations, Irish patients have been our highest priority, and ensuring their continued access to effective and appropriate treatments is the key focus of all our efforts.” It was agreed that the positive engagement between the

Department, agencies and industry would continue as Government prepares for Brexit. The Irish and British Governments have committed to the shared objective of maintaining the CTA arrangements, under which Irish citizens and British citizens who live in, work in, or visit the other state have the right to access healthcare there. Provision has been made to ensure the arrangements necessary to maintain health service cooperation for the period after a no deal Brexit. These include the maintenance of current arrangements for access to routine, planned and emergency health services for UK/ Irish citizens and visitors in the other jurisdiction. It also includes health cooperation on access to specialist health services in the other jurisdiction including, for example, continued access to specialist paediatric cardiology services on an all island basis and access to specialist cancer services. As part of the whole of Government response to Brexit, including through our work with the EU, the Department of Health is working to ensure a comprehensive and coordinated set of preparations to ensure continuity of health services post-Brexit. The Withdrawal of the UK from the EU (Consequential Provisions) Act 2019 has a specific part on healthcare (Part 2 – Arrangements in relation to health Services). This Provides for legislative mechanisms to enable essential Common Travel Area healthcare arrangements to be maintained between Ireland and the UK which, if required, will allow the Minster for Health to make Orders and Regulations to enable necessary healthcare arrangements to be maintained between Ireland and the UK in a no-deal scenario. No Medicine Shortages Medicines for Ireland (MFI), the representative body for generic, biosimilar and value-added medicines and the largest supplier of medicines to the HSE, has moved to reassure patients that their members do not anticipate medicine shortages on 31 October next, even in a scenario where the UK leave the European Union without a deal. Medicines for Ireland has been working closely with key stakeholders, including the Department of Health, HSE and Health Products Regulatory Authority for almost a year to ensure that the impact of Brexit is minimised in respect of


continuity of medicine supplies for Irish patients.

Jon Joins the Top5

Owen McKeon, Chair of Medicines for Ireland, spoke out following the Taoiseach's speech at British-Irish Chamber event on 5 September. “The Taoiseach’s speech at the British-Irish Chamber event, particularly his comments on the impact that border checks could have on the supply of medicines to Ireland, was a stark reminder of the realities of a no-deal Brexit. “Medicines for Ireland and its fellow industry partners are engaging with the Department of Health and HSE in preparation for Brexit, and we are well placed to manage the challenge in the short-term. Building additional stock, supply chain and patient engagement all feature as part of our contingency plans. “In tandem, the emphasis must now be on the types of medicines agreements, structures and practices we have as a country into the medium-term. Consideration needs to be given to fast tracking a new Medicines Pricing Agreement. The current agreement, which only covers the minority of medicines dispensed every day, is informed by the old rather than new realities. “We look forward to continuing to work with Government and others to both prepare for the short-term, while pivoting for the next challenges that are fast approaching.” Wholesaler Planning Both of Ireland’s major wholesalers have been ensuring effective planning in the run-up to Brexit. A spokesperson for Pharmasource told us, “The PharmaSource team have been working on provisions for mitigating risks post Brexit for the past 24 months. Maintaining continuity of supply to the Irish market has been at the forefront of developing our Brexit strategy.” In the event of a ‘no deal’ Brexit scenario, PharmaSource have identified customs implementation, delays at borders and stock piling leading to shortages as the biggest risks to continuity of supply and in order to mitigate against any disruption in supply, they have increased current stock holdings of EMPs sourced directly from the UK. “The PharmaSource Procurement team have also been working with suppliers from other EU Member States to establish supply routes and to discuss what customs requirements or alternative options may apply if their current route is via the UK land bridge,” the spokesperson added.

Jon Brier, Pharmacy Manager, Loughrey’s CarePlus Pharmacy The Top5 Finalists in the Manager of the Year Award category has been named by the largest retail representative organisation in Ireland, Retail Excellence. Jon Brier, Pharmacy Manager with Loughrey’s CarePlus Pharmacy has been shortlisted for 2019. The Retail Excellence Awards, which were established in 1997 to promote best practice and encourage high standards in the Irish retail industry and are now the largest and most prestigious of its kind in Ireland. The Retail Excellence Awards, will take place on Saturday, November 9th in the Great Southern Hotel in Killarney. In our last issue we detailed that thirteen community pharmacies have this year made it on to the list of Retail Excellence’s Top100 Stores in Ireland including Adrian Dunne Balbriggan and Kilbarrack; Cunningham’s Pharmacy in Athlone and Monskland; McCabes Pharmacy for their Blanchardstown and Malahide stores; and McCauley Health & Beauty Pharmacy with their flagship Charlemont Street Pharmacy and New Ross Pharmacy. Also making the shortlist was Allis Pharmacy in Knocklyon, Liberty Pharmacy in Thurles, Lynch’s Pharmacy in Kells, Phelan’s Pharmacy in Skehard Road, Cork, and Walkers Chemist in Enfield, Meath.

The solution to all your sourcing pains

For more information please contact: Free Phone 1800 440 440 I PharmaSource@uniphar.ie I www.uniphar.ie



Endurance and Talent – Celebrating 85 Years in Business Established some 85 years ago in Ireland under the innovative thinking, dedication and commitment of the Gardiner family, Ovelle continues to grow from strength to strength. Joseph Gardiner, Ovelle Founder

skin conditions like eczema, dermatitis and psoriasis. Ovelle became the first Irish manufacturing skincare Apothecary in 1934. Created by Joseph Gardiner to service the traditional Chemist shop across the whole island of Ireland and subsequently led by Sean Gardiner, Rose Gardiner and Gerald Gardiner and now the third generation, Joanna Gardiner and Patrick Gardiner.

Ovelle now export their multi-award winning skincare brands for sensitive skin to three continents globally. The company has received recognition from Vogue and this, combined with year-on-year industry and parenting awards for skincare, means the future is very bright for Ireland’s home-grown business success story. As the incidence of eczema and skin sensitivity rises with 25% of babies developing eczema and 12% of adults with chronic dry sensitive conditions, the expertise in dermatology over three generations has found its place in the global category of healthy skin. On a fast growth trajectory, Ovelle exports 60% internationally and has a very strong base in Irish Pharmacy. Ovelle Heritage Since 1934 the Gardiner family have been making traditional family skincare products over three generations since Joseph Gardiner created the first Family Skincare Apothecary in Ireland. Up to this point in history, creams and ointments had been made up by apothecary chemists in individual chemist shops. Ovelle set out to manufacture apothecary bases, creams and ointments and trusted BP formulations to remedy

Ovelle traded and performed through major events in history including the Second World War, multiple recessions and the massive changes across society in Ireland since 1934. Based on the border Ovelle navigated the troubles and endured through many difficult times employing three generations of loyal staff in Dundalk. “One great achievement is our endurance which is down to our talented and conscientious hardworking staff over many years. I personally believe the character of the people of Dundalk, a high achieving industrial town, sometimes against the odds, has allowed us to endure, adapt and in many ways survive for 85 years,” says Joanna Gardiner, CEO. Throughout the years Ovelle invested in high quality standards and pioneered scientific advances in dermatological skincare in their Irish research and manufacturing facility. They research, manufacture and distribute from Dundalk to the whole island of Ireland, the UK, The Gulf states and Middle East and more recently Hong Kong and China. It is through investment in world recognised standards that they have sustained this growth. “Standards that allow us manufacture pharma licensed

Ovelle receive recognition in Vogue


medicines, medical devices and certified natural organic formulations to the highest ethical Sedex & Environmental standards ISO 14001 and PETA cruelty free and vegan standards are at the heart of our success,” adds Patrick Gardiner, Research & Quality Director. Joanna concludes, “I am proud to announce that we are the first manufacturing site in Dundalk to invest heavily in renewable solar panels to allow us generate our own electricity on site. I know this matters to our staff.” All of Ovelle’s dermatological formulations are safety tested to the highest international Pharma standards and independently certified. This is why their

formulations are trusted and recommended by pharmacists, pharmacy assistants and medical professionals for the treatment and management of chronic skin conditions. Ovelle also has strong links with medical professionals and is a long term supplier into hospitals and aid agencies worldwide. Their expertise in making traditional Ovelle apothecary products like Silcock’s Base, Aqueous Cream and Emulsifying Ointment allowed the team to draw on dermatological advances in skincare to create Multi-award winning Elave sensitive skincare which helps prevent flare up of sensitive including eczema, dermatitis and rosacea prone skin.

in the ongoing battle against serious childhood diseases.




Targeting the Aura around Migraine Migraine is the most common headache disorder seen by pharmacists and GPs. Confirmation of the diagnosis of migraine is a very important part of the consultation. In children and adolescents, migraine attacks are generally of shorter duration than those seen in adults. Children often give a history of travel sickness and recurrent abdominal pain or cyclical vomiting syndrome, prior to the development of headaches in their late teens or adulthood. Diagnosis Summary  Unilateral or bilateral, typically lasts 4 to 72 hours

 Associated with other symptoms such as sensitivity to light/ sound, nausea, vomiting, diarrhoea, disequilibrium, neck pain  Aura can occur with or without headache - Typical aura symptoms include visual, sensory, speech disturbance and occasionally motor symptoms which are reversible  Frequency < 15 days per month = EPISODIC MIGRAINE +/aura ≥ 15 days per month = CHRONIC MIGRAINE +/- aura

 Pulsating or throbbing pain, moderate or severe

The WHO (World Health Organisation) Global Burden of Disease (GBD) Studies have recently ranked migraine as the second highest cause worldwide of years lost due to disability (YLD).

quality of life while nearly 50% are concerned about their productivity, and 20% are concerned about their family and relationships.

A hundred people lined Dublin’s iconic Samuel Beckett Bridge to promote public awareness and understanding of migraine last month. The gathering, supported by Teva Pharmaceuticals Ireland (Teva), depicted the extent to which migraine impacts hundreds of thousands of Irish people.


Migraine is the leading cause of YLD in the age group 15-49 years. YLD is considered to be the most appropriate measure of disability in non-fatal medical conditions. It is estimated that there are currently more than a billion people with migraine on the planet and there are approximately 600,000 to 700,000 people in the Republic of Ireland with this condition.

Migraine is considered to be a primary disorder of the brain. It is a complex neurovascular condition that involves activation and sensitisation of neuronal pathways within the peripheral and central nervous systems. This involves sensory information passing from the periphery to more central areas such as the trigeminovascular complex. Neuronal activation, cortical spreading depression (CSD) and vascular changes are present during the migraine attack. However, blood vessel dilatation and constriction are not necessary or sufficient to induce an attack.

Teva’s 1 in 7 migraine awareness campaign aims to educate the public as well as raise the profile of migraine and the extent to which it impacts on people living in the Republic of Ireland.

The WHO estimates that 10% 14% of global population have migraine. Migraine patients may experience episodic or chronic symptoms, and the latter is usually associated with the most significant disability. There is often a component of overuse of painkillers or analgesics (medication overuse) in patients with more chronic symptoms. Furthermore, there is an increased risk of certain medical comorbidities in patients with chronic migraine including depression, anxiety, fibromyalgia and obesity. New research to mark Migraine Awareness Week, which took place from 9-15th of September has revealed gaps around awareness and understanding of migraine, as well as a stigma attached to the condition. The research shows that almost 70% of migraine sufferers are concerned about their overall

As migraine is most often seen in females of childbearing ages, most pharmacists will have seen women who relate their migraine to their menstrual cycle. Most will also have many children with infantile colic. In such cases, it is now considered important to ask if there is a family history of migraine. Emphasise the importance of regular lifestyle, diet, exercise, avoidance of stress, alcohol, smoking and other stimulants. Early in their migraine history, many patients are initially worried about the migraine symptoms that they experience. Often, patients are concerned that they may be suffering from a sinister medical condition, such as a “brain tumour”.


Key findings from the research1 include:  Almost 70% of migraine sufferers are concerned about their overall quality of life.  Nearly 50% are concerned about their productivity, and 20% are concerned about their family and relationships.  2 in 3 migraine sufferers said that the most common form of stigma associated with migraine is that they are over-reacting to a bad headache.  71% of sufferers have or know someone who has left work early or not finished a task in work due to migraine.  36% of sufferers have left a job or reduced weekly hours due to migraine. Clodagh Kevans, Director at Teva Pharmaceuticals added, “Migraine is more than just a headache but a debilitating condition, which is often poorly understood by the wider public. Our campaign aims to create a better awareness of the condition and encourage those with migraine to seek professional support. “For people living with migraine, diagnosis and treatments are improving. Increasingly there is a greater understanding of the biology of the condition, and this is driving the development of new and emerging treatments that help prevent migraine.” To read more about the findings from the public survey on migraine carried out exclusively in Ireland please visit https://www.teva.ie/ migrainepublicsurvey. 1 Consumer Survey, undertaken by Amarach Research, of a representative sample 1,000 adults, on behalf of Teva Pharmaceuticals Ireland, March 2019 2 Migraine: Diagnosis and Management from a GP Perspective 10 December 2018 & Population of ROI (2018), www.cso.ie April 2018 3 Migraine: Diagnosis and Management from a GP Perspective 10 December 2018 Authors: Dr Mary Kearney Dr Martin Ruttledge Ms. Esther Tomkins. Page 6: https://www.icgp.ie


EXCLUSIVE OTC PRODUCT FOR PHARMACIES ONLY* *Sumatran Relief is a non-prescription migraine treatment, containing sumatriptan. Sales must be referred to the pharmacist. Please use your consultation aid. Medicinal product not subject to medical prescription. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork, P75 V009. Freephone: 1800 304 400 Fax: 027 50417 E-mail: rowex@rowa-pharma.ie. Date of preparation (09-19) CCF No:22529

ABBREVIATED PRESCRIBING INFORMATION Product Name: Sumatran Relief 50 mg Tablets. Composition: Each tablet contains 50 mg sumatriptan (as sumatriptan succinate). Description: Pink, biconvex, oblong tablet with a break-line on both sides. Indication(s): The acute treatment of migraine attacks with or without aura. Only to be used where there is a clear diagnosis of migraine. Dosage: Only in Adults aged 18 to 65 years: Recommended adult dose is a single 50 mg tablet. If a patient responds to the first dose of sumatriptan, but the symptoms recur a second dose may be taken for the same attack but no sooner than 2 hours after the first tablet was taken. If a patient does not respond to the first dose, a second dose should not be taken for the same attack (in these cases the attack can be treated with paracetamol, acetylsalicylic acid, or non-steroidal anti-inflammatory drugs). No more than 100 mg (2 tablets) should be taken in 24 hrs. The recommended dose should not be exceeded. Contraindications: Hypersensitivity to the active substance or to any of the excipients or sulphonamides; Should not be used prophylactically; A history of myocardial infarction, ischaemic heart disease or coronary vasospasm (Prinzmetal’s angina;) Peripheral vascular disease; Symptoms or signs consistent with ischaemic heart disease; A history of stroke (cerebrovascular accident (CVA)) or transient ischaemic attack (TIA) or cardiac arrhythmia; Renal or hepatic impairment; Hypertension or a history of hypertension; History of seizures or other risk factors which lower the threshold; Concomitant administration of preparations containing ergotamine or ergotamine derivatives (including methysergide) or any triptan/5-hydroxytryptamine 1 (5-HT1) receptor agonist; Concomitant use of monoamine oxidase inhibitors and the use of sumatriptan within 2 weeks after discontinuation of therapy with monoamine oxidase inhibitors; Management of basilar, hemiplegic or ophthalmoplegic migraine. Warnings and Precautions for Use: Only for use where a clear diagnosis of “migraine” has been made by a doctor initally. For pharmacy supply, patients should have an established pattern of migraine (a history of five or more migraine attacks occurring over a period of at least 1 year). Migraineurs whose typical headaches persist for longer than 24 hours, who experience four or more migraine attacks per month, or in whom the pattern of symptoms has changed or whose attacks have become more frequent, more persistant, or more severe, or who do not recover completely between attacks, should seek advice from their doctor. Following administration, sumatriptan can be associated with transient symptoms including chest pain and tightness, which may be intense and involve the throat. Where such symptoms are thought to indicate ischaemic heart disease, no further doses of sumatriptan should be given. A medical evaluation should be obtained immediately. Note that migraineurs may be at increased risk of certain cerebrovascular events (e.g. CVA, TIA). Medication should be stopped if they experience atypical symptoms (i.e. unilateral motor weakness, double vision, ataxia etc.) and they should seek medical advice. Not to be used in migraineurs without a prior cardiac risk assessment by a doctor or pharmacist. As migraine is a chronic condition, cardiovascular risk should be evaluated

regularly in patients who use sumatriptan intermittently, over the longer term. Sumatriptan is effective for migraine occurring during menstruation, but women with migraine who are taking the combined oral contraceptive have an increased risk of stroke and should seek advice from their doctor if migraine attacks started recently (within the last 3 months), migraine symptoms have worsened, or they have migraine with aura. Not to be given to patients (especially postmenopausal women and males over 40 years of age) with risk factors for ischaemic heart disease, including those patients who are heavy smokers or users of nicotine substitution therapies, without prior cardiovascular evaluation. Risk factors for heart disease include hypercholesterolaemia, regular smoking, marked obesity, diabetes or a family history of early heart disease (father/brother developed heart disease before the age of 55, mother/sister developed heart disease before the age of 65). The diagnosis of medication overuse headache (MOH) should be suspected in patients who have frequent or daily headaches despite (or because of) the regular use of headache medications (e.g. triptans, opioids, ergotamine or combination of these drugs for 10 days or more per month). Patients with headache present on more than or 15 days per month for three months whose headache has developed or markedly worsened during medication overuse should be referred to their doctor for further management. Contains lactose monohydrate. Interactions: There have been rare post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the use of SSRIs and sumatriptan. Serotonin syndrome has also been reported following concomitant treatment with triptans and SNRIs and is also a risk with concomitant use with lithium. Undesirable effects may be more common during concomitant use with herbal preparations containing St John’s Wort (Hypericum perforatum). Pregnancy and Lactation: Not to be used during pregnancy or breast-feeding unless on the advice of their doctor. Ability to Drive and Use Machinery: Drowsiness, dizziness and weakness may occur as a result of migraine or its treatment with sumatriptan. This may influence the ability to drive and to operate machinery. Undesirable Effects: Common: Dizziness, drowsiness, sensory disturbance including paraesthesia and hypoaesthesia. Transient increases in blood pressure arising soon after treatment, flushing. Dyspnoea. Nausea and vomiting occurred in some patients, but it is unclear if this is related to sumatriptan or the underlying condition. Sensations of heaviness (usually transient and may be intense and can affect any part of the body including the chest and throat), myalgia. Pain, sensations of heat or cold, pressure or tightness (these events are usually transient and may be intense and can affect any part of the body including the chest and throat); feelings of weakness, fatigue (both events are mostly mild to moderate in intensity and transient). Marketing Authorisation Holder: Rowex Ltd., Bantry, Co. Cork. Marketing Authorisation Number: PA 711/272/1. 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: April 2018



Childhood Vaccinations:

Not a Given Part Two As discussed previously in part one of this educational piece, it is up to new parents to bring their children for the recommended vaccinations to protect them from vaccine preventable diseases. It is important as pharmacists that we have a working knowledge of what vaccines are required and when, so we can help expecting mothers and new mothers plan for the vaccinations. Table 1 (below) shows the current vaccination schedule from birth to 1 year old in Ireland as recommended by the National Immunisation Advisory Committee and provided by the HSE1. The 6 in 1 vaccine protects against diphtheria, hepatitis B, haemophilus influenza type b (Hib), pertussis (whooping cough), polio and tetanus infection. As well as being able to discuss the above with new parents, pharmacists can refer them to download the booklet “Your child’s immunisation – A guide for parents” from the HSE website or print a copy of the short guide to give to them yourself. Herd (Community) Immunity The early childhood vaccination schedule is designed to give maximum protection for our children from vaccine preventable diseases and our population from diseases that were once prevalent and now are almost eradicated thanks to vaccinations.

schedule herd immunity is only achieved when 95% of children have been vaccinated. The more children that are immunised the lower the risk of infection for all. However uptake of MMR vaccine, though reaching 92% has never reached 95%. Therefore, in Ireland though measles is no longer endemic, outbreaks of measles still occur among those who are not vaccinated or incompletely vaccinated when the disease is brought into the country. The success of vaccines in reducing the incidence of all vaccine preventable diseases, like measles is remarkable. Vaccination was arguably the most significant advancement in medicine of the twentieth century. The measles vaccine for example resulted in a 79% reduction in measles deaths between the year 2000 and 2015 worldwide, preventing an estimated 17 million deaths2.

generation to vaccinate their children and reach herd immunity. Currently in the 21st century we are now experiencing another level of misinformation or “fake news” as it were. The largest number of voices and points of view can now reach the maximum number of minds in the minimum time frame. Through attacks on vaccines and social media scare stories, we are dealing with a very real risk to our public health. Getting the right information to the public in the most balanced way possible is vital. And it is our job as key health professionals in the community to do this. Social media scares and anti-vaccine attitudes

Recently we received a factsheet from the HSE on the HPV vaccine. This was to prepare us as pharmacists for requests for information about the HPV vaccine The success of reducing these children might be getting when dangerous and infectious starting secondary school. When diseases from Ireland is really well I read the evidence for the use illustrated in the diagram below, of the HPV vaccine in secondary The success of a vaccination wherePart we can Childhooddepends Vaccinations: Not a Given Twosee the progress schools and the positive effect it programme on bringing made from 1950’s Ireland to the can have on reducing cancers, I population immunity to a level current day (Fig. 1, page 52). As imparts discussed inthat part one of this educational piece, it is up was to new totobring theirit. veryparents motivated promote that herdpreviously immunity to The evidence is overwhelmingly However, these diseases have population. This is achieved when children for vaccinations. It is important as pharmacists that we have a working knowledge of what in favour of the HPV vaccine and not gone away and now with a the bacteria or virus runs out of vaccines are required and when, so we can help expecting mothers new mothers plan for and the the benefits to the individual resurgence of measles disease and and non-immune hosts to infect and population are huge. It also seems deaths in Europe we must protect thus is not passed on and leaves vaccinations. to be one of the safest and wellthe progress we have made by the population entirely. For the strongly encouraging vaccines the Irish vaccines have. Table 1inshows thechildhood current vaccination schedule fromeach birthnew to 1 year studied old in Ireland aswe recommended

by the HSE1.

Table 1 Immunisation Schedule

Table 1 Immunisation Schedule Age 2 Months 4 Months 6 Months 12 Months 13 Months

Visit 1. 3 injections, 1 oral drop 2. 2 injections ,1 oral drop 3. 3 injections 4. 2 injections 5. 2 injections

Vaccination 6 in 1, Men B, PCV, Rotavirus 6 in 1, Men B, Rotavirus 6 in 1, PCV, Men C MMR, Men B Hib/Men C, PCV

The 6 in 1 vaccine covers diphtheria, hepatitis B, haemophilus influenza type b (Hib), pertussis

PHARMACYNEWSIRELAND.COM (whooping cough), polio and tetanus.

Author: David Reilly, Supervising Pharmacist with McCauley Chemist Navan Shopping Centre. David worked as a community pharmacist in the UK for seven years before returning to practice in Ireland in 2016

The HSE has extolled the individual benefits to the child and the population benefits of achieving herd immunity in its recent campaign. And yet you will in the coming weeks find at the gates of every school in the country, parents who have concerns about the vaccine and even some who will not allow their children to be vaccinated against HPV. This may be because of old stories re-emerging recently in social media about the HPV vaccine causing the following: Postural orthostatic tachycardia syndrome (POTS) and Complex regional pain syndrome (CRPS). The HSE say they are aware of these stories circulating. To reaffirm the lack of evidence for a link they have stated in the factsheet that the European Medicines Agency (EMA) had already conducted research in 2015 and found there was no evidence that the HPV vaccine leads to an increase in these conditions. This is another example of a link between a vaccine and a condition, based on little or no evidence. The worrying thing is that the story still needs to be addressed even though it was proved untrue four years ago. “Anti-vaxxer” is an umbrella term I have heard several times in the past few years on various platforms. Claims from “anti-vaxxer groups may be totally unscientific and unfounded, but the power of social media and the confusion that a careless and unfounded claim can create through this medium means these anti-vaccine attitudes can be found in places beyond the internet. In our schools for example. I have

Primary Childhood Immunisation Schedule Children born on or after 1 October 2016 Age








Visit 1

6 in 1+PCV+MenB+Rotavirus 3 Injections+Oral Drops

Visit 2

6 in 1+MenB+Rotavirus 2 Injections+Oral Drops

Visit 3

6 in 1+PCV+MenC 3 Injections

No Rotavirus vaccine on or after 8 months 0 days





Visit 4

MMR+MenB 2 Injections

Visit 5

Hib/MenC+PCV 2 Injections

Remember to give your baby 3 doses of liquid infant paracetamol after the 2 and 4 month MenB vaccines. 1. Give 2.5 mls (60 mg) of liquid infant paracetamol at the time of the immunisation or shortly after. 2. Give a second dose of 2.5 mls (60 mg) 4 to 6 hours after the first dose. 3. Give a third dose of 2.5 mls (60 mg) 4 to 6 hours after the second dose.

Remember five visits to your GP (doctor)

www.immunisation.ie Order code: HNI00984



Vaccines Work

Figure 1 Pre and post vaccination Ireland

These bubbles are sized to the annual number of cases in Ireland during the pre-vaccine era versus 2018. It is clear that significant progress has been made. However, we must not become complacent. We need to keep vaccine update at 95% to stop outbreaks of these serious infectious diseases.

Ireland, 1950 (annual disease cases in Ireland)

Polio 500

Ireland, 2018 (annual disease cases in Ireland)

Rubella 5,000 Rubella 5

Meningococcal 587

Diphtheria 500*

Polio 0 Diphtheria 0

Meningococcal 89

Measles 82

Measles 15,000 Pertussis 117

Pertussis 5,000

*The figure refers to numbers of diptheria cases in 1948 as pre-vaccine data is not available

had several recent reports of parents who have expressed that they will not let their child get the HPV vaccine as they don’t believe it is safe. These individuals may not think of themselves as “anti-vaxxers” as such but it is not difficult to imagine that their attitudes have been unwittingly or deliberately influenced using social media, by anti-vaccination groups or even individuals. The temptation for the scientific community is to be dismissive of people who have concerns about the safety of vaccines. Based on the evidence in the literature and my understanding of how vaccines work I am confident to advise any patient that they are very safe and very effective. But it is important we are not dismissive, as healthcare professionals, and that we approach these patients with even more care and an over-abundance of even-handed information. We must be impartial and lay the evidence before a patient as it is. In order to at least

give them a chance to decide in an informed manner. The HSE have done a great job of using this approach in their “Facts about Vaccines for students starting secondary school 2019” factsheet3. The way the information is displayed is excellent and easy to follow. The negative effects of the disease are listed and compared to the negative side effects of the vaccine for people to decide, which is worse? It is clear the effects of the disease are far worse. This is exactly the approach pharmacists should use when advising patients on vaccinations or trying to inform a parent who has a negative attitude to vaccinations. Vaccinating in the pharmacy Finally, the question comes to mind, is providing the early childhood vaccinations in pharmacy a possibility for the future? Could we deliver a more cost effective and more easily accessible service in pharmacy


for the early childhood vaccination schedule? There would have to be a huge shift in attitudes of stakeholders and support in the form of remuneration to make this happen. Perhaps even a huge shift in the view of pharmacists themselves, many of whom may feel uneasy even with current vaccination services offered. Do we feel confident as a profession to deal with an allergic reaction in a young baby or child? Understandably there would be concerns about how we would be supported or remunerated for such a service. It is an important debate, one that goes to the heart of what we see as the future of the profession, though perhaps not one for right now. However, in my opinion the more we can expand our role in the arena of vaccinating the better. Pharmacy in Ireland has delivered well in the provision of the flu vaccine. We are good value for the HSE and patients are now beginning to see us as the natural

choice for their flu vaccine. We all deserve a pat on the back for the progress made in the flu service. This year’s expansion to include all patients over ten years of age is another encouraging development. Pharmacies also have a potentially big role to play in providing travel vaccinations and clinics as discussed in this publication, in the July CPD article by Alan Moran of Hibernian Healthcare. Once all of these services are well established and successful, we should have the structures in place to expand into childhood vaccines and thustake another massive step forward in securing our importance in the community. References 1. https://www.hse.ie/eng/health/ immunisation/pubinfo/pcischedule/ immschedule/ 2. https://www.ipha.ie/getattachment/ Publications-Submissions/IPHApublications/IPHA-Vaccines-for-Life. pdf.aspx 3. http://www.who.int/vaccine_safety/ committee/topics/hpv/en/

News Urgent Pharmacy Recall The Health 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 Those who are in the possession of any Emerade pen, should be advised to return it to their local pharmacy where they can receive a replacement alternative product. In line with existing medical guidelines, it is advised that patients continue to carry two pens at all times. Emerade is administered through a pre-filled pen, or autoinjector. The reason for the recall is that a number of reports of failure to activate have been received on other markets. The cause of these activation failures and the defect rate remain unknown. This is a separate issue to a potential needle blockage issue for Emerade pens which was previously communicated by the HPRA in July 2018 and July 2019. It is possible, however, for both defects to be present in a pen with the potential for failure of administration of this potentially life-saving medication.


Over Half of Consumers not getting Flu Vaccine As September came to an end, and the new flu season arrived swiftly, Boots Pharmacy have announced the commencement of its annual flu vaccination service. This comes as new research by the pharmacy reveals over half of people in Ireland have never been vaccinated against the flu with 52% of those surveyed not planning of getting vaccinated for the 19/20 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. 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 longterm 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*. Caoimhe McCauley, Director of Pharmacy, Boots Ireland, commented, “Getting vaccinated against the flu each season is the first step in staying healthy during the winter months. Some patients may be eligible for a free vaccine depending on their HSE scheme eligibility and risk factors. The consultation appointment can be booked on-line with walk-ins also welcome. The vaccination can help to prevent the spread of the virus to both you and those around you, helping protect those who are vulnerable against flu this season. Our in-store pharmacists

are available to answer any questions about the vaccination service and give advice on general winter wellness. More information on the service is also on Boots.ie.” 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. [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/

Men at greater Cancer risk There are stark findings for men and their chances of surviving cancer in a new report out at the start of this month (October), warned the Irish Cancer Society. Donal Buggy, Head of Services for the Irish Cancer Society

The Society was responding to new figures set out in the Annual Report of the National Cancer Registry which finds that men are both more likely to develop cancer and more likely to die from cancer. Reacting to the report, Donal Buggy, Head of Services for the Irish Cancer Society said, “These figures could not be clearer. Men in Ireland are much more likely to get, and die from, cancer. An estimated 12,769 males are diagnosed with an invasive cancer each year, compared to just over 11,000 for women. When adjustments for age are made, this means an increased risk of getting cancer of almost a quarter. “If we look at mortality, the numbers are even more worrying. The report states that the risk of

dying from cancer was about 32% higher for men than for women. “It is vital that we all take collective action on it. Men’s health needs a renewed focus and funding by the State for cancer prevention programmes. We also need further research into what the barriers are

for men when it comes to choosing healthy behaviours or accessing healthcare and screening.” After non melanoma skin cancer, the most common cancers in men are prostate cancer, bowel cancer and lung cancer. They account for over 50% of cases every year.


Topic Team Training – Fish Oils 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. decided to phase it out as a welfare food. Fish oils are most commonly used in supplements for conditions related to the heart and blood system. They may also be used for many kidney-related problems. Importance of Fish Oils There is little doubt that n-3 fatty acids have an important role in nutrition. They are significant structural components of the phospholipid membranes of tissues throughout the body, particularly in the brain and retina.

Key Points: Check your pharmacy team are aware and understand the following key points:

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 Fish Oils. Fish oil's popularity has soared in recent years, propelled by research that suggests consuming omega-3 fatty acids can ward off heart disease. Community pharmacists play an important role in helping patients make informed decisions about fish oil and omega-3 supplementation. But with hundreds of OTC options available (and labels claiming that

the supplements treat everything from bipolar disorder to menstrual cramps) how can pharmacists distinguish between them to help patients make the best choice? Sold by pharmacists since the early years of the 20th century, cod liver oil is one of the oldest and most well-known food supplements. The oil first gained its reputation as an effective preventative against rickets because of its high vitamin D content and it was taken by generations of children, decreasing in popularity only when, in the 1960s, the British government

Consider:  Am I/my team familiar with the current trends in fish oils and supplements  Am I/my team aware of the health conditions which could benefit from fish oil supplements?  Am I/my team aware of customer groups who would benefit from supplementation?  Am I aware of the supplements category in-store offering?  Am I aware of the drug interactions?  Am I/my team aware that fish oil supplements should be pregnancy-specific to avoid high doses of vitamin A, and breastfeeding women should continue with vitamin D and fish oil supplementation.


 Those who could benefit from an increased intake of n-3 fatty acids. The typical Irish diet contains relatively low amounts of these.  Fish oil appears to reduce the risk of CHD. It may help to reduce the risk of thrombosis (by increasing bleeding tendency), reduce blood levels of triacylglycerols, prevent atherosclerosis and arrhythmias and reduce blood pressure.  Fish oil may have a role in various mental disorders, such as depression, schizophrenia and Alzheimer’s disease, but research in this area is in its infancy.  Fish oil supplements appear, in general, to be safe. However, patients on anticoagulants or with blood clotting disorders should be monitored.  Fish oil could have beneficial effects in inflammatory conditions such as rheumatoid arthritis, Crohn’s disease and ulcerative colitis, but evidence of any benefit in asthma and psoriasis is poor.

Because of their role in cell membranes, n-3 fatty acids are essential for the formation of new tissue and are therefore important for development and growth (eg, during foetal and infant development). During the last three months of pregnancy, n-3 fatty acids rapidly accumulate in the brain and nervous system of the foetus. Babies born pre-term may miss some of this period and could have a suboptimal ability to synthesise long chain fatty acids. Thus, they may require these to be provided pre-formed. Long chain n-3 fatty acids (and other fatty acids) are present in breast milk and European Union regulations now allow their addition to infant formulas.

Actions:  Include POS with associated conditions relating to this category  Ensure efficient sign posting to further help and advice or reputable sources for fish oils  Ensure there is a discreet area in which staff can assist with advice and product selection  Keep products merchandised together, along with related products to help build sales  Ensure the team are able to communicate lifestyle advice  Train the team to meet all the above considerations


CarePlus Conference

CarePlus Pharmacy looks to the Future CarePlus Pharmacy held their fourth annual conference in Carton House in Maynooth, Co. Kildare on Sunday 15th September. Dr Nina Byrnes, Media Medical Expert our screens as co-presenter of the popular RTÉ series Health of the Nation. Since then she has become a familiar face in Irish media and is a well-known and respected Media Medical Expert.

CarePlus Pharmacy hosted their fourth Annual Conference in Carton House in Maynooth, Co. Kildare on Sunday 15th September. Since opening the first CarePlus Pharmacy in Cobh in February 2015, there are now over 60 CarePlus Pharmacies operating across Ireland. The theme of this year’s conference was FutureSense; where the focus of the day was looking at the evolution of Pharmacy and how innovation is playing a key role in shaping the future of the industry. Dr Nina Byrnes The conference was opened by MC Jonathan Healy from Newstalk, who introduced the first speaker of the day, Dr Nina Byrnes. Dr Nina Byrnes first appeared on

She is also part of the team for Doctor in the House on Virgin Media One. In the show she uses her expertise to identify key and potential health risks, and ensures each household wakes up to the health challenges they are facing. Nina’s work encompasses all areas of general family practice, but her special interests are cardiovascular and preventive health, women’s health and lifestyle medicine. She is known for her ability to break down medical jargon and her empathetic straight-talking approach. Nina spoke about the importance of GPs and Pharmacists working together, rather than working in competition with or against one another. She spoke about the need to improve and increase the level of open communication between the two professions for the greater good of the patient.

Lucy Kennedy, Eugene Daly, Paula Keating and Niamh Lynch


CarePlus Plenary Session Next up, there was a CarePlus Plenary Session on stage hosted by CEO, Simon Healy, joined by Breege McTigue, Head of Customer Engagement; Lee-Ann McCarthy, Head of Marketing and Niamh Lynch, Commercial Director. The Management Team set out their 5 year vision for the company, strategic projects and officially unveiled their new Generation 2 of CarePlus Pharmacy. Business Networking Session After a break for lunch, the attendees reconvened in the Conference Centre for a networking “speed dating” session. Here, suppliers each had a table and CarePlus Pharmacy staff and Pharmacists moved around from table to table and supplier to supplier, spending 5 minutes with each one, during which time the suppliers shared key information and points about their product offering or the company itself. Pharmacy staff were free to ask any questions to suppliers before moving onto the next supplier stand. At three intervals during the Business Networking session, Enda McNulty’s Performance Team hosted 2-minute energy boosting sessions which involved a mix of different exercises to keep the body and mind alert.

After the networking session, Axium Buying Group Managing Director, John Carroll, gave an update about about Axium as the company celebrated its 10th year in business this year. Stuart Lancaster The final speaker of the day was former Head Coach for the England Rugby Football Union, Stuart Lancaster. He took the England Team to the World Cup in 2015 and faced some harsh ups and downs during this process. Learning valuable lessons of leadership, management and identity, Stuart shared what he has learned from the field into the boardroom. Stuart now coaches for Leinster Rugby in Dublin. Learning from his experiences, he shared tips on creating a positive team culture, implementing change within a team, achieving buy-in from players and process versus outcome. The ultimate leadership speaker who has lived through the highs and the lows and has extensive leadership, coaching and management experience, Stuart is the perfect keynote to end the conference on. AWARDS As the afternoon session drew to a close, attendees got ready for the evening ahead, starting with

Kathleen Healy, Dervilla Kirwan and Eugene Daly

51 a drinks reception, followed by dinner and the Annual CarePlus Awards Ceremony. Lucy Kennedy (from the renowned TV series “Living with Lucy”) was the host for the awards ceremony for the second year running. For the third year, CarePlus is recognising CarePlus Pharmacies across Community participation, Customer Service Excellence, Digital Baby Category, Build & Boost Category, Derma Category, Innovation and Supplier of the Year. The winners of each award were as follows:

4. Baby Category Development Award of the Year (sponsored by Teva) – Spooner’s CarePlus Pharmacy, Templeogue, Co. Dublin 5. Build + Boost Category Development Award of the Year (sponsored by Naturalife) – Kilcock CarePlus Pharmacy, Kilcock, Co. Kildare 6. Derma Category Development Award of the Year – Park CarePlus Pharmacy, Cabinteely, Dublin 7. Innovation Award of the Year (sponsored by Rowex) – Keane’s CarePlus Pharmacy

1. 2019 Community Award of the Year (sponsored by Perrigo) – Mullins CarePlus Pharmacy, Salthill, Co. Galway

8. CarePlus Supplier of the Year Perrigo

2. Customer Service Excellence Award of the Year (sponsored by Valeo Healthcare) – Keating’s CarePlus Pharmacy

A big congratulations to all the winners on the evening and to all in attendance for supporting their wins.

3. Digitally Proactive Award of the Year (sponsored by Retail Solutions) – Conaty’s CarePlus Pharmacy, Dunshaughlin, Co. Meath

After the awards ceremony came a special performance from The High Tails, followed by fantastic entertainment from Joe Petit and his band.

9. Axium Supplier of the Year Teva

CarePlus Stuart Lancaster

CarePlus 'speed dating'

Lucy Kennedy & Mullins CarePlus Pharmacy - award winners



CarePlus Conference

Keane’s CarePlus Pharmacy – Award winners

The High Tails

Kelly O'Carroll, Katie Cashman, Kathleen Healy and Niamh Bourke

Lucy Kennedy, Paul Neill and John Carroll

Lucy Kennedy, Cormac Spooner, Eleanor Spooner and Paul Neill

Lucy Kennedy, KilcockCarePlus Pharmacy Award winners and Niamh Lynch



S D im iff p er le en t!

Added Extra Added Confidence Adex Gel Adex Gel does not contain topical corticosteroids


Adex Gel offers an effective, simple and different approach to the treatment and management of mild to moderate eczema, contact dermatitis and psoriasis. Adex Gel emollient can help reduce inflammation and redness because Adex Gel provides Added Extra anti-inflammatory action.

Recommend Adex Gel and see the results

Essential Information: Adex™ Gel Presentation: White opaque gel. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and/or inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Directions: Adults, the elderly and children from 1 year of age. For generalised all-over application to the skin. Apply three times daily or as often as needed. Adex Gel can be used for as long as necessary either occasionally, such as during flares, or continuously if the added anti-inflammatory action is beneficial. Seek medical advice if there is no improvement within 2-4 weeks. Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. Keep away from the eyes, inside the

AdexGel.ie for further information

nostrils and mouth. Temporary tingling, itching or stinging may occur with emollients when applied to damaged skin. Such symptoms usually subside after a few days of treatment, however, if they are troublesome or persist, stop using and seek medical advice. Rarely skin irritation (mild rashes) or allergic skin reactions can occur on extremely sensitive skin, these tend to occur during or soon after the first few uses and if this occurs stop treatment. As safety trials have not been conducted during pregnancy and breast-feeding, seek medical advice before using this product. Care should be taken as emollients which soak into clothing, pyjamas, bedlinen etc. can increase the flammability of these items. Patients should avoid these materials coming into contact with naked flames or lit cigarettes etc. As a precaution, dressings and clothing, etc., should be changed frequently and laundered thoroughly.

Ingredients: Carbomer, glycerol, isopropyl myristate, liquid paraffin, nicotinamide, phenoxyethanol, sorbitan laurate, trolamine, purified water. Pack sizes: 100g tube and 500g pump pack. Legal category: Class III medical device with an ancillary medicinal substance. Further information is available from the manufacturer: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: August 2017. ‘Adex’ is a trademark. Adverse events should be reported to Dermal.



Managing Psoriasis in Winter


his time of year can be more severe on those suffering from psoriasis. Some people with psoriasis notice seasonal changes in the severity of their condition, sometimes experiencing a worsening of symptoms in winter.

Over these months, things like dry air from central heating and reduced exposure to sunlight can contribute to this deterioration. More generally, psoriasis tends to improve in warmer climates and worsen in colder ones. Psoriasis is more than just a skin disease. It increases the risk of developing a wide range of other inflammation-related conditions, while its visible nature often leads to anxiety and depression for sufferers. Although there is no cure as yet, there are a range of effective treatment options available. Treating psoriasis is important for good disease management, as well as general health.

28 days. In psoriasis, this process is accelerated, only taking about 4 days. The new skin cells reproduce too quickly and move toward the skin surface in an immature form, causing a build-up of silvery scale (dead skin cells). There is also an increased blood flow to the skin and a thickening of the epidermis, leading to the development of red, raised plaques (a plaque is a raised, red, scaling, well defined area more than 1cm in size).


Psoriasis is a condition which tends to run in families. Several different genes have been identified but the exact way in which the disorder moves from generation to generation has not yet been established.

Psoriasis affects at least 73,000 people in Ireland. Normally, skin cells reproduce and mature as they move from the deeper layers of the epidermis (the outermost layer of the skin) to the surface. This process is called proliferation and usually takes approximately

Environmental factors can also play a role in developing the condition. In some cases, emotional stress (like moving house, a divorce or bereavement), infection (such as a strep throat), injury to the skin or certain medications can trigger the


first episode of psoriasis, while certain lifestyle factors (such as heavy drinking and smoking) may worsen it. Appearance and Sites Plaque psoriasis is the most common form of psoriasis, affecting approximately 90% of patients. The plaques can vary in number, size, and location but the sites most frequently affected, are the knees, elbows, scalp and sacrum (lower back). The plaques are often itchy and painful, and can crack and bleed. The extent of the skin surface involved can range from 1 to 100%. Erythrodermic psoriasis is the term used to describe instances where almost the entire body surface is involved, and is characterised by red skin with a diffuse, fine, peeling scale. It is quite rare, generally occurring in those who have unstable plaque psoriasis. Guttate psoriasis usually has a sudden onset with the widespread appearance of small, red teardrop

shaped patches less than 1.5cm in size. The onset is often preceded by a streptococcal throat infection. In many cases, the condition disappears by itself after a few weeks or months. Flexural psoriasis occurs in skin folds (flexures), such as under the breasts, in the armpits or the groin. The plaques are usually red, smooth and shiny. There is very little or no scale, due to the presence of sweat, which moistens the keratin (dead skin cells) and prevents scaling. The scalp is one of the most common sites to be affected by psoriasis, and sometimes it is the only area of involvement. It usually extends to, or just beyond the hairline and commonly occurs behind the ears. While the palms of hands and soles of feet may be involved in both plaque and guttate psoriasis (and on occasion, may only affect these areas), another form of psoriasis that is confined to these areas, is called localized pustular psoriasis. The palms and/or soles become

Superior results for your patients with moderate to severe plaque psoriasis1,2* 5 years of sustained efficacy and a consistent safety profile3

Complete Treatment† Complete Confidence‡ ▼

ABBREVIATED PRESCRIBING INFORMATION ▼ COSENTYX 150 mg solution for injection in pre-filled pen. This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 of the SmPC for how to report adverse reactions. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: COSENTYX 150 mg solution for injection in pre-filled pen. Therapeutic Indications: The treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy; the treatment of active ankylosing spondylitis in adults who have responded inadequately to conventional therapy; the treatment, alone or in combination with methotrexate (MTX), of active psoriatic arthritis in adult patients when the response to previous disease modifying anti rheumatic drug (DMARD) therapy has been inadequate. Dosage & Method of Administration: Plaque Psoriasis: Recommended dose in adults is 300 mg given as two subcutaneous injections of 150 mg. Dosing at Weeks 0, 1, 2 3 and 4, followed by monthly maintenance dosing. Ankylosing Spondylitis: The recommended dose is 150 mg by subcutaneous injection with initial dosing at Weeks 0, 1, 2 3 and 4, followed by monthly maintenance dosing. Psoriatic Arthritis: For patients with concomitant moderate to severe plaque psoriasis or who are anti TNFα inadequate responders, the recommended dose is 300 mg by subcutaneous injection with initial dosing at Weeks 0, 1, 2 3 and 4, followed by monthly maintenance dosing. Each 300 mg dose is given as two subcutaneous injections of 150 mg. For all other patients, the recommended dose is 150 mg by subcutaneous injection with initial dosing at Weeks 0, 1, 2, 3 and 4, followed by monthly maintenance dosing. Based on clinical response, the dose can be increased to 300 mg. For all of the above indications, available data suggest that a clinical response is usually achieved within 16 weeks of treatment. Consideration should be given to discontinuing treatment in patients who have shown no response up to 16 weeks of treatment. Some patients with initially partial response may subsequently improve with continued treatment beyond 16 weeks. The safety and efficacy in children below the age of 18 years have not yet been established. Contraindications: Severe hypersensitivity reactions to the active substance or to any of the excipients. Clinically important, active infection (e.g. active tuberculosis). Warnings/Precautions: Infections: Cosentyx has the potential to increase the risk of infections. Serious infections have been observed in patients receiving Cosentyx in the post-marketing setting. Infections observed in clinical studies are mainly mild or moderate upper respiratory tract infections such as nasopharyngitis not requiring treatment discontinuation. Non serious mucocutaneous candida infections more frequently reported for secukinumab than placebo in psoriasis clinical studies. Caution in patients with a chronic infection or a history of recurrent infection. Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur. If a patient develops a serious infection, close monitoring and discontinue treatment until the infection resolves. Should not be given to patients with active tuberculosis. Anti tuberculosis therapy should be considered prior to initiation in patients with latent tuberculosis. Inflammatory bowel disease: Cases of new or exacerbations of Crohn’s disease and ulcerative colitis have been reported. Caution should be exercised when prescribing to patients with inflammatory bowel disease including Crohn’s disease and

ulcerative colitis. Patients should be closely monitored. Hypersensitivity reactions: In clinical studies, rare cases of anaphylactic reactions have been observed in patients receiving Cosentyx. If an anaphylactic or other serious allergic reactions occur, administration should be discontinued immediately and appropriate therapy initiated. Latex-sensitive individuals: The removable cap of the Cosentyx pre filled pen contains a derivative of natural rubber latex. Vaccinations: Live vaccines should not be given concurrently with Cosentyx. Patients may receive concurrent inactivated or non live vaccinations. Concomitant immunosuppressive therapy: Use in combination with immunosuppressants, including biologics, or phototherapy have not been evaluated. Interactions: Live vaccines should not be given concurrently with Cosentyx. In a study in subjects with plaque psoriasis, no interaction was observed between secukinumab and midazolam (CYP 3A4 substrate. No interaction seen when administered concomitantly with methotrexate (MTX) and/or corticosteroids. Fertility, Pregnancy and Lactation: Women of childbearing potential should use an effective method of contraception during treatment and for at least 20 weeks after treatment. It is preferable to avoid the use of Cosentyx in pregnancy as there are no adequate data from the use of secukinumab in pregnant women. It is not known whether secukinumab is excreted in human milk. A decision on whether to discontinue breast feeding during treatment and up to 20 weeks after treatment or to discontinue therapy with Cosentyx must be made taking into account the benefit of breast feeding to the child and the benefit of Cosentyx therapy to the woman. The effect of secukinumab on human fertility has not been evaluated. Undesirable Effects: Very common (≥1/10); Upper respiratory tract infections. Common (≥1/100 to <1/10); Oral herpes, rhinorrhoea, diarrhoea, urticaria Uncommon (≥1/1,000 to <1/100); Oral candidiasis, tinea pedis, otitis externa, neutropenia, conjunctivitis. Rare (≥1/10,000 to <1/1,000) Anaphylactic reactions. Please see Summary of Product Characteristics for further information on undesirable effects. Legal Category: POM. Marketing Authorisation Holder: Novartis Europharm Ltd, Vista Building, Elm Park, Merrion Road, Dublin 4, Ireland. Marketing Authorisation Numbers: EU/1/14/980/004-005. Date of Revision of Abbreviated Prescribing Information: October 2018. Full prescribing information is available upon request from: Novartis Ireland Limited, Vista Building, Elm Park Business Park, Elm Park, Dublin 4. Tel: 01-2204100 or at www.medicines.ie. Detailed information on this product is also available on the website of the European Medicines Agency http://www.ema.europa.eu ▼ This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Adverse events should be reported. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517; Website: www.hpra.ie E-mail: medsafety@hpra.ie. Adverse events should also be reported to Novartis Ireland by calling 01-2080 612 or by email to: drugsafety.dublin@novartis.com

* Secukinumab was shown to be superior to ustekinumab in clearing skin of subjects with moderate to severe plaque psoriasis in 52-week, double-blind study, in which subjects were randomized 1:1 to subcutaneous injection of secukinumab 300 mg or ustekinumab per label. Primary end point was 90% or more improvement from baseline Psoriasis Area and Severity Index score (PASI 90) at week 16.1 Secukinumab was shown to be superior to ustekinumab in clearing skin of subjects with moderate to severe plaque psoriasis in a 52-week, double-blind study, in which subjects were randomized 1:1 to subcutaneous injection of secukinumab 300 mg or ustekinumab per label. Co-primary endpoints were 90% or more improvement from Baseline Psoriasis Area and Severity Index (PASI 90) and Investigator’s Global Assessment (IGA) mod 2011 0/1 (clear or almost clear) response rates at Week 12.2 † Complete refers to the fact that Cosentyx has demonstrated efficacy in various manifestations of psoriasis (psoriatic arthritis, nail, scalp and palmoplantar)4-6 ‡ Used in over 150,000 patients and no new safety signals seen in clinical studies up to 5 years3,7 References: 1. Thaçi D et al. J Am Acad Dermatol 2015; 73(3): 400-409. 2. Bagel J et al. Dermatol Ther 2018 ;8(4):571-579. doi: 10.1007/s13555-018-0265-y. 3. Bissonnette et al. J Eur Acad Dermatol Venereol 2018: doi: 10.1111/jdv.14878. 4. Kavanaugh A et al. Arthritis Care Res 2017; 69; 347-355. 5. Reich et al. Poster 7382 presented at AAD 2018. 6. Cosentyx SPC, Novartis Ireland. 7. Novartis (15 May 2018). Novartis ARROW trial to assess mechanistic superiority of direct IL-17A inhibition (Cosentyx) over IL-23 inhibition (Tremfya) [press release]. https://www.novartis.com/news/media-releases/novartis-arrow-trial-assess-mechanisticsuperiority-direct-il-17a-inhibition-cosentyxr-over-il-23-inhibition-tremfyar Accessed 10 January 2019. Date of Preparation: January 2019 IE02/COS18-CNF043a

Scalp Psoriasis Guidance red and scaly, with white/yellow sterile pustules (blisters of noninfectious pus). Generalised pustular psoriasis is extremely rare. It can occur on any part of the body and is characterised by the development of white/yellow sterile pustules, on a background of red skin. It is not an infection and is not contagious. It tends to be preceded by other forms of psoriasis and is often trigged by an infection, or the withdrawal of certain medication. TREATMENT TIPS IN WINTER 1) Emollient therapy

the right emollient is often a matter of trial and error – the best emollients are those that sufferers prefer to use and will continue to use every day. 4) Applying emollients to the skin Sufferers should always use a clean spoon or spatula to prevent contamination. Emollients should be applied in a smooth, downward motion, in the direction of hair growth, after a bath/shower and before going to bed. 5) Treatment options for psoriasis

While the treatment of psoriasis depends on its severity and location, the use of emollients (commonly known as moisturisers), and emollient wash products (used instead of soap and shower gel), play an important, but often undervalued, role in management. Used every day, emollients help to soften the scale, soothe dry, itchy skin and increase the effectiveness of prescribed treatments.

There are many effective treatment options available and sufferers should not be disheartened if at first they don’t succeed; topical treatments (preparations applied directly to the skin), phototherapy (a form of artificial ultraviolet light therapy, delivered in hospital dermatology departments), and medicine taken in tablet form or by injection.

2) Avoid ordinary soap, shower gel and bubble bath

Topical corticosteroids - these are the most common treatment for mild to moderate psoriasis. They work by slowing the production of skin cells. Topical corticosteroids range in strength from mild (hydrocortisone) to very potent (clobetasol). Overuse can lead to developing a tolerance and skin atrophy.

Winter conditions can be very drying on the skin, and soapbased products can further dry out the skin. Instead, advise on choosing soap substitutes/ emollient wash products when bathing or showering. 3) Choosing an emollient Emollients come as lotions, creams and ointments. Finding

Topical Treatments

Vitamin D analogues - the Vitamin D analogues suppress the production of skin cells. The most widely used Vitamin D analogue


is calcipotriol (Dovonex®), which is used to treat mild to moderate psoriasis. Calcipotriol generally has few side-effects if used correctly. Dovonex® now have an OTC version pharmacists can recommend to those previously diagnosed with psoriasis following a specific protocol. Dithranol - this has been used for over 50 years in the treatment of plaque psoriasis. It is effective in suppressing the production of skin cells and has no side-effects. However, it is typically only used as a short-term treatment under hospital supervision, as it stains everything it comes into contact with including skin. It is normally only applied to skin for five minutes before being washed off to reduce the risk of skin staining. Dithranol is often used in combination with phototherapy. Tazarotene - this cream contains a retinoid that slows the production of skin cells. It is used in the treatment of moderate plaque psoriasis. The most common side effect is skin irritation. Tazarotene can cause birth defects so it should be strictly avoided during pregnancy or if breastfeeding. It is not recommended for children or teenagers. Coal tar - a thick heavy oil that is probably the oldest treatment for psoriasis. How it works is not exactly known, but it reduces scaling, inflammation and itchiness. Coal Tar can stain clothes and has a very strong smell. It is often used in combination with phototherapy.

The Irish Skin Foundation (ISF) has published a new stand-alone Managing Scalp Psoriasis leaflet, with guidance on how to manage and treat what can be a very frustrating part of living with the condition. The scalp is one of the most common sites to be affected by psoriasis, and sometimes is the only area of involvement. Almost 80% of people with psoriasis will have scalp involvement at some point in their lives, and it is not unusual for the scalp to be the first site to display symptoms of psoriasis. The ISF’s health promotion team has found that scalp psoriasis is one of the most common concerns raised with them. This new guidance leaflet is the result of valued feedback from dozens of people living with psoriasis over the last six months during their outreach work. Presentation of scalp psoriasis can vary from person to person, ranging from mild psoriasis of the scalp, whilst others can experience severe scalp psoriasis. Symptoms may include; flaking, red scaly patches and intense itching. Scalp psoriasis can prove difficult to manage for obvious reasons like the presence of thick or long hair making it difficult to reach and treat. With this in mind the ISF scalp psoriasis leaflet includes a step-by-step treatment section which includes some really useful techniques sufferers can use at home to treat their scalp psoriasis with over-the-counter and prescribed treatments.

Burning questions: Upper GI Problems


pper gastrointestinal disorders are widespread but remain poorly understood by the public. So what can pharmacists do to equip patients with the necessary knowledge to take control of their symptoms?

People often confuse the symptoms of upper gastrointestinal (GI) disorders, but in the main, indigestion or dyspepsia refers to pain or discomfort in the upper abdominal area after eating, while heartburn refers to the burning pain felt behind the sternum associated with acid reflux, which is often accompanied by nausea, water brash or regurgitation of acid or bile. Dyspepsia usually occurs when stomach acid irritates the stomach lining, oesophagus or top part of the bowel, perhaps after a heavy meal, whereas most cases of acid reflux or gastro-oesophageal reflux disease (GORD) occur due to weakening of the lower oesophageal sphincter. Heartburn & Dyspepsia For anyone experiencing the discomfort associated with heartburn and dyspepsia, finding rapid relief is a top priority. Heartburn and dyspepsia are common gastrointestinal (GI) complaints that, if left unresolved, may negatively affect an

individual’s overall quality of life and restrict or limit activities or ingestion of certain foods. Because many patients elect to self-treat mild to moderate cases of heartburn and dyspepsia, pharmacists are likely to encounter patients seeking advice on the various non-prescription products available for the prevention and treatment of both conditions. Pharmacists also are instrumental in identifying patients at increased risk for developing heartburn and dyspepsia because of certain medications, medical conditions, or lifestyle habits. Heartburn, or pyrosis, is characterised as a burning sensation arising from the substernal area and moving toward the neck or throat. There are 2 main types: postprandial heartburn occurs within 2 hours after a meal, when bending over, or when lying down, and nocturnal heartburn occurs during sleep and often is responsible for interrupting it. Pharmacists should ask openended questions about concurrent

medications and supplements, such as NSAIDs, aspirin, glucosamine, and others, that may list heartburn among their side effects. Sometimes pointed questions about lifestyle can help patients select appropriate lifestyle modifications. Pharmacists should remember that for gastrointestinal reflux, certain symptoms should raise an alarm. If patients report any symptom indicative of one of these, referral to a physician is warranted. Refer those who have been self-treating unsuccessfully continuously for ≥4 weeks; are ≥45 years old with new or recently changed indigestion symptoms; have unintended weight loss in association with indigestion. Dyspepsia is pain that manifests in the gastroduodenal region. Symptoms may include postprandial fullness, epigastric pain, and burning. GORD is caused by acid leaking up from the stomach and coming into contact with the oesophagus.

While the stomach is able to withstand litres of acid without pain, the gullet is not. GORD has a significant impact on quality of life and productivity, with sufferers reporting impaired sleep and interference with social activities and work. Incidence of GORD is certainly rising as obesity rates accelerate. People are also binge drinking and eating more fatty or calorific food, which increases acidity levels and contributes to poorer digestive health. Lifestyle Issues Lifestyle modifications can help to ease the severity of symptoms of GORD and dyspepsia, although many patients will also need to take medication. For example, eating smaller, more frequent meals can help to control reflux and indigestion by reducing pressure on the abdomen, as can avoiding dietary triggers, such as coffee, alcohol, citrus fruits, chocolate and fatty foods. These may relax the lower oesophageal sphincter and/ or delay gastric emptying.

CASE STUDY The use of proton pump inhibitors among older adults with intellectual disability: A cross sectional observational study: Hadiah AlMutairi, School of Pharmacy, Trinity College Dublin; Máire O'Dwyer, School of Pharmacy, Trinity College Dublin; Mary McCarron, Faculty of Health Sciences, Trinity College Dublin; Philip McCallion, School of Social Work, Temple University, Philadelphia and Martin Henman, School of Pharmacy, Trinity College Dublin

Older people with Intellectual Disability (ID) have a high prevalence of gastrointestinal conditions such as GastroOesophageal Reflux Disease (GORD). However, despite this, information about treatment, in particular the use of Proton Pump Inhibitors (PPIs), in this population is sparse and limited. Objective: To investigate the prevalence and pattern of PPI use among older people with ID. Method: Data on PPI use and key demographics was analysed from Wave 2 (2013/2014) of IDS-TILDA, a nationally representative longitudinal study of 677 participants aged 40 years and above in Ireland. Descriptive statistics, bivariate analyses and binary logistic regression were carried out.

Giving up smoking may also help, as smoking can exacerbate GORD symptoms by relaxing the lower oesophageal sphincter. Losing weight, if overweight or obese, should also help to control symptoms, but sufferers should avoid over-exertion and exercises like sit-ups, as these can provoke acid reflux. The symptoms of GORD are often worse at night, especially for overweight individuals, but raising the head of the bed by 20cm by placing blocks underneath it may help. Propping the head up with pillows is not advisable as this may put extra pressure on the abdomen. It may also be beneficial to avoid wearing tight clothes, stooping or bending forwards. Treatment Options – what are they? Alongside lifestyle measures and reviewing medication, the firstline treatment options for mild to moderate GORD and dyspepsia are antacids and alginates. Antacids are alkali liquids or tablets that provide immediate relief by neutralising excess stomach acid, although the effects are often short-lived so extra doses may be needed. Care should be

taken to avoid taking antacids alongside other medicines, as they can interfere with absorption or damage the coating of certain tablets. Alginates protect the oesophagus by forming a barrier or ‘raft’ over the top of the stomach contents, helping to suppress the backflow of acid. Antacids and alginates are available in combination to provide dual action relief against both heartburn and indigestion. For patients with persistent symptoms that are not relieved by antacids or alginates, acid suppressants are available, including histamine H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs). H2 blockers, such as cimetidine, famotidine, nizatidine and ranitidine, prevent the parietal cells in the stomach from responding to histamine by releasing acid. PPIs, such as lansoprazole, omeprazole, pantoprazole, rabeprazole and esomeprazole, are more commonly prescribed or recommended for managing GORD than H2 antagonists, and are also used to treat H. pylori infections. They work by reducing the production of stomach acid by


inhibiting the hydrogen-potassium adenosine triphosphatase enzyme system, otherwise known as the ‘proton pump’. This reduction in acid reduces reflux symptoms, helping to heal the oesophagus as well as ulcers in the stomach or duodenum. Dyspepsia in Pregnancy Most people are affected by indigestion from time to time, but women are often affected by it while they are pregnant. As many as 8 out of 10 women experience indigestion at some point during their pregnancy. Indigestion tends to become more common as the baby develops. Indigestion during pregnancy is mainly due to changes that occur in the body, such as rising levels of hormones and increased pressure on the abdomen. These changes can often result in acid reflux, the most common cause of indigestion. Some women may find that their indigestion gets worse as their pregnancy progresses. However, in most cases, after giving birth, the symptoms disappear. Indigestion during pregnancy rarely causes complications.

Results: Just over a quarter, 27.9% (n = 189), of participants reported use of PPIs, and 53.4% (n = 101) were female. The largest proportion of PPI users (53.4%) were aged between 50 and 64 yrs. Most of the PPIs were used in maximum doses (66.7%). However only 43.9% of PPI users had an indication for PPI use (GORD, stomach ulcer or/and an NSAID use), and further 13.2% were also taking an antiplatelet agent. Use among those in residential care homes (54.3%) was much higher than for those living independently or with family (7%). PPI use among those who have severe/profound ID was 25% higher than those with mild ID. Information about the length of PPI use was missing for 31.2%, but of those with data, just over half recorded using the PPIs for more than a year. Apart from an indication, the factors associated with PPI use were older ages (≥50 years), severe/profound level of ID. Conclusion: PPI use among older people with intellectual disability is prevalent and frequently long term, often without a clear indication. PPI use especially among those with severe/profound ID and those who live in residential care homes, could predispose these individuals to additional comorbidities and in order to avoid inappropriate long term of use regular review is required.

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Please consult the Summary of Product Characteristics before prescribing, information about this product can be found at www.medicines. ie. Further information is available on request from UCB Pharma Ireland Ltd, United Drug House, Magna Drive, Citywest Road, Dublin 24. MA Numbers: Zirtek 1 mg/ml oral solution: PA 891/8/3, Zirtek Plus Decongestant 5/120mg Prolonged Release Tablets PA 891/8/1, Zirtek Tablets PA0891/008/005. Product licence holder: UCB Pharma Ireland Ltd. Legal Category: OTC. Classification: Zirtek tablets & oral solution: Cetirizine dihydrochloride. Zirtek Plus Decongestant prolonged release tablets: Cetirizine dihydrochloride, Pseudoephedrine hydrochloride. Adverse events should be reported to the Health Products Regulatory Authority at www.hpra.ie or via email to medsafety@hpra.ie Adverse events should also be reported to UCB Pharma Ireland Ltd via email UCBCares.IE@ucb.com Zirtek Allergy Relief is available as an oral solution for 2 years of age and upwards and in tablets suitable for 6 years of age and upwards. Zirtek Plus Decongestant is suitable for adults and adolescents from 12 years of age and upwards.

Cetirizine dihydrochloride Always read the label For further advice please consult your GP or Pharmacist

June IE-P-ZI-ALY-1900047

Cough and Sore Throat Market in Pharmacy


esearch has shown that a large proportion of those who visit their GP with a winter ailment expect an antibiotic, and with antibiotic resistance becoming a serious problem in Ireland, and throughout the UK and Europe, pharmacists and their teams are well placed to help educate customers on the dangers and importance of effective OTC treatments.

Pharmacists should be continuing to remind consumers not to take antibiotics for colds and flu, sore throat, coughs, vomiting and diarrhoea.

Increased levels of resistance, coupled with the lack of new antibiotics coming on stream, means there is a risk that we could return to the ‘pre-antibiotic era’ if this overuse is not addressed. This will not only cripple our ability to fight routine infections, but will also undermine the treatment of more complicated infections, especially in patients with chronic diseases and could make many surgeries impossible.

Overuse of antibiotics in Ireland, and around the world, represents one of the most significant threats to long term public health. According to the IPU, health services are experiencing an increase in the levels of antibiotic resistant infections, and this is largely being attributed to the overuse and misuse of antibiotics.

President of the IPU, Daragh Connolly, says, “It is essential that everyone takes responsibility for ensuring that antibiotics are only used when absolutely necessary. The key message is that antibiotics should only ever be taken when a patient actually requires them to treat a specific bacterial infection. For anyone suffering from coughs,

Pharmacy staff can reinforce the message by informing patients to come to them as their first port of call. Pharmacy staff are accessible, have time to advise and stock an armoury of OTC products to manage symptoms.


colds, sore throat, sinusitis, flu, vomiting and diarrhoea, antibiotics will not work and should not be taken. “It is concerning that, at a time when we should be reducing our use of antibiotics, in the first half of this year the rate of antibiotic consumption in Ireland has actually increased, with Irish people taking 7% more antibiotics than they were 15 years ago.1 We are taking too many antibiotics and this is causing the very concerning rise in antibiotic resistance. If this problem isn’t tackled, the antibiotics used to treat infections today will become ineffective or may stop working altogether in the future.” Advising on Cough Cold and flu season is the time

of the year when pharmacists are more likely to see patients scanning the pharmacy shelves in search of the perfect remedy to manage a cough. Patients may be overwhelmed by the numerous OTC cough products, but pharmacists are in an ideal position to evaluate and aid patients in selecting a cough product for selftreatment, as well as to encourage patients to seek further medical care when warranted. During winter, most coughs are caused by viruses such as colds and flu and can be safely managed at home using OTC remedies. Coughs are classified as “acute” or “chronic”. An acute cough is most common and lasts up to three weeks. It’s usually caused by a cold or flu virus and most improve after one to two weeks.


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Sore throat that is due to a virus should go away within 7 to 10 days. When a person has strep throat, however, throat pain starts out gradually and quickly becomes severe and constant. Patients should be referred to their GP if they have a persistent fever of 38oC plus which doesn’t improve with analgesics, they have any difficulty swallowing or breathing or they are in severe pain. Advise customers to drink plenty of fluids and take analgesics at regular intervals to ease pain. Lozenges and throat sprays can help ease pain, in addition to a salt water gargle to reduce inflammation. Planning in Advance Chronic cough lasts for eight or more weeks. The most common causes include acid reflux, asthma, TB, COPD, bronchitis and smoker’s cough. Red-flag signs include: • Coughing up blood • Unexplained weight loss • Night sweats • Cough worsening after three weeks • Shortness of breath • Voice changes • Lumps/swellings in neck • Chest pain Dry or chesty cough? A dry cough is caused by inflamed airways due to a viral infection such as a cold or flu. A chesty cough produces phlegm. This is caused by the lungs producing extra fluid due to an infection. It is important to get a detailed overview of the patient’s symptoms. Is their cough productive? How long have they had the cough and what action has been taken? Pharmacists should ask if a patient has any medical conditions that may affect any treatment or product you recommend. The Right Medicine The role of cough medicine is to ease symptoms while the body heals. There are many brands of OTC cough medicines. But there are only three basic types: Expectorants help thin mucus, making it easier to cough up. The ingredient is guaifenesin. Suppressants help cut the number of times someone coughs. The active ingredient listed is usually dextromethorphan (DM). Other cough suppressants

include camphor, eucalyptus oil, and menthol. Combination cough products have more than one active ingredient. They have both guaifenesin and dextromethorphan. Cough medicines may also contain ingredients to help coat and soothe the throat. Combination products may have medicines to ease other symptoms, that may include decongestants for stuffy nose, antihistamines for allergies or a runny nose, or painkillers. Cough drops can also help relieve a cough and may ease a sore throat (see below). Sore throat Sore throat is typically caused by a viral or bacterial infection. An estimated 200 - 300 different strains of virus cause colds and sore throat. In up to 90% of cases, sore throat is caused by viruses linked to the common cold or flu. The other 10% of cases result from bacterial infections or some other medical condition. The bacteria that most commonly cause sore throat are streptococci. Infection with streptococcal bacteria is commonly called strep throat. Sore throat can also be caused by irritants such as air that is low in humidity, smoking, air pollution, excessive yelling, postnasal drip caused by allergies, and breathing through the mouth. Injury to the back of the throat and stomach acid backing up into the throat and mouth are other causes of sore throat. Sore throat symptoms are easily recognised. The throat hurts and is irritated, swollen, or scratchy. Pain increases when swallowing. Some sufferers may also have tenderness in the neck.


The changing season brings opportunities to re-organise your store, to rearrange fixtures and fittings and to develop a clear merchandising plan featuring beacon brands in both the P and GSL sections. Planograms are helpful guides that can be used to assist with arranging retail shelves to help maximise front-end sales. These visual plans, that are backed by research, show exactly where in the store certain products should be placed and they indicate the products that will increase profits and move quickly. Store plans also show how products should be arranged based on the general categories and subcategories with the most profitable products typically going onto the shelf at eye level, known as the ‘cone of vision’. Products that shoppers seek out no matter where they are, called destination items, can go on shelves outside of the cone of vision. Have a look at the shelves that are devoted to winter remedies, both on the shop floor and on the medicines counter, and ask yourself the following questions: • Is it clear to customers and staff which products are suitable for children and which are for adults only? • Are your staff up-to-date and clear on the risk of analgesic overdose due to combination products?

• Are details about your flu vaccination service clearly displayed? Pharmacy managers should consider the range of medicines stocked – the more successful local pharmacies take note of the brand market share levels and build their fixture accordingly. Cold/flu shoppers tend to buy across the fixture and potential for link sales is good. Site products next to each other across the category to help shoppers find what they need quickly. When customers look at winter remedies, presence of which symptoms will be targeted becomes more important than either strength or active ingredient. The split of cough, cold and flu into distinct subcategories helps simplify the fixture and make it easier to navigate for those who prefer to self serve. Advice leaflets available at the fixture can also help customers with choosing appropriate products. The Paediatric Patient When temperatures start turning colder and kids are inside and interacting with each other in greater numbers, cold and flu season inevitably follows. Children under the age of 6, and particularly under age 2, are at an especially high risk during cold and flu season. Whilst it is known that antibiotics won’t help when it comes to clearing up an infection, there are steps pharmacists can advise parents to take to help their child feel better while their immune system battles the virus. Advise on keeping the child hydrated to help reduce cold and flu symptoms and make them feel better. Fevers can result in dehydration. Children suffering with the cold or flu may not feel as thirsty as they normally would, and they may be uncomfortable when drinking, so it’s important to encourage them to drink plenty of fluids. Medicated nasal sprays aren’t recommended for young children. Fortunately, there are several easy ways to clear up a stuffy nose without medication.

• How could you make this fixture easier to understand and navigate?

Use a cool-mist humidifier in the child’s room. This will help break up mucus. Another option is using a saline nasal spray or drops, which makes thin mucus easier to blow out or remove with a bulb syringe. This is especially helpful before feeding and bedtime.

• Are all staff clear on the symptoms that should ring an alarm bell if mentioned by a patient with a cough, cold or flu?


• Are staff aware of the sales restrictions for certain decongestants?

Heart Month


Strike on Stroke promoted in pharmacy September was Irish Heart Month and the Irish Heart Foundation was urging the public to strike before stroke, as it marked the beginning of a month-long awareness campaign supported by the HSE and focused, for the first time, on stroke prevention among men and women over 40. Research shows that stroke can strike at any age as 2,000 working age people are now affected annually by the disease in Ireland. Community pharmacists have an increasing role in stroke prevention in Ireland; investing in educating your customers about this will help to save lives and will also reduce the pressure on the HSE in terms of treating those suffering from stroke. Last month, the message was that prevention is key. 60% of over 45s in Ireland have high blood pressure which is a major risk for stroke. Highly accessible and embedded in rural and urban communities, pharmacy teams across Ireland are ideally positioned to enhance awareness and understanding around blood pressure, and to support patients to manage high or pre-high blood pressure through healthy living services, dispensing medication and medication reviews. Medical Director of Irish Heart, Dr Angie Brown says, “Stroke is a serious medical emergency mostly associated with older age but the reality is that people of working age are now accounting for one in four of all strokes in Ireland and this is growing rapidly in spite of Ireland’s ageing population. Preventable risk factors such as high blood pressure and smoking are significant contributors, as well as unhealthy eating and a sedentary lifestyle.

Dr Angie Brown, Medical Director, Irish Heart

“This September at Irish Heart we want to provoke a younger age group into action that prevention starts now. People in their 40’s often don’t understand their own level of risk nor would they think that a blood pressure check is relevant to them. Yet 60% of over 45s in Ireland have high blood pressure which is a major risk for stroke. In particular we’re talking to men because they account for almost three-quarters of strokes across the younger age categories and a blood pressure check is a useful indicator of risk.” Janis Morrissey, Irish Heart Health Promotion Manager added: “Everyone knows the phrase ‘prevention is better than cure’ and most people agree with its logic. But in reality, when we’re young, even middle aged – stroke prevention seems like ‘it’s not for me’ – it’s for someone else. This September – prevention is for you. Don’t suffer from one of the 8 out of 10 strokes that are preventable. We all have a responsibility to those who love us – we have a responsibility to look after our health for them. This September, let’s strike before stroke – start with a blood pressure check and start getting to know your number. We’re here to help so

don’t miss our stroke prevention tips on irishheart.ie”.

physical activity, losing weight and stopping smoking.

Role of Pharmacy

Top Tips

Community pharmacists are well positioned to provide extra support for those at risk of stroke and more opportunities for simple screening could be explored as part of preventative approaches to healthcare. They are able to provide appropriate information and support through signposting or having leaflets readily available in their pharmacies. Pharmacists can also provide simple lifestyle advice, such as healthy eating,

Heart healthy diet: Cut down on salt – it can increase blood pressure levels and therefore increase the risk of heart disease and stroke Get more exercise: People should aim for at least 30 minutes of moderate-intensity activity a day Stop Smoking: Smoking doubles the risk of a stroke, 40% of younger stroke sufferers are smokers

Escape the Chair during Heart Month An Ipsos MRBI Omnipoll revealed that people in Ireland spend on average 7.3 hours a day sitting down. Higher levels of sedentary behaviour are associated with a 147% increase in the risk of heart disease and stroke. There is increasing evidence that the positive health benefits of exercise may not entirely counteract the negative effects of a mostly sedentary lifestyle. September is Irish Heart Month and the Irish Heart Foundation has launched its month-long heart health campaign entitled, ‘Escape Your Chair’. The campaign, which aims to raise awareness of prolonged sitting as a risk factor for heart disease and stroke, was launched by Dr Ciara Kelly, GP, Columnist and Newstalk Radio Broadcaster. As part of its #EscapeYourChair heart month campaign, the Irish Heart Foundation has created a

range of resources to help people move more and sit less. These include, an online sitting time calculator, a Deskercise video, a Move More Walking Challenge, a Couch to 5k guide, as well as expert tips and advice on how to increase physical activity levels. These are available at www.EscapeYourChair.ie. On Saturday, September 28th, the Irish Heart Foundation encouraged everyone to walk, jog, or run at their local parkrun for the Irish Heart Foundation’s ‘Heart Hero 5K’

in association with parkrun Ireland. To encourage and everyone to get involved, the Irish Heart Foundation provided a number of different training guides and plans. Tara Curran, Slí na Sláinte Coordinator with the Irish Heart Foundation says, “80% of premature heart disease and stroke is preventable. As physical inactivity is a major risk factor for heart disease and stroke, we are encouraging people to make small changes to incorporate more physical activity into their day. It

is recommended that we get 30 minutes of moderate intensity activity at least 5 days of the week, but this does not cancel out the damage caused to our health by sitting for long periods of time. According to the latest Irish Sports Monitor (2017), 13% of Irish adults are sedentary. “Small changes can go a long way to improve your heart health so check out ways to move more and sit less at www.EscapeYourChair. ie” she added.




Pharmacist role in Mouth Cancer Awareness Mouth cancer claims far more lives than cervical or testicular cancer, yet worryingly one in five people remain unaware of this deadly disease. How can community pharmacists raise awareness? Mouth Cancer Awareness Day took place on 18th of last month (September). Awareness is a major issue and it is important people know what to look out for. Mouth cancer is an important global healthcare problem. There are more than 700 cases of mouth, head and neck cancer reported in Ireland every year. More than 400 of these cancers effect the mouth (oral cavity and pharynx). These cancers are more common in men than in women. However, the occurance of cancer of the mouth in women has increased significantly at a rate of 3% per year since 1994. It mainly affects older people although younger people are being diagnosed now. In Britain, the incidence of mouth cancer has increased faster than any other cancer in the past 25 years. According to the National Cancer Registry in Ireland, roughly half of all mouth cancers and even fewer cancers of the pharynx are diagnosed at an early stage. This can result in more complex treatment with greater impact on

quality of life and overall survival. Whilst it depends on the cancer site, it is known that more than half of those treated will have good survival outcomes and these continue to improve each year. Research suggests that smoking causes more than 60% of mouth and throat cancers and that giving up reduces the risk of mouth cancer by more than a third. At particular risk are those people who smoke and drink alcohol to excess, as this increases their chances of mouth cancer 30-fold. Even people exposed to passive smoking have an increased risk of the disease. The exact cause of mouth, head and neck cancers is unknown. Research continues to study possible causes. Risk factors include: • Age: Risk increases with age. Mouth, head and neck cancers are more common in people over 50 years of age. • Gender: Mouth, head and neck cancers are more common in men.

• Smoking: Those who smoke pipes are more likely to develop cancer of the lip. Those who chew tobacco have a higher risk of developing oral cancers. • Alcohol: Those who drink a lot of alcohol, particularly spirits, are more likely to develop a mouth, head and neck cancer. • Sun exposure • Diet • Human papilloma virus (HPV) Early diagnosis transforms a person’s chances of beating the disease – from 50 to 90% – so it is crucial that pharmacy teams know what to look out for. It is important to encourage customers who have noticed any unusual or persistent changes to their mouth or neck to tell their doctor. The key signs and symptoms include ulcers or sores that won’t heal and last longer than three weeks, an unexplained lump in the neck, a lump on the lips or in the mouth, or a red or red and- white patch in the mouth. If they notice anything unusual or persistent,

that is when they should go to the doctor to get it checked out. It is most likely something less serious than cancer but, if it is cancer, an early diagnosis could make a big difference. Pharmacy Advice Advise customers on how to make sure their mouth stays healthy: 1. Visit a dentist regularly even if they wear dentures. 2. When brushing the teeth, look out for any changes in the mouth or neck. Early warning signs include ulcers that do not heal within three weeks, red or white patches in the mouth, or other unusual changes in the mouth or neck. 3. When exposed to the sun, make sure to use the correct type of barrier cream on the lips. 4. Eat plenty of fresh fruit and vegetables. A good diet, rich in vitamins A, C and E, helps the body to protect itself from most cancers. 5. Avoid the risk factors for mouth cancer.

Adrian Dunne Kilbarrack Charity Walk Adrian Dunne Pharmacy staff of their Kilbarrack Branch, together with members of the local community, recently took part in a Sponsored Walk in aid of Lucy Smith. The Walk raised much needed vital funds as the staff took part in a sponsored 6K walk around the Kilbarrack/Raheny area in aid of Lucy Smith. We will be starting from the shop at 10AM and returning to the shop for light refreshments. We would love for anyone to join us on our walk to help us to support the Smith family.

The team from Adrian Dunne Pharmacy Kilbarrack who took part in a recent sponsored walk


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Providing pharmacists with Biosimilar advice Accord has once again teamed up with Pharmabuddy to provide pharmacists with further information on Biosimilar medicines. Dr Paul Ryan, Pharmabuddy Medical Director, Professor JJ Keating, Lecturer of Organic and Pharmaceutical Chemistry, School of Pharmacy, University College Cork and Tony Hynds, MD Accord Healthcare Ireland Ltd

Biosimilars have been approved in the EU since 2006 and although the EU is the most advanced adopter of biosimilars, Ireland has one of the lowest biosimilar penetration levels across Europe. Why is this when the European Medicines Agency says that biosimilars have no clinically meaningful difference compared with the reference medicine. “We know that the HSE had already spent all its ‘new medicines’ budget for the year by April, yet there is still no biosimilar policy in Ireland, which is alarming, as biosimilars provide the opportunity to increase patient access by delivering additional savings and allow resources to be directed toward new innovative medicines that could potentially make a difference, says Padraic O’Brien, Accord’s Head of Commercial. “Accord launched Pelgraz in

December 2018, our second biosimilar, which underlines our commitment and expertise to oncology, following on from the launch of our first biosimilar Accofil in 2016. Like our work in generic substitution, we along with our MFI colleagues have delivered ¤1.6 billion in savings to the Irish State since 2013 and we can deliver more, if a robust biosimilar policy is developed in Ireland” adds Mr O’Brien. “Irish patients deserve the same access to medicines as patients across Europe, and one way to help free up the HSE budget is to increase the use of biosimilars in the Irish market, we can all play our part. That’s why we have once again teamed up with Pharmabuddy to create an informative video to answer any outstanding questions pharmacists may have on biosimilars, explains Mr O’Brien.

Professor J.J. Keating, Lecturer of Organic and Pharmaceutical Chemistry, School of Pharmacy, University College Cork, answers questions posed on biosimilars such as, ‘Is the administration device and formulation of a biosimilar medicine identical to its reference medicine?’ ‘Is the method of administration of a biosimilar medicine identical to that of its reference medicine? Speaking at the launch Dr Paul Ryan, Pharmabuddy Medical Director said, “With over 4,000 registered Irish pharmacists, Pharmabuddy.ie is the number one platform used by Irish pharmacists to communicate in Ireland. We offer CPD modules on a range of different topics and are really excited to launch this module on biosimilars, which we believe will be of great assistance to our members. “I would encourage all pharmacists to log onto the Pharmabuddy website and view this highly informative video, then call your Accord representative to schedule a meeting, to see what savings you can make for the state, for patients and for your own business”, concluded Mr O’Brien.

UD support Pharmacy Students United Drug are proud to sponsor the lab coats for the new Junior Freshman Class of Trinity College Dublin school of Pharmacy and Pharmaceutical Sciences! They wish the best of luck to all the students this year. PHARMACYNEWSIRELAND.COM

Launch of Vaccine Alliance A new Vaccine Alliance has been launched, aimed at boosting the uptake of childhood vaccines and reducing vaccine hesitancy. The Alliance will include healthcare professionals, policy makers, patient advocates, students, and representatives from groups most affected by vaccine hesitancy. A Steering Group to guide the work of the Vaccine Alliance has already met and includes a wide range of organisations including Barnardos, Unicef Ireland, Science Foundation Ireland, Pavee Point, and the Union of Students of Ireland, as well as parents, doctors, nurses, midwives and pharmacists. Further organisations will be added once the vision, values and aims of the Alliance have been agreed. The Alliance was launched by Minister for Health Simon Harris TD who said, “Vaccination rates across the country are falling and diseases we had consigned to the history books are now making a comeback. We cannot afford to do nothing. We cannot allow the success of our childhood immunisation programme become its enemy. “This Alliance will build on the success we have had with the HPV vaccine where rates increased from 51% to 70% in a short period of time and it will ensure parents have accurate, evidence-based information about vaccinations.” The Minister of State with responsibility for Health Promotion, Catherine Byrne, also spoke at the launch and welcomed the establishment of the Vaccine Alliance, saying, “Increasing the uptake of vaccines is key to protecting the public from threats to their health and wellbeing. This is central to the vision of Healthy Ireland where our primary focus is on prevention. Minister Harris also announced that the Royal College of Physicians of Ireland has agreed to rename its Medal for Patient Advocacy, the ‘Laura Brennan Advocacy Medal’, in recognition of the late advocate’s work in increasing the HPV vaccine uptake.



Automation: Innovation in Compliance and Patient Care Some €39m worth of medication was wasted in Ireland last year. Startling figures indeed. Brian O'Donoghue, CEO, Virginia Medical

Solutions for improving compliance and reducing this wastage are continually being sought. With the health and wellbeing of patients, and saving time for pharmacists in dispensing medicines in mind, local company Virginia Medical Supplies are renowned for their innovative thinking in this field. The team behind the business are now establishing yet another new dimension to their portfolio. Founder Brian O’Donoghue, also a pharmacist, is passionate about ensuring patients receive the optimum in quality care, not just for them, but also for their family and carers and he has recognised a need in the market to improve stock management whilst freeing up pharmacist time. Brian and his team developed the Nu-life Monitored Dosage System (MDS) (Blister Packs): A webbased application that allows for improved communication channels between all relevant stakeholders i.e. pharmacist, patient, doctor, nursing home and HIQUA. This in turn improves compliance, due diligence, responsibility and accountability for all concerned, ultimately leading to a much higher standard of patient care. Brian is currently in the process of manufacturing a new robot for the pharmacy industry. “We decided to move from a paper-based system to an electronic medication management system a while ago,” he explains. Peter Ahearn, Sales and Research & Development Manager with the company, worked as a nurse within the nursing home setting for seven days in order to fully ascertain the needs and wants of their customers and patients within the electronic system. Nu-Life MDS is very practical and sturdy with large transparent

compartments that make it fast and simple for the pharmacist to fill, and importantly, the patient can easily see the medication to be taken at the prescribed times. The computer application allows the pharmacist print out a “Medicines Management Page” for each patient which is attached to the Nu-Life Pack. This page shows: the name of the medication: a colour picture and description of each medication: the time it is to be taken during the day: and medical indications. As well as being user friendly for the patient when taking the medication, the “Medicines Management Page” also allows the pharmacist make a comprehensive final Check of the medications against the patient’s prescription when filling the Nu-Life MDS, ensuring compliance.

Even the most experienced pharmacist or technician is slower than a machine. Automation allows pharmacies to fill more orders more quickly while freeing up human beings to do essential tasks that can’t be automated, like engaging face to face with patients. Accuracy is a major concern in the pharmacy world. Even the most seasoned or careful human can make mistakes. For many medications, an error in dosage can cause adverse effects or even kill a patient. Automating the process of measuring out

medication greatly reduces the chances of error. The HB160 robot is a semiautomated pill dispensing machine which dispenses medication into blister packs. The Machine utilises the Nu-life patient and medication cloud database as its data source. Upon completion of the dispense cycle the pharmacist inspects and approves the blister packs and attaches the blister pack seals and the patient information chart. Brian is confident this new robot will assist with compliance and streamline their hugely popular portfolio even further.

Their next phase lies in introducing a robotic system. “We decided to make this move in order to free-up and compartmentalise our staff,” explains Brian. “We have so many customers wanting to avail of our blister pack system but we were not able to accommodate them. The robot is very much still in its infancy but we are very hopeful it will bring huge and notable benefits.” Virginia Medical Supplies continues to grow from strength to strength. The Irish company has witnessed their portfolio grow from 65 pharmacies using their blister packs in 2012 to now well over 750. Many have subscribed to the notion that automation, and the use of robots in pharmacy is the way forward.

HB-160 Semi-automated Pill Dispensing Machine



Business CPD

Courage, Risk and Reward -

60 Second Summary

Is Community Pharmacy A Game Worth Playing?

The Rules of the Game are Changing… How ready are you to play by the new rules?

IPN’s Pharmacy Business Excellence Series is for community pharmacists committed to growing their professional and business knowledge and skills to overcome challenges and thrive as a community pharmacist.

IPN is proud to partner with 4Front Pharmacy to bring you the ‘IPN/4Front Pharmacy Business Excellence Series.’ Our goal for you and your team is that you develop the knowledge, skill and the courage to embrace your challenges and opportunities, take the necessary leaps of faith to reap the rewards as you commit to pharmacy business excellence.

LEARNING OUTCOMES At the end of article, you will be able to… • Outline the purpose of the IPN/4Front Pharmacy Business Excellence Series • Assess the risks of the status quo • Describe key changes community pharmacists must navigate to survive and thrive • Recognise opportunities to be cutting edge community healthcare leaders • Showcase examples of pharmacy business excellence in action • Reflect on what is possible for you LESSON CONTENT Two Community Pharmacy Leaders, both high achievers, but only one truly successful. A Tale of Courage, Risk and Reward. Which game is worth playing? Sean* and Una* both own several community pharmacies in Ireland. The pharmacy groups are the same size, have the same number of employees, and offer the same services. However, Una* is hitting ambitious Key Performance Indicators (KPIs), while Sean* is not. What’s the difference? In spite of past success, Sean* now thinks of his community pharmacies more like a life-sucking liability than a life enhancing business asset. He is worried about his future. His focus is on

battling to preserve the status quo. He feels over-worked, barely in control and overwhelmed. He blames numerous external threats - government policy, increased regulation, the labour market, changing customer habits, robots, artificial intelligence - for his stagnant revenue and difficulty in attracting and retaining high quality staff and loyal customers. He has focused single-mindedly on cutting costs, but has ignored opportunities for implementing sound business growth principles. These days, he struggles to communicate his business vision to his employees. His cost cutting focus leaves no room to create and implement a strategic business growth plan that he and his team could execute. Meanwhile, his pharmacists and other

employees are becoming ever more uninspired, demotivated, disengaged and unaccountable, resulting in customers experiencing inconsistent service. There is no team-wide training or standards to deliver consistent, outstanding service. As a result, Sean* is stressed and frustrated, and is not far from burning out and selling up. Meanwhile, Una* sees herself as a dynamic, cutting edge, community healthcare leader, with unparalleled access to patients, and therefore unparalleled opportunity to provide products and services to meet their healthcare needs.She thinks about her pharmacies as an evolving business asset and not a lifesucking liability. She is optimistic about the future. Her focus is on seeking new opportunities, optimising existing strengths, and on strategically letting go of what is no longer working. She is laser focused on making a positive difference in areas that are within her control. She clearly sees external challenges and proactively works with her team to mitigate risks and embrace opportunities. • Instead of battling against regulation, she promotes her commitment to professional and business excellence to attract customers and staff dedicated to delivering high quality patient care. • Instead of being threatened by technological advances, she learns how these can be leveraged to free up time for higher value work and improve customer experience. • Instead of complaining about changing customer habits, she seeks to understand and respond to their evolving needs. • Instead of having a single minded focus on cutting costs, she is constantly looking for ways to invest in her most valuable assets to grow her business. 4Front Pharmacy Six P's of Pharmacy Excellence


Community pharmacists have multiple competing personal, professional and business priorities. The environment in which we live and work is radically changing. Business, regulation, retail, communities, healthcare, pharmacy….are all changing. Technological advances mean that anything that can be SOP’d, is already being done better by artificial intelligent robots. What we value, how we learn and our expectations in a modern workplace are changing. Customers expect more than ever. In short, clinging to the status quo is not a sustainable survival option. But what are the alternatives? In this article, meet Sean* and Una*, two community pharmacists who have taken different approaches to playing the game. As you read it, consider ‘Which game plan most inspires you and why?’ *not real names Each month, Rachel Dungan poses strategic questions aligned with 4Front’s 6Ps of Pharmacy Excellence Framework. She shares best practice tips, insights from pharmacy leaders and showcase examples of pharmacy business excellence in action. Each article in the series is accompanied by a sample CPD Cycle to use as inspiration to take action and record the impact in your own CPD Cycle in your ePortfolio. Share your successes and submit your questions for the IPN/4Front Pharmacy Business Excellence Series to rachel.dungan@4FrontPharmacy.ie


Business CPD

Through coaching, she created her vision and aligned it with a strategic business plan. She got her employees motivated, engaged and aligned to execute theplan. She now sees herself (as leader) and her employees as her most valuable assets. To support them to deliver, she partnered with 4Front Pharmacy to provide company-wide, online and onsite pharmacy team training and development. In Una’s* business, training is a strategic priority, not something to be fitted in, when you hope to have time. It is a term and condition of employment, with expected engagement levels defined, tracked and reported on a weekly basis. She holds herself and her employees accountable for delivering service excellence – no excuses. Her business has earned a reputation for having a high performance culture. As a result, she attracts high performing employees, dedicated to making a difference to people’s health and wellbeing. Her employees are motivated, fulfilled, engaged and accountable. She has built a business that delivers services to customers in acompassionate and yet consistent manner. Una* loves her work. Her business makes a difference to people’s health and wellbeing in the communities her pharmacies serve. She is proud to be a pharmacist, and privileged to be CEO of a successful pharmacy business. Whose game plan most inspires you, Sean’s* or Una’s*? How could you create a more effective game plan for your pharmacy? What would happen if you did? What will happen if you don’t?

PHARMACY BUSINESS EXCELLENCE TIPS – Joe Haire MPSI 1. VISION: Start by defining a compelling future vision you are proud to be associated with. Then work with your team to create and implement a roadmap to achieve it. Question: What do you stand for? What does your pharmacy stand for? 2. ALIGNMENT: As Kilkenny supporters know, a team that wins together, trains together. Otherwise you get a disjointed group of high achievers who persistently under-perform. Question: Is team training and development a key strategic business priority for you? If not, what is that decision costing you? 3. EXECUTION: Dedicate at least one hour at the end of each week to take a strategic pause, reflect on wins and challenges and prioritise the highest value work for the next week. Question: What do you need to stop doing and delegate in order to focus on higher value work? About Joe: A passionate Kilkenny supporter, Joe is a 3rd generation pharmacist, whose business has grown from one to six pharmacies. About Kissanes Pharmacy Group Vision and Its Customer Promise: At Kissanes, we are a team driven by a desire to make a difference to people’s lives their health and sense of well-being. We do this through life long relationships, with leadership, professionalism and a commitment to continuous improvement. As a customer, you can trust our exceptional pharmacist-led teams to deliver personal care for you and your family’s health and well-being. Before: Joe was exhausted, juggling 3 full time jobs, as supervising pharmacist, superintendent pharmacist and pharmacy owner in addition to being Dad, Kilkenny supporter and athlete. His turnover had stagnated. He had lost key members of staff. Challenge: He was burning out from constantly putting out fires, and not having enough time to create capacity within his pharmacy to create a sustainable business model. He was concerned that ‘service delivery was not what it should be.’ Solution: Joe partnered with 4FrontPharmacy to simultaneously invest in up-skilling all staff at all levels of the business, a top-down and bottom-up culture of continuous development, dedicated to delivering service excellence – no excuses. To implement, we agreed metrics, assessed baseline data, created and developed the leadership team, provided weekly online product knowledge and consultation skills training for ALL pharmacy staff and hosted strategy progress meetings to assess progress. Results: In just six months,


From 0.02% to 18.17% OTC sales growth in 6 months Joe Haire MPSI. Owner and Superintendent Pharmacist Kissanes Pharmacy Group - 6 Pharmacies in Kilkenny/Carlow Area.


• pharmacist clinical intervention rate increased by 201% and • the quality of pharmacy consultations improved by 84% (using standardised observation techniques.) • Between 68% and 93% of staff completed ALL 26 online training modules assigned over a six month period, • Group OTC sales growth of 18.17% year on year • Even better, despite many fires, Joe has stayed laser focused on his priorities, and led his team to complete three capacity enhancing projects which enable his team to focus on higher value work, providing a firm foundation for continued growth through service excellence.

What would results like this mean for you, your pharmacy team, your local community and your pharmacy business? To support your engagement with CPD, IPN is proud to partner with Rachel Dungan MPSI, CEO of www.4FrontPharmacy.ie to share examples of CPD cycles.

AUTHOR: Rachel Dungan MPSI, ACC. Community Pharmacist. Award-Winning Medical and Leadership Coach and CEO of www.4FrontPharmacy.ie, a leading-edge online training platform for pharmacies, proven to drive patient safety, staff engagement, and increased sales, through raising the quality of pharmacy / patient interactions. Known as ‘The Pharmacist Coach,’ Rachel worked for 20 years as a supervising and superintendent pharmacist. Rachel’s entire career has focused on developing and applying professional and business excellence to enable pharmacy teams to deliver exceptional results.


Suggested Superintendent Pharmacist / Pharmacy Owner CPD Cycle


Self-Appraisal WHAT I intend to learn and why When I completed the PSI Pharmacy Assessment System, two of the ‘areas for improvement’ identified from the ‘Management and Supervision’ section and the ‘Sale and Supply of Non-Prescription Medicines’ Section related to providing evidence that all staff are trained and competent in their role. I realised that I have no formal method of standardising or demonstrating staff training and I want to address this.


Personal Plan HOW I intend to learn it I plan to research training options available in Ireland. I plan to ask my staff to bring in their course completion certificates. I plan to speak to staff at performance appraisal to explore their learning needs.


Action What I actually did I reviewed IPU OTC off-site training and distance learning. I read OTC related articles in pharmacy magazines such as IPN. I spoke to my staff about their qualifications and training needs. I contacted www.4FrontPharmacy.ie for a demo of their online Pharmacy Training Programme.


Document What I have learned specifically Three key realisations • Training staff to manage OTC sales of medicines is a core part of the Medicines Supply Chain. • The true cost of off-site training, taking into account the training fee, travel expenses, overnight and food expenses, pharmacy cover, day’s wages for person attending the training. • The value of online team training extending beyond the expertise, to include leveraging and implementing whole team learning with marketing and sales activities, for the sake of patient care.


Evaluate ONE example of how I put my learning into practice • By using an online programme designed by pharmacists for pharmacy teams, at the tip of a button, I can demonstrate my team’s up-to-date training and meet PSI training guidelines.

Ethical Standards for Pharmacy On World Pharmacists Day, the Pharmaceutical Society of Ireland (The PSI), the pharmacy regulator, launched a revised statutory Code of Conduct, which sets out the ethical standards that all pharmacists practising in Ireland must meet. An extensive consultation process formed part of the substantial review of the pre-existing Code, which had been in place since 2009. The result is a distinctly patient-centred revision that addresses developments in the delivery of healthcare over the past decade. The Code is aimed at supporting pharmacists in their current and future professional practice, and to ensure that pharmacists provide the best possible health outcomes for their patients. The new Code of Conduct comes into effect on 21st October 2019. As with its predecessor, the revised Code of Conduct – Professional Principles, Standards and Ethics for Pharmacists focuses on ensuring that all pharmacists practice in a way that maintains and improves the health, wellbeing, care and safety of patients. It provides seven key principles that are centred on professionalism and care, such as effective communication; upholding public trust and confidence in the profession; maintaining competence, as well as the importance of collaboration with patients and other healthcare professionals.

Mary Rose Burke, CEO Dublin Chamber of Commerce

It sets the standards for good professional practice. In the event of a finding of serious misconduct for a breach of the Code, the Council of the PSI can impose sanctions, which include the suspension or cancellation of a pharmacist’s registration to practice. Speaking at the launch, Niall Byrne, Registrar and Chief Officer, PSI, encouraged every pharmacist to familiarise themselves with the Code including the professional responsibilities which it sets out and the ethical standards that the public, patients and other healthcare professionals expect from pharmacists. Mr Byrne said, “What was clear to the PSI from our engagement during this review is that there is a desire amongst professionals and the wider public that healthcare is ethically-led. Pharmacists offer unique expertise in the area of medicines, the most common intervention in resolving people’s health issues, and that is an

Mary Kirwan, Barrister, and Lecturer at RCSI

area of professional practice that is evolving, challenging and complex. The Code of Conduct is a public declaration of the high degree of trust which people should be able to have in the care they receive in a pharmacy and from pharmacists. With over two million visits made by the public to pharmacies every month, maintaining that professional trust is vital and requires pharmacists to display full technical competence in their chosen profession, but also to behave with probity and integrity and to be accountable for their actions or omissions. I hope that this revised Code is something pharmacists can take pride in as they demonstrate their commitment in their day-to-day practice to professional, patientcentred care.”

• I can now concentrate on leveraging the expanded team skill base to extend my pharmacist service offering. • My time is now used for higher value activities that ONLY a pharmacist can do, and I am confident that OTC sales conducted by my staff, will be referred appropriately.


Domains (and Competencies) Superintendent Pharmacist selected Competencies under the following domains for this CPD Cycle: 1. Professional Practice (Engages in appropriate CPD), 2. Personal Skills (Teamworking Skills), 3. Supply of Medicines (Manages the Medicine Supply Chain).


Jack Shanahan, Pharmacist, Editor IPU Review

The Code of Conduct applies to all pharmacists whether they practise in community, hospital, industry, in regulation or in any other form of professional practice.




Towards a Healthier Ireland Health Research Charities Ireland (HRCI), the new name for the Medical Research Charities Group, has launched “Research towards a healthier Ireland”, a position paper that sets out a series of critical actions if Ireland is to have a world-class research environment that delivers better outcomes for patients. HRCI, the national umbrella body for 37 medical and health research charities representing over one million patients in the areas of rare diseases, childhood illnesses, mental health, chronic illness and disability, published the document at a conference marking the 21st anniversary of the founding of the organisation. The full document can be located at www.hrci.ie

The document sets out five high-priority actions to advance the development of health research in Ireland: • Investment in clinical research • Public information campaign • Federation of patient registries • Genomics strategy • Public and patient involvement.

Shirley Guerin, Chief II Pharmacist, Phoenix Pharmacy Department, Health Service Executive, and Dr Avril Kennan, CEO, Health Research Charities Ireland (HRCI), pictured at the recent launch by HRCI of the Research Towards a Healthier Ireland position paper

Hidden burden of Eczema exposed Eczema can be painful and embarrassing, but community pharmacists can help spot the signs and advise on how to manage this common condition. New Irish survey findings released by the Irish Skin Foundation (ISF) ahead of World Atopic Eczema Day (14th September), revealed the hidden burden of this common skin condition, with over 40% of those surveyed reporting the need to cut household expenditure because of the day-to-day cost of managing atopic eczema.

The ISF survey revealed that 42% of carers of children and 49% of adults reported cutting back on household expenses due to the cost of managing AE. The figures suggest that one quarter of those surveyed spend at least ¤2,300 annually on doctor's fees, overthe-counter management products and prescription treatments.

Atopic eczema (AE), or atopic dermatitis, is a common, noncontagious, inflammatory skin condition. AE can start at any time of life but is most common in childhood and is thought to affect as many as one in five children and one in ten adults.

The survey findings also reveal the pronounced negative impacts that AE can have on quality of life, including sleep disruption, absences from school, as well as participation in exercise and social activities.

The cost of eczema treatments and doctor's appointments needed to manage the condition can be a significant financial burden.

Consultant Dermatologist, Professor Anne-Marie Tobin says, “These new Irish survey findings provide us with valuable insights into the often-hidden burden

Dr Anne Marie Tobin, Consultant Dermatologist, Tallaght Hospital and Naas General Hospital; Clinical Associate Professor in Trinity College Dublin

experienced by those living with or caring for people with moderatesevere atopic eczema. To mark the 2nd World Atopic Eczema Day, the ISF survey findings further underscore that people living with this very common condition experience a whole host of challenges in their daily lives, beyond the pain and discomfort of this very common debilitating skin disease.”

PMI Women in Leadership The Pharmaceutical Managers’ Institute recently held its second Annual Women in Leadership lunch in the Kingswood House Hotel. The event featured Liz O’Donnell as the guest speaker. Prior to joining MSD as their Director of Policy, Government Affairs & Communications; Liz held many varied roles in her career including journalism, public affairs consultancy, lecturing and of course her time as a politician. Liz talked about the importance of mentoring & encouragement of women the workforce.



The BioXtra range of mouth care products offers a complete solution to dry mouth that works throughout the day and night.

Ultimate Dry Mouth Relief MOISTURE, COMFORT & PROTECTION For dry, sore or sensitive mouths

The Range Includes: Toothpaste and Mouthrinse for oral hygiene. Foam free toothpaste reduces dryness and doesn’t need rinsing from the mouth. The mouthrinse has NO alcohol and leaves the mouth fresh and clean.

Available in your local pharmacy.

Spraygel and Moisturising Gel for instant and long term relief from the effects of dry mouth, perfect for all night comfort - prevents waking to drink water at night. Containing enzymes and proteins similar to those present in natural saliva. The BioXtra products reinforce the natural defences of saliva, which can be deficient in the case of dry mouth. Prescribed and recommended by doctors and dentists


COPD - THE HARD FACTS FACT: Nearly half a million people in Ireland are estimated to have Chronic Obstructive Pulmonary Disease (COPD)* FACT: 50% of those with COPD do not know they have it*

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Budesonide/Formoterol Easyhaler

Maintenance and Reliever Therapy






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

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Voltarol Emulgel Voltarol P 1% w/w Gel Emulgel P 1% w/w Gel contains contains diclofenac diethylammonium. diclofenac diethylamm Always read Always the label/leaflet. read the label/leaflet.



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Voltarol Emulgel Voltarol P 1% w/w Gel (diclofenac). Emulgel Indications: For the local P symptomatic 1% w/w relief of pain and Gel inflammation (diclofenac). in trauma of tendons, ligaments, muscles, Indic joints and localised joints forms of softand tissue rheumatism. localised Dosage: Adults and adolescents forms 14 yearsof and over: soft 2g to 4g oftissue gel, applied topically rheumatism 3-4 times daily for up to a maximum up of 7 days. to Consult a amaximum doctor if the condition does notof improve. 7Contraindications: days. Patients Consult with or without a chronic doctor asthma in whom attacks if the of asthma, urticaria ofor asthma, acute rhinitis are precipitated urticaria by aspirin or other non-steroidal or acute anti-inflammatory rhinitis agents. Hypersensitivity are to diclofenac, precipitate acetylsalicylic acid, non-steroidal acid, anti-inflammatory non-steroidal drugs or any other ingredients. Use anti-inflammatory in third trimester of pregnancy, in children and adolescents drugs aged less than or 14 years. any Warnings and Warnings Precautions: Caution with oral and NSAIDs as may Precautions: result in unwanted side effects. AvoidCaution use with other productswith containing diclofenac. oral ApplyNSA only to intact, non-diseased to intact, skin and not to skinnon-diseased wounds or open injuries. It should not beskin used with occlusion. and It should not not be allowed to skin to come into contact wound with the eyes or mucous the membranes eyes and should or nevermucous be taken by mouth. Application membranes over extensive areas for prolonged and periods or should application in excess never of recommendedrecommended dosage may give rise to systemic effects. These dosage include gastrointestinal may disturbancesgive and bleeding,rise irritability, fluid to retention, systemic rash, hepatitis, e renal dysfunction, renal anaphylaxis and dysfunction, rarely blood dyscrasias, bronchospasm anaphylaxis and erythema multiforme. Discontinue and if rashrarely develops. Use withblood caution in dy patients with apatients history of peptic ulcers, gastrointestinal with bleeding, a history hepatic or renal insufficiency, of peptic or bleeding diathesis, ulcers, or intestinal inflammation. gastrointes Pregnancy and Lactation: and The systemicLactation: concentration of diclofenac is lower The after topical systemic administration, compared concentration to oral formulations. During the first andof seconddiclo trimester of pregnancy, trimester diclofenac should not of be given pregnancy unless clearly necessary. Only , use diclofenac during lactation on the adviceshould of a health professional. not Diclofenac be is g contraindicated contraindicated during the third trimester of pregnancy. Shouldduring not be applied on thethe breasts of third nursing mothers, trimester nor elsewhere on large areas of of skin pregn or for a prolonged period a prolonged of time. Side effects: Very rare: rash period pustular, hypersensitivity of (including time. urticaria), Side angioedema, effects: asthma, photosensitivity Very reaction. Rare: rare Dermatitis bullous. Dermatitis Common: Dermatitis (including bullous. contact dermatitis), rash, Common: erythema, eczema, pruritus.Dermatitis Overdose: The low systemic absorption (including of topical diclofenac renders diclofenac overdosage extremely unlikely. renders MA Holder: GlaxoSmithKline overdosage Consumer Healthcare (Ireland) extremely Limited, 12 Riverwalk, Citywest unlikely Business Campus, Dublin Campus, 24, Ireland. MA Number: PA Dublin 678/140/2. Legal Category: 24,Pharmacy Ireland. only. Text revised: MA May 2019. Number: Further information available Pon A request. 678/1

Trade marks are Towned rade by or licensed marks to the GSK group are of companies. owned CHGBI/CHVOLT/0275/17a(1) by or licensed to the GS

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