IPN October 2025

October 2025 Volume 17  Issue 10 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

In this issue: NEWS: Community Pharmacy Agreement Page 4

Meet the newest member of the MACU-SAVE family

COMING SOON

MEDICINES: Shortages Remain Cause for Concern Page 6

PROFILE: Celebrating 60 Years in Pharmacy Page 12

FEATURE: The MACU-SAVE range — now for every generation

Towards Tobacco Free Ireland Page 18

TEAM TRAINING: Emergency Contraception Page 38

CPD: Sleep Disorders Page 41

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*Vitamin B2 Helps maintain normal vision MACU-SAVE is a ZEON Healthcare Ltd. brand.

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WOMEN'S HEALTH: Menopause Page 50

3

Contents

Foreword

Page 5: Calls to unlock the full potential of community pharmacies

Leading news this month is that the Minister for Health, Jennifer Carroll MacNeill T.D. has published the Community Pharmacy Agreement 2025, following the successful conclusion of negotiations with the Irish Pharmacy Union (IPU).

Page 6: Medicine shortages remain a headache for the profession Page 10: HPRA detains almost 400,000 Units of Illegal Medicines

5

Welcoming its publication IPU President Tom Murray said, “This agreement marks a major step forward for community pharmacy and the patients we serve. It brings long overdue investment, recognises the vital expertise of pharmacists, and opens the way for new and expanded services in every community in the country.” “By strengthening the role of pharmacies, it makes healthcare more accessible and ensures patients get the care they need quickly and conveniently.”

Page 14: Celebrating Excellence at the PHX Ireland Page 18: Towards a Tobacco Free Ireland Page 36: First Steps in Footcare: A Pharmacist’s Guide

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Page 60: Théa Pharma: Innovation, Partnership, and Leadership

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EDITOR Kelly Jo Eastwood: 0044 787654 8989 kelly-jo@ipn.ie

CONTRIBUTORS Sandra Byrne Dr Eimear Foley Dr David Breen Eimear O’Reilly Fathimah Kara Bernie Carter Dr Edward O’Sullivan Professor Eoin Feeney Dearbhla Walsh DESIGN DIRECTOR Ian Stoddart Design

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“Medicine shortages can have severe consequences for patients, compromise public health and come at a high cost for doctors, pharmacies and countries alike,” said Klaus Heiner Lehne, the ECA Member leading the audit. “The EU needs an effective remedy to cure critical shortages and must tackle them at their roots, also as a matter of European strategic autonomy.”

Our Women’s Health Special Focus this issue carries a multitude of relevant clinically content, including anticoagulation therapy for women, menopause, incontinence and breast cancer while meanwhile, on page 76 Dr Edward O’Sullivan gives readers an overview of Migraine, common management and treatment therapies and paves the way for greater understanding of this debilitating condition.

MANAGING DIRECTOR Natalie Maginnis natalie@ipn.ie

SALES MANAGER Amy Evans | amy@ipn.ie 0872799317

Turn to page 4 for the full story.

In other news on page 6, medicine shortages are under the spotlight. Medicine shortages have been a recurring issue throughout the EU for years, but the EU still lacks a welloiled system for coming to grips with severe shortages of medicines, according to a new report by the European Court of Auditors (ECA).

Page 46: New Appointment at United Drug

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This landmark agreement supports the delivery of safe, equitable, and efficient healthcare, and ensures that community pharmacists are better equipped to contribute to national health priorities through structured engagement, sustainable funding, and integrated service delivery. The agreement is supported by a ¤75 million new investment across 2025 and 2026.

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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.

Regulars FEATURE: MORE THAN A HEADACHE

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TEAM TRAINING: EMERGENCY CONTRACEPTION

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CPD: SLEEP DISORDERS

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WOMEN’S HEALTH: INCONTINENCE

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CLINICAL PR:

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4

News

Community Pharmacy Agreement 2025 The Minister for Health, Jennifer Carroll MacNeill T.D. has published the Community Pharmacy Agreement 2025, following the successful conclusion of negotiations with the Irish Pharmacy Union (IPU). This landmark agreement supports the delivery of safe, equitable, and efficient healthcare, and ensures that community pharmacists are better equipped to contribute to national health priorities through structured engagement, sustainable funding, and integrated service delivery. The agreement is supported by a €75 million new investment across 2025 and 2026.

Speaking on the publication this month, the Minister for Health said, “Community pharmacies are at the heart of our healthcare system, they are among the most trusted and accessible healthcare professionals. This agreement recognises their vital role and sets out a meaningful pathway to expand services, improve access, and modernise how care is delivered.”

Welcoming its publication IPU President Tom Murray said, “This agreement marks a major step forward for community pharmacy and the patients we serve. It brings long overdue investment, recognises the vital expertise of pharmacists, and opens the way for new and expanded services in every community in the country.”

“By strengthening the role of pharmacies, it makes healthcare more accessible and ensures patients get the care they need quickly and conveniently.”

“Pharmacists are medicine experts. This Agreement puts that knowledge to work for patients making it easier to access more of the services they need, when they need them, in the convenience of their community pharmacy. This will make everyday healthcare easier and free up capacity in the wider health service,” continued Mr Murray.

Key features of the Agreement include:

the vital role pharmacies play and helps keep services sustainable.

• Expanded Services: Community pharmacies will play a greater role in contraception, immunisation, bowel screening, and the safe return and disposal of unused medicines.

“The agreement will also support the digital transformation of our health service by integrating community pharmacy into national digital health systems and streamlining work processes.

• Digital Integration: Pharmacies will actively support national eHealth reforms, including the National e-Prescription Service and National Electronic Health Record.

“We welcome the commitments to reduce unnecessary red tape and to invest in the digitalisation of health services. These measures will allow our highly trained pharmacists to spend more time delivering direct patient care.”

• New Funding: ¤25 million in 2025 and ¤50 million in 2026 will support fee adjustments, service development, and training.

• Strategic Collaboration: A new collaborative framework will be established to support the shaping and implementation of community pharmacy services.

The Agreement also introduces new fees and allowances for participating pharmacies, supports the training and development of pharmacy teams, and a programme of work aimed at reducing administrative burdens on community pharmacies.

“This is the first increase in pharmacy fees in a generation, and it is much needed. It recognises

Concluding, Mr Murray paid tribute to the pharmacists of Ireland, saying, “Pharmacists have been saying for many years that we are ready, willing, and waiting to do more for patients. I commend the profession for its ambition and commitment to patient care.”

“This agreement delivers real benefits for patients, provides meaningful support for pharmacies, and strengthens Ireland’s health service. Now it is essential that every element of this deal is implemented without delay, and we look forward to continuing our ongoing engagement with the Department of Health and the HSE to ensure this happens.”

Congratulations for McCabes Pharmacy Congratulations to McCabes Pharmacy Letterkenny on being nominated as a finalist in the Highland Radio Customer Service Awards 2025 in the Customer Service category!

This recognition is a testament to the team’s dedication, care, and commitment to going above and beyond for the local community every day.

Wishing the team the very best of luck for the awards night!

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Alzheimer’s Awareness September was Alzheimer’s Awareness month, and Sunday, 21 September, marked World Alzheimer’s Day. This year’s theme is “Ask About Dementia, Ask about Alzheimer’s”. It provides us with an opportunity to learn more about dementia, understand how we can reduce our risk of developing it, and show understanding and support for family members, neighbours and friends who have been affected by dementia.

Since 2018, the HSE has partnered with the Alzheimer Society of Ireland and many national and local organisations and individuals through the Dementia: Understand Together community campaign to improve awareness of dementia, combat stigma, and support the inclusion of people with dementia in their local communities. Over 1,600 dementia champions and 60 national partners have joined the campaign to date, leading dementia-inclusive initiatives at national and local level.

Minister for Older People, Kieran O’Donnell said, “The Government strongly supports the important work being done through the Dementia: Understand Together campaign to build supportive communities that enable people with dementia to live as independently as possible in their own homes, for as long as possible.”

Minister O’Donnell continued, “Over the past five budgets, the Government has invested ¤19 million in new dementia diagnostic services and expanded community-based supports like dementia day care, day care at home and dementia advisers. We have also funded the Alzheimer Society of Ireland to provide activity clubs for people with young onset dementia, who often find it difficult to fit into existing service provision which is directed mainly towards older people. Together with initiatives like Understand Together, these investments are providing meaningful supports for people with dementia and their families, enabling them to live as well and as independently as possible in their own homes and communities.”

News

5

Be Familiar with Sepsis

Calls for Unlocking the Full Potential of Community Pharmacies

Ahead of World Sepsis Day, the HSE is encouraging everyone to become familiar with the signs and symptoms of sepsis. Sepsis is a potentially life-threatening complication that can hide behind any infection. It can affect anyone of any age and can lead to rapid deterioration in health. Sepsis is treatable if it is identified and treated early.

Without quick treatment, sepsis can lead to multiple organ failure and death.

Community pharmacists are amongst the most accessible and trusted healthcare professionals in Europe, often serving as the first point of contact with the healthcare system for millions of patients each day.

Michael O’ Dwyer, Clinical Lead, HSE Sepsis Programme, said, “Sepsis can be hard to spot, which is why we ask everybody to make themselves aware of the signs and symptoms. Timely intervention can save lives. If you suspect you or someone you know has sepsis, seek urgent medical care and always ask, ‘Could it be Sepsis?’

Improving treatment of sepsis is a key priority of the HSE Sepsis Programme. This is reflected in the recent update to sepsis clinical guidelines in Ireland.

Research has found that symptoms of sepsis are easy to dismiss, miss or mistake for something else. If sepsis is suspected, seek urgent medical care and always ask, ’Could it be Sepsis?’

Earlier this month, the National Sepsis Programme and the National Clinical Effective Committee (NCEC) updated its National Clinical Guideline No.26 on sepsis management for adults (including maternity).

In addition to these updates, a comprehensive training and education programme will be delivered to all hospitals by the end of 2025. To align with the changes to the guidelines, the HSEL and sepsis training has been updated. This training is mandatory for all clinical staff in acute hospitals.

A mandatory training programme for clinical staff in non-acute settings, such as community and primary care, is currently being developed and will be available in 2025.

At an event held in the European Parliament, co-hosted by MEP Michalis Hadjipantela (EPP) and MEP Vytenis Andriukaitis (S&D), and alongside the launch of the new Report on Pharmacy Services in Europe, the Pharmaceutical Group of the European Union (PGEU) highlights how expanding pharmacists’ scope of practice can transform healthcare delivery, ensuring patient-centred and sustainable care is provided closer to where people live.

Dispensing medicines is the foundation of pharmacy, and it is now complemented by an enhanced range of patientfocused services. Across Europe, pharmacists deliver vaccinations, promote health, conduct early screenings, manage chronic diseases, perform medication reviews, and provide digital health support, among other essential services that enhance patient experience and support adherence to treatments. These services have been shown to improve health outcomes, reduce hospitalisations, and reinforce the resilience of healthcare systems, particularly in underserved and rural communities.

The COVID-19 pandemic further reinforced their vital role, with pharmacies ensuring continuity of care, administering millions of vaccines, and offering trusted public health guidance in a situation where the healthcare system was strained and overburdened.

PGEU President Clare Fitzell said: “Europe’s 160,000 community pharmacies and over half a million pharmacists are a cornerstone of healthcare. With supportive regulation, sustainable financing,

Clare Fitzell IPU and full integration into care pathways, pharmacists are already keeping people healthy, delivering services closer to home, and increasing the capacity of health systems. Our report sets out a practical roadmap to build on this success and expand these benefits to patients in every community.”

Pharmacy services have already demonstrated their value, and with more supportive legal frameworks, fair remuneration models, and better digital health integration, their full potential can be realised.

To advance the implementation, development, and recognition of pharmacy services across Europe, PGEU calls for: • A strategic policy shift: recognising community pharmacies as essential partners in delivering peoplecentred, sustainable healthcare and empowering them through supportive regulation, appropriate investment, and systemic integration.

• Regulatory reforms: expand pharmacists’ scope of practice according to competency areas and remove barriers to service provision.

• Sustainable financing: ensure appropriate and consistent remuneration for pharmacy services to reflect their clinical and public health contributions.

• Workforce planning: strengthen education, leadership, and ongoing professional development.

• Crisis preparedness: fully integrate pharmacies into national public health response frameworks.

• Access and equity: strengthen pharmacies’ role in reducing health inequities by ensuring their presence in underserved areas and enabling access to specialty medicines, supporting territorial cohesion.

• Antimicrobial stewardship: enable pharmacies to take a proactive role in infection control and antibiotic use.

The outcomes of the PGEU Event on Shaping the Future of Pharmacy Services in Europe demonstrated that policymakers, health professionals and patients are ready to align priorities and advance the implementation and development of new and expanded pharmacy services across the continent.

Date for your Diary: Return of the Great Debate The Pharmaceutical Manufacturers’ Institute (PMI) is bringing back one of their most anticipated events – The Great Debate.

This year, they tackle one of the pressing questions for healthcare’s future: Healthcare 2030: The Price of Progress – Can Innovation and Affordability Coexist?

Join the team for an evening of sharp insights, bold arguments, and expert perspectives as their panel of thought leaders go head-to-head, moderated by MC, Ivan Yates. After the debate stay for refreshments and the chance to connect with colleagues and industry leaders.

The event takes place on Thursday, 16th October at 6.30pm for a 7.30pm start at the RCSI, Dublin.

Visit www.thepmi.com for more details.

PHARMACYNEWSIRELAND.COM

6

News

Medicine Shortages Remain a Headache Medicine shortages have been a recurring issue throughout the EU for years, but the EU still lacks a well-oiled system for coming to grips with severe shortages of medicines, according to a new report by the European Court of Auditors (ECA).

Suicide Reduction Strategy Minister for Mental Health Mary Butler has appointed 22 members to an Expert Advisory Group to guide the development of Ireland’s next national suicide reduction strategy.

The new strategy, building on Connecting for Life (2015-2024), will set out the government’s approach to suicide reduction, intervention, and postvention from 2026 onwards. The Expert Advisory Group for the next suicide reduction strategy will play a central role in shaping the strategy, ensuring it is informed by the latest evidence, crosssectoral expertise, and the lived experience of those affected by suicide.

The expert group, chaired by Dr Eileen Williamson, former CEO of the National Suicide Research Foundation, comprises 22 members representing clinical, academic, policy, and community sectors.

While EU measures in recent years have proven helpful, structural problems persist and efforts to tackle the root causes of shortages remain at an early stage. Since it could take time before they bear fruit, Europeans remain at risk of running short of medicines, including common antibiotics and other vital treatments.

Shortages can affect all categories of medicines, including innovative patented medicines, off-patent generics, or vaccines. They become critical when a country has no suitable alternatives and coordinated EU action is needed to resolve the shortage. In the EU, reported shortages peaked in 2023 and 2024, with EU countries running critically short of 136 medicines between January 2022 and October 2024.

“Medicine shortages can have severe consequences for patients, compromise public health and come at a high cost for doctors, pharmacies and countries alike,” said Klaus Heiner Lehne, the ECA Member leading the audit. “The EU needs an effective remedy to cure critical shortages and must tackle them at their roots, also as a matter of European strategic autonomy.”

The auditors found that the system for preventing and mitigating critical medicine shortages needed to be improved as it lacked an adequate legal framework as well as timely and actionable information. Although the European Medicines Agency (EMA) has seen its role increase in recent years, particularly during the COVID-19 pandemic, and the agency has provided important coordination to help reduce the impact of shortages, it still does not have legal powers to help EU countries outside a health crisis. Moreover, it is not made sufficiently aware of shortages to be able to prevent them. The audit revealed EMA also lacked data to continuously help mitigating existing shortages as notifications from industry were often late and incomplete.

The European Commission has identified many root causes of shortages such as supply chain vulnerabilities, with parts of production – particularly for antibiotics and painkillers – largely outsourced to Asia. Its work to address them, however, is only starting and faces many challenges. The obligation for industry to provide continuous supply, for example, does not work well in practice. Faced with rising shortages, many EU

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countries began to stockpile medicines, which could worsen shortages in other EU countries as they failed to coordinate between them. The first EU-wide list of critical medicines is therefore an important step but work so far has not ensured their availability. In fact, the auditors found some to be in critically short supply.

The EU’s single market for medicines is fragmented, which hinders their free flow and availability, and contributes to unequal access to them.

Most medicines are authorised nationally and those authorised for the entire EU are not marketed in all countries, while packages differ between countries. Moreover, the Commission did not properly address cross-border barriers to trade. As a result, it was difficult to mitigate shortages by a possible redistribution of medicines.

The Commission has taken initial steps by proposing changes to EU law. Once passed, these could bring significant improvement to the system, though the auditors warn that they may fail to address all issues, including the need to report shortages in good time or influence industry action during a critical shortage.

A parallel Lived Experience Reference Group will work closely with the Advisory Group to ensure that lived experience is central to the development of the strategy. This group will be chaired by Joe O'Donovan and coordinated by the National Suicide Research Foundation.

The work of both Groups will be informed by the recent public consultation for the new strategy which was launched by the Minister in March of this year. The Department of Health received almost 2,000 responses to the consultation, including the participation of over 200 members of the public and professionals in a series of focus groups.

Speaking at the first meeting of the Expert Group this week, Minister Butler said, “Ensuring the voices of lived and living experience are included in the development of policy is critically important to me. I want to thank Joe O’Donovan for taking on the important role of chairing a parallel Lived Experience Reference Group to ensure the insights of people with experience of suicide inform the work of the expert group.”

Kopen Sugar Free 250mg/5ml Powder for Oral Solution Phenoxymethylpenicillin

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Date of preparation: July 2025 Ref: IE2025/003/00

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News

Transforming Pharmacy Pharmacy Success Launches “The Leadership Series” to Transform Community Pharmacy Pharmacy Success has unveiled its newest initiative — The Leadership Series, a first-of-its-kind programme created exclusively for community pharmacy leaders.

Heart Foundation Pre-Budget 2026 Higher taxes on cigarettes should be a key Government priority alongside a major new crackdown to combat tobacco smuggling. At the Irish Heart Foundation, they want a ¤1.55 hike on a pack of cigarettes to discourage youth smoking – as evidence clearly indicates it is a myth that higher prices lead to increased smuggling.

Revenue data shows that 26% of cigarettes smoked in Ireland are illegal – the vast majority contraband of commercial brands bought outside the country and smuggled in. The Tax Strategy Group’s latest paper on excise estimates a notional loss to the Exchequer of ¤684 million from the illicit market in 2024.

In their pre-Budget submission, the Irish Heart Foundation have included that the ‘biggest lever’ to discourage young people from starting smoking is a high tax regime.

“If the State doesn’t put up tobacco tax, the cigarette companies will raise the price anyway, transferring revenue from the Exchequer straight onto the bottom line of big tobacco.

Main pic: Brian Battles, founder, Pharmacy Success Right middle: Brian Battles, founder, Pharmacy Success with Fergus Brennan, Brennans Pharmacy Group and Marian Byrne, Leadership Coach Bottom left: Marian Byrne, Leadership Coach Bottom middle: Fergus Brennan, Brennans Pharmacy Group After years working closely with pharmacy owners and pharmacists, one message stood out: leadership is the single biggest factor in transforming a pharmacy from the inside out. Yet, too often, pharmacists find themselves firefighting day-to-day operations, managing teams, and carrying the weight of the business without structured support.

“Leadership skills don’t come automatically with a pharmacy degree or ownership. They must

be developed — and when they are, the impact on culture, patient care, and profitability can be extraordinary,” says Brian Battles, founder of Pharmacy Success.

Inside the Programme Held at the Glenroyal Hotel, Maynooth, Co. Kildare, the series runs across three immersive days: The 13th September saw the start of the three day series.

Each day blends interactive leadership workshops in the

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morning with practical pharmacy business sessions in the afternoon.

The result is a balance between personal growth and tangible business improvement.

• Morning workshops: Led by Marian Byrne, an accomplished leadership coach with over 22 years’ experience coaching and 12 years mentoring leaders.

• Afternoons: Guest speakers and focused sessions on pharmacy margins, operational excellence, and implementation support.

If you would like more information or to register your interest in upcoming January 2026 dates email Brian: brian@pharmacysuccess.ie

Chris Macey, Director of Advocacy and Patient Support with the Irish Heart Foundation said, “We need to review average sentencing and fines for cigarette smuggling; when you compare the penalties against the damage being done, the punishment doesn’t seem to fit the crime.”

The Government also needs to fast track last year’s promised 50c/ml tax on vapes, and an awareness campaign helping people to quit – neither of which have been rolled out.

Mr Macey added “Every day that goes by, more kids are going to be lost to lifelong nicotine addiction.”

The Foundation is also imploring the Government to fully implement the National Stroke Strategy and ensure the National Review of Cardiac Services is properly funded.

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10

News

HPRA Detains almost 400,000 Units of Illegal Medicines The Health Products Regulatory Authority (HPRA) has reported that 382,395 dosage units* of falsified and other illegal medicines were detained between January and June 2025. Recent detentions include sedatives, anabolic steroids, erectile dysfunction medicines, and more than 10,000 unauthorised GLP1 patches claiming to contain semaglutide or tirzepatide. The HPRA is reminding the public today that purchasing prescription medicines from unregulated sources means you can't be sure what you're getting.

These products may be unsafe, ineffective, or fake—and could seriously harm your health.

Gráinne Power, Director of Compliance at the HPRA

In the first six months of 2025, the most significant categories of illegal products detained included sedatives (30%), anabolic steroids (16%), erectile dysfunction medicines (16%), GLP-1 products, (6%), and analgesics (5%). The breakdown, with comparisons to the previous six-month period (JulDec 2024), is as follows: • Sedative medicines – 114,916 units detained (65,913 units in H2 2024) • Anabolic Steroids – 62,751 units detained (42,981 units in H2 2024) • Erectile dysfunction medicines – 60,184 units detained (46,658 units detained in H2 2024) • GLP-1 products – 11,350 units detained (716 units detained in H2 2024) • Analgesics – 17,454 units detained (17,074 units detained in H2 2024)

or tirzepatide. These include unauthorised tablets, pens and vials as well as the growing trend of transdermal patches. While unauthorised patches we sent for testing did not contain semaglutide as was claimed, you simply don’t know what you are purchasing.

These products are not authorised medicines, have no proven efficacy, and should not be used under any circumstances.”

With 2,820 websites, webpages, e-commerce listings and/or social media pages amended or shutdown in the first six months of 2025, cyber interventions for the first six months of 2025 In conclusion, Ms Power have already surpassed the stressed that “prescription whole of 2024 (2,553). These medicines obtained online actions include the removal or from unregulated sources of approximately 263 Shopify may be counterfeit, falsified or product listings, 30 Facebook contaminated. These factors profiles, and 689 Facebook adverts pose a serious threat to the health Gráinne Power, Director of Compliance at the HPRA,claims highlighted promotion of these unauthorised featuring spurious relating the ongoing detentions of illegal of anyone who uses them. The products, an emerging trend to medicines, medical devices and unauthorised medicines and emphasised the serious risks they pose to the public.

HPRA strongly advises the public identified in early 2025, make and cosmetics, with some using to safeguard their health by only claims as to HPRA approval as the HPRA logo consumers to falsely claim “We remain deeplyfrom concerned risks that are takingusing when they attempt to obtain prescription medicines well as endorsement national by the featured products were endorsed under thenotable guidanceincrease of a qualified charities, hospitalsonline and individual illegal medicines and from other sources. There has been in the by theunregulated HPRA. healthcare professional and by healthcare professionals. All these prevalence of unauthorised GLP-1 products claiming to contain semaglutide, liraglutide or sourcing products authorised for claims are untrue. Microneedle Gráinne Power, Director of from a registered patches containing Compliance at pens the HPRA, tirzepatide.

These semaglutide, include unauthorised tablets, and vials as wellthe asIrish the market growing trend of pharmacy. We urge anyone who tirzepatide or any GLP-1 type highlighted the ongoing transdermal patches. While unauthorised patches we sent for testinghas didpurchased not contain semaglutide as prescription medicine are not available as detentions of illegal and unauthorised was claimed, you treatments. simply don’t know what you are purchasing. products from are not authorised approved medical unauthorised medicines and These medicines sources to stop using them Results fromhave recent testing serious risksunder they any medicines, noHPRA proven efficacy,emphasised and shouldthenot be used circumstances.” immediately and seek advice from of a sample of these transdermal pose to the public. a healthcare professional if they patches found that they did not “We “prescription remain deeply concerned In conclusion, Ms Power stressed that medicines obtained or from unregulated haveonline any concerns.” contain semaglutide, despite the by the risks that consumers are claims made in their promotion sources may be counterfeit, falsified or contaminated. These factors pose a serious threat to the The HPRA welcomes reports of taking when they attempt to obtain and packaging. health of anyone who uses them. The HPRA strongly advises the public to safeguard their health by suspicious activities linked to the illegal medicines online and from supply of medicines and other As part of its enforcementmedicines remit, other unregulated sources.

There only using prescription under the guidance of a qualified healthcare professional and by health products. Anyone can the HPRA continues to monitor has been notable increase in sourcing products authorised for the marketoffrom a registered pharmacy.

We urge to anyone who report in confidence the HPRA and disrupt online activity theIrish prevalence unauthorised at reportacase@hpra.ie or at promoting unapproved medicines, GLP-1 products claiming to has purchased prescription medicines from unauthorised sources to stop using them immediately medical devices, and cosmetics. contain semaglutide, liraglutide 01 634 3871.

and seek advice from a healthcare professional if they have any concerns.”

Other of note notedetained detainedbybythe the HPRA: Other products products of HPRA:

A total of 11,350 GLP-1 type medicines were detained including products promoted as containing semaglutide, liraglutide or tirzepatide. Authorised GLP-1 prescription-only medicines are intended for specific medical purposes such as diabetes or weight management under certain conditions. While 533 of the detained products included unauthorised tablets, pens and vials containing powder or clear liquid, the HPRA also detained a further 10,817 transdermal delivery microneedle patches. It is claimed these patches contain semaglutide or tirzepatide. The online

PHARMACYNEWSIRELAND.COM The HPRA welcomes reports of suspicious activities linked to the supply of medicines and other

health products. Anyone can report in confidence to the HPRA at reportacase@hpra.ie or at 01 634

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COMMERCIAL FEATURE Anne Smyth, Life Pharmacy Dundalk, Co. Louth

Celebrating 60 Years in Business: A Career Rooted in Family and Community

“My mum was an amazing businesswoman.

She juggled six kids and embraced the local neighbourhood. We lived above the pharmacy, so she was on call 24 hours a day, seven days a week”.

Born into a busy household of six children, pharmacy was in Anne’s bl ood f r o m t h e v e ry beginning. Her mother was a pioneering pharmacist and businesswoman, running a local community pharmacy from their family home. Living above the pharmacy meant Anne’s mother was on call 24/7, her unique selling point in the community of Dundalk, answering to people at all hours for medicines and advice.

Her mother’s dedication left a lasting impression on Anne, but ironically, none of her older siblings followed their mother into the profession.

“My Leaving Cert results were mediocre and nowhere near good enough for pharmacy. The funny thing was, it was only when I saw my results that I realised I really did want to do pharmacy”.

After attending a boarding school in Kilkeel and two years of hard work, Anne was offered a place in both Queen’s University Belfast and Trinity College Dublin, ultimately choosing Trinity.

When Anne qualified in 1991, she returned straight

to her family’s pharmacy in Dundalk. Her return marked a turning point for her mother. After years of commitment to the pharmacy, Anne’s mother retired with Anne taking her place.

“The day I qualified and walked in the door, my mother passed the baton to me. It felt like the right time after she had dedicated so much of her life to the pharmacy”.

Like her father, who once stepped in to keep the pharmacy running when her mother was ill, Anne sees herself as both a caretaker of people and of the business. Anne believes that too often pharmacists undervalue themselves by

providing services free.

Learning to balance care with business was a turning point for her.

Once she introduced a fee for services, people valued her even more, and the demand for her services grew.

“I’m more like my father in many ways — I love the business and the people side. And I think today’s pharmacists need to be more business savvy.

Valuing yourself makes others value you”.

Covid-19 brought unexpected challenges. To protect the business. Anne split her team into two and while one team was on the other team was off. Since

then, she has embraced a four-day working week. It’s a shift Anne sees mirrored in younger generations, who put a great emphasis on work-life balance. Anne understands the value of time away from business as well as time in it.

“We worked incredibly hard on those days on, It was one of the best things that happened to me in terms of balance”.

testing, travel vaccines — all of these let us interact directly with patients”.

These moments create a s p ace f o r ge n u in e conversations and connections, allowing Anne the ability to make a real difference in people’s everyday lives.

For Anne, the rewards aren’t in policy or profit but in the people. Since the pandemic, she has

noticed a clear shift in how pharmacists are perceived, no longer just a convenient option, but often the first port of call for people’s health concerns. That trust has made pharmacists in their communities, a role Anne takes great pride in.

“It reminded me why I do this — the appreciation of people whose lives you touch.”

And Anne’s advice for

In 2008, Anne’s Dundalk store was the very first Life Pharmacy in Ireland chosen as the pilot site for the new retail concept by Uniphar.

The shift marked a turning point in Anne’s career, allowing her to expand her services beyond illness into wellness, prevention and lifestyle. Anne has since embraced the idea that a pharmacy is more than just a place to collect prescriptions, it is a hub for living well.

“I became the pilot — the first Life Pharmacy in Ireland, around 2008.

It was one of the best business decisions of my life”.

Anne has witnessed first hand how the role of the pharmacist has evolved over the years, from a service focused largely on dispensing medicines to one that sits at the very centre of community healthcare.

Today’s pharmacies are hubs of support and advice and for Anne, these opportunities are the most rewarding part of the job.

“The number of prescriptions is ever growing; it’s the expansion of services is what I love.

Vaccinations, blood pressure checks, diabetic

Join Life Pharmacy Life Pharmacy is always looking to expand its community of independent pharmacists. To learn more about joining, contact Laura Garrett at lgarrett@uniphar.ie or speak to any Life Pharmacy board member.

anyone considering a career in pharmacy?

“You need to really enjoy interacting with people and caring for them. That’s the heart of it. For me, it’s in my genes — I love my work, however you’re only as good as the people you have on board and I take immense pride in minenone of this would have been possible without the incredible team I’ve built up over the years."

14

News

Celebrating Excellence at the PHX Ireland Recognising People Awards 2025 PHX Ireland placed its people firmly in the spotlight last month, as colleagues from across the group gathered at the Mansion House, Dublin, for the Recognising People Awards.

AI in Healthcare The Graduate School of Healthcare Management at RCSI University of Medicine and Health Sciences has announced a brand-new, ground-breaking AI in Healthcare course, delivered in partnership with Microsoft and featuring a lifelike AI-powered avatar of Dr John Sheehan, consultant radiologist and healthtech innovator.

The programme is open to all with an interest in the topic, but is particularly geared towards healthcare professionals, managers, administrators and allied healthcare professionals seeking to understand and apply AI in clinical and nonclinical roles, with no prior AI experience required.

The course, a pioneering new offering among RCSI’s Postgraduate portfolio, was announced at a keynote event at the WHX Tech conference in Dubai, where RCSI has a significant regional hub and alumni base.

The event highlighted the individuals and teams whose commitment and values drive the success of PHX Ireland’s businesses, which include McCabes Pharmacy, United Drug, TCP Homecare and PHX Ireland itself.

Now a key date in the company calendar, the awards are designed around PHX Ireland’s six values: customer focused, quality driven, collaborative, ambitious, innovative and inclusive. With more than 550 nominations submitted and 90 finalists recognised across nine categories, the ceremony underlined the dedication and passion that exists within the organisation.

Hosted by broadcaster Darren Kennedy, the evening saw senior leaders present awards and share their admiration for colleagues’ achievements. CEO Paul Reilly opened and closed proceedings with words of encouragement, reinforcing the pride felt across the group.

After the formalities, celebrations continued with music from Smash Hits, rounding off a night that combined recognition with a sense of community.

Award Winners 2025

More than Awards

• Customer Focused: Orlagh Dunne, United Drug Wholesale & McCabes Pharmacy, The Mill Shopping Centre

The Recognising People Awards go beyond individual accolades. They reflect PHX Ireland’s wider mission to deliver health: supporting patients and customers, strengthening pharmacy and healthcare partnerships, and fostering innovation across its network.

• Quality Driven: Niamh Banks, PHX Ireland & Pharmacovigilance Team, TCP Homecare • Collaborative: Retail Rebranding Team, McCabes Pharmacy

• Innovative: Fiona O’Connell, McCabes Pharmacy

Every nomination carried a story of commitment and teamwork, underscoring that it is the people across PHX Ireland who enable the group to deliver health, grow its partnerships, and build on its role as a trusted healthcare partner in Ireland.

• Inclusive: Ray Lynch, United Drug Distributors

Why It Matters to the Supply Chain

• Employee of the Year: Karen O’Hora, TCP Homecare

For pharmacists, manufacturers and suppliers alike, these awards are a reminder that the strength of PHX Ireland lies in its people.

By investing in a culture built on shared values, PHX Ireland reinforces the reliability and collaboration that underpin its partnerships. In practice, this means more effective supply chain connections, better service for pharmacies, and ultimately, improved care for patients.

• Ambitious: Trading Team, PHX Ireland

• Team of the Year: Learning & Development, PHX Ireland • Manager of the Year: Mary Higgins, PHX Ireland • Spirit of PHX: McCabes Pharmacy Letterkenny • We Deliver Health: The Kaizenators, United Drug Wholesale

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Dr John Sheehan, consultant radiologist and adjunct faculty, RCSI Graduate School of Healthcare Management, said: “AI isn't replacing clinicians – it's amplifying our capabilities and allowing us to focus on the human elements of care.

“The rapid evolution of AI creates an urgent need for safe, ethical and effective adoption that supports clinicians, patients, and health systems. Here are four things that everyone, from senior professionals to patients, would agree we need: safer clinical decision-making, smarter resource allocation, more compassionate patient care, and enhanced professional development.

“How can we use AI to achieve these shared goals? Solutions are already available, and this course is an important milestone on that journey for newcomers and experienced professionals alike.”

Dr Sheehan trained at Northwestern Memorial Hospital in Chicago, has held clinical and strategic roles at Blackrock Health, Mobile Medical Diagnostics and xWave Technologies, and serves as Chair of Innovation at the AIMS Summit. Participants in his programme study practical examples, case studies, and interactive elements across four modules: Core Concepts and Applications, Ethics, Safety & Governance, Clinical Applications, and Administrative Applications.

As Ireland’s leading healthcare provider, PHX Ireland places people at the heart of everything we do. From supply chain to retail pharmacy through to clinical home nursing, our goal is to make a real, lasting difference to our patients and communities health across Ireland.

Discover our values, explore career opportunities, and see how we’re shaping the future of healthcare at www.phxireland.ie Follow us on LinkedIn for updates on our progress, our teams and industry news.

16

Oral Health

When Strong Bones Come at a Cost: Bisphosphonates and the Hidden Risks to Dental Health Written by Sandra Byrne, The Dental Health Foundation Bisphosphonates have transformed bone health for millions of patients. From menopausal women fighting osteoporosis to cancer patients living with metastatic bone disease, these drugs offer protection against fractures and skeletal complications that can devastate quality of life. But there’s a catch: what helps strengthen bones elsewhere in the body may carry unexpected risks for the jaw, with serious consequences for dental treatment and oral health.

Welcome to the complex world of bisphosphonates and dentistry, where fracture prevention meets the real danger of jawbone necrosis.

The Bone Builders Bisphosphonates work by slowing down the cells that break down bone (osteoclasts), tipping the balance towards stronger, denser bone. They are widely prescribed for: • Osteoporosis in postmenopausal women • Paget’s disease of bone • Cancer-related bone complications (including breast, prostate, and multiple myeloma) • Hypercalcaemia of malignancy For women after menopause, oral agents such as alendronate and risedronate are household names. Cancer patients, meanwhile, may receive powerful intravenous versions like zoledronic acid or ibandronate.

The benefits are clear: fewer fractures, greater independence, and protection against painful skeletal events. But these benefits come with a rarely discussed trade-off.

The Jaw: A Unique Vulnerability The jaw is unlike any other bone in the body. It has one of the highest turnover rates, is constantly subjected to mechanical forces from chewing, and lives in close contact with a world of bacteria.

When bisphosphonates suppress bone renewal, the jaw can become unable to repair itself after even minor trauma.

The result, in some cases, is medication-related osteonecrosis of the jaw (MRONJ)—dead bone that becomes exposed and fails to heal. It can follow a tooth extraction, dental implant, or sometimes occur spontaneously.

How Big Is the Risk?

The numbers tell an important story: High-dose IV

bisphosphonates (typically used in oncology): risk of MRONJ between 1–10%. Oral bisphosphonates (osteoporosis treatment): risk well under 0.1%, but higher after more than four years of continuous use.

Other risk factors include poor oral hygiene, smoking, diabetes, steroid use, and invasive dental procedures. Unsurprisingly, women make up a large proportion of cases, as they are the main users of osteoporosis medications post-menopause.

Why Does MRONJ Happen?

The precise science is still debated, but several theories overlap: • Blocked bone turnover: without osteoclast activity, microdamage accumulates.

• Poor blood supply: Bisphosphonates reduce blood vessel formation, slowing healing.

• Oral bacteria invasion: infections can set in when the bone is exposed.

Everyday Care • Regular cleanings, meticulous oral hygiene, and early treatment of gum disease are essential.

• Fillings, root canals, and other non-invasive treatments are safe and should be prioritised over extractions.

• Dentures must be carefully fitted to avoid causing trauma to the gum and underlying bone.

Surgical Decisions • Extractions and implants should be avoided if possible. If unavoidable, dentists may use minimally invasive techniques alongside antibiotics and antiseptic rinses.

• Patients require close followup, as early detection of MRONJ dramatically improves outcomes.

Beyond the Mouth: Wider Consequences The impact of bisphosphonaterelated jaw problems goes well beyond the dental chair.

• Chewing stress: repetitive strain makes the jaw more vulnerable.

• Nutrition: Patients with jaw pain or missing teeth may struggle with eating, leading to poor diet and frailty.

The result is often painful, exposed bone that can last for months, impairing eating, speaking, and quality of life.

• Mental health: Living with chronic pain, oral disfigurement, or fear of dental treatment takes a psychological toll.

Dentistry in the Age of Bisphosphonates

• Adherence: Some patients, especially menopausal women, stop taking their osteoporosis medication for fear of jaw problems, only to face a much higher risk of fractures instead.

For dentists, treating patients on bisphosphonates requires an extra layer of caution. What would normally be a routine extraction or implant can turn into a long-term complication.

Prevention First Ideally, patients undergo a full dental check-up before starting bisphosphonates, especially intravenous forms. Any necessary extractions, periodontal care, or restorative work should be completed before treatment begins.

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Pharmacists on the Frontline Pharmacists are often the first point of contact for patients collecting their prescriptions. Their role in bridging the medical and dental divide is crucial.

• Educate: Patients need to know the importance of regular dental care, oral hygiene, and reporting symptoms like jaw pain or loose teeth.

• Reassure: Context matters, oral bisphosphonates for osteoporosis carry a very low risk of MRONJ, and the fractureprevention benefits far outweigh the dangers.

• Coordinate: Pharmacists can flag bisphosphonate use to dentists, ensuring both sides are aware before invasive procedures.

• Support adherence: With long-term therapy, reminders and encouragement make a real difference, especially for women reluctant to stay on treatment.

What About Alternatives?

The conversation around bone drugs is evolving: • Drug holidays: Some clinicians pause bisphosphonates before surgery, though their long half-life means the benefits are limited.

• Denosumab: An increasingly popular alternative, denosumab is reversible and wears off quickly, making dental surgery planning easier. But it also carries a risk of MRONJ. • Future directions: Researchers are investigating biomarkers that may predict MRONJ risk, potentially offering a way to tailor treatment more safely.

The Takeaway Bisphosphonates save bones, but sometimes at a cost to the jaw. For many patients, especially postmenopausal women on oral therapy, the risk is tiny compared to the benefits. However, when complications arise, they can be life-changing.

That’s why collaboration between GPs, pharmacists, dentists, and specialists matters. With good preventive care, clear communication, and patient education, the risks of jaw damage can be kept in check, allowing patients to continue reaping the life-saving benefits of bisphosphonates without unnecessary fear.

Interactions: Se SPC for detailed information. Inhibitors of the cytochrome P450 (CYP) isoforms 3A4 (major oute) and 2C9 (minor oute) isoenzymes uch as CYP3A4 inhibitors: Itraconazole, ketoconazole, erythThe romycin, cimetidine, HIend V protease inhibitorof saquinavir: Maerectile y reduce sildenafil clearance and increasproblems? e sildenafil plasma levels. Consider a starting dose of 25 mg. Strong CYP3A4 inducers e.g. rifampicin may increase sildenafil clearanTouch ce and decrease sildenafil plasma cwood. oncentrations. Grapefruit juice: May give rise to modest increases in plasma levels of sildenafil. Nicorandil (Hybrid of potas ium chan el activator and nitrate): Due to the nitrate component it has the potential to have serious interaction with sildenafil. Sildenafil potentiates the hypotensive effect of nitrates. Alpha blocker: Concomitant administration of sildenafil may lead to symptomatic hypotension in a few susceptible individuals. Patients should be hemodynamical y stable on alpha-blocker therapy prior to init ating sildenafil treatment. Sildenafil potentiates the antiag regatory effect of sodium nitroprus ide in vitro. Not recommended in patients with a history of ble ding disorders or active peptic ulceration. Not recommended to use with other pulmonary arterial hypertension treatment containing sildenafil. Caution when sildenafil is init ated in patients treated with sacubitril/valsartan. May result in a increase of bosentan availabil ty.

Ability to Drive and Use Machinery: Minor influence, diz ines and altered vision were reported. Patients should be aware of how they react o sildenafil before driving or using machinery. Undesirable Effects: Very common: Headache. Common: Diz ines , visual disorders, visual colour distortion, vision blur ed, flushing, hot flush, nasal congestion, nausea, Available over the counter. No prescription required. dyspepsia. Se SPC for more adverse effects.

Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork. Marketing Authorisation Number: PA 071 /170/0 2. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Fre phone: 180 304 40 Fax: 027 50417 E-mail: rowex@rowa-pharma.ie Adverse events should be reported. Reporting forms and information can be found on the Legal Category: Not subject o medical prescription.

HP R A we b s i t e ( w ww. h p r a . i e ) o r b y e m a i l n g R o w e x p v @ r o w a p h a r m a . i e Date of Preparation: Jan 2024 Always read the leaflet. Available in a 4 or 8 pack.

ABBREVIATED PRESCRIBING INFORMATION Product Name: Sidena 50 mg Tablets.

Composition: Each tablet contains, 50 mg sildenafil (as citrate) .

Description: Light blue, round, slightly dotted tablets. Cross breaking notch on one side and marked ‘50’ on the other side. Can be divided into equal quarters. (Only two quarters of the 50 mg is covered by posology).

Indication(s): Treatment of men with erectile dysfunction, which is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance.

Dosage: Adults and elderly: 50 mg taken as needed approximately one hour before sexual activity. Dose may be decreased to 25 mg. Max dose: 50mg once daily. Impaired renal and hepatic function: Sildenafil clearance is reduced in hepatic and severe renal impairment. Consider a dose of 25 mg. Dose may be increased step-wise to 50 mg if tolerated. Children and adolescents below 18 years of age: Contraindicated. Use in patients using other medicines: Starting dose of 25 mg with CYP3A4 inhibitors (not advised to use with ritonavir). To minimise postural hypotension in patients receiving and alpha-blocker, stabilise patient first on the alpha blocker and use a starting dose of 25 mg sildenafil.

Contraindications: Hypersensitivity to sildenafil or any of the excipients. Concomitant with ritonavir, nitric oxide donors or nitrates in any form, guanylate cyclase stimulators e.g. riociguat.

In patients that sexual activity is inadvisable (e.g. severe cardiovascular disorders such as a recent (6 months) acute myocardial infarction (AMI) or stroke, unstable angina or severe cardiac failure). Refer these patients to a doctor. Patients with loss of vision in one eye due to NAION. Known hereditary degenerative retinal disorders. Severe hepatic impairment. Hypotension.

Anatomical deformation of the penis. Not intended if no erectile dysfunction. Women.

Warnings and Precautions for Use: First diagnose erectile dysfunction and determine potential underlying causes (e.g. hypertension, diabetes mellitus, hypercholesterolaemia or cardiovascular disease), before considering pharmacological treatment. Consider the cardiovascular status of patients, since there is a degree of cardiac risk associated with sexual activity.

Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death, ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and hypotension have been reported post-marketing in temporal association with the use of sildenafil. Most, but not all, of these patients had pre-existing cardiovascular risk factors. Sildenafil has vasodilator properties, resulting in mild and transient decreases in blood pressure. Caution: Patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). Advise patients that in case of priapism, prolonged erections (longer than 4 hours) or sudden visual defect, they should stop taking sildenafil and consult a physician immediately. Administer to patients with bleeding disorders or active peptic ulceration only after careful benefit-risk assessment, as there is no safety information available.

Interactions: See SPC for detailed information. Inhibitors of the cytochrome P450 (CYP) isoforms 3A4 (major route) and 2C9 (minor route) isoenzymes such as CYP3A4 inhibitors: Itraconazole, ketoconazole, erythromycin, cimetidine, HIV protease inhibitor saquinavir: May reduce sildenafil clearance and increase sildenafil plasma levels. Consider a starting dose of 25 mg. Strong CYP3A4 inducers e.g. rifampicin may increase sildenafil clearance and decrease sildenafil plasma concentrations. Grapefruit juice: May give rise to modest increases in plasma levels of sildenafil. Nicorandil (Hybrid of potassium channel activator and nitrate): Due to the nitrate component it has the potential to have serious interaction with sildenafil. Sildenafil potentiates the hypotensive effect of nitrates. Alpha blocker: Concomitant administration of sildenafil may lead to symptomatic hypotension in a few susceptible individuals. Patients should be hemodynamically stable on alpha-blocker therapy prior to initiating sildenafil treatment. Sildenafil potentiates the antiaggregatory effect of sodium nitroprusside in vitro. Not recommended in patients with a history of bleeding disorders or active peptic ulceration. Not recommended to use with other pulmonary arterial hypertension treatment containing sildenafil. Caution when sildenafil is initiated in patients treated with sacubitril/valsartan. May result in a increase of bosentan availability.

Ability to Drive and Use Machinery: Minor influence, dizziness and altered vision were reported. Patients should be aware of how they react to sildenafil before driving or using machinery. Undesirable Effects: Very common: Headache. Common: Dizziness, visual disorders, visual colour distortion, vision blurred, flushing, hot flush, nasal congestion, nausea, dyspepsia. See SPC for more adverse effects.

Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork. Marketing Authorisation Number: PA 0711/170/002. 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 Adverse events should be reported. Reporting forms and information can be found on the Legal Category: Not subject to medical prescription.

HPRA website (www.hpra.ie) or by emailing Rowex pv@rowa-pharma.ie Date of Preparation: Jan 2024

Date of preparation: (10-24) CCF: 26643

Supply status: Supply through pharmacies only.

Date of preparation: (10-24) CCF: 26643

Supply status: Supply through pharmacies only.

18

Smoking Cessation

Towards a Tobacco Free Ireland: Wins, Challenges and the Road Ahead Written by: Foley E1, MB BCh BAO MRCPI, Respiratory SPR Interventional Respiratory Unit, Galway University Hospital Breen D1, MB BA BCh BAO MRCPI MRCP(UK) Consultant Respiratory Physician/ Lung Cancer Lead Galway University Hospitals 1. Interventional Respiratory Unit, Department of Respiratory Medicine, Galway University Hospitals, Galway, Ireland.

Corresponding author: Dr Eimear Foley: Interventional Respiratory Unit, Galway University Hospital, Newcastle Road, Galway, Ireland, H91 YR71. Email: Eimear.foley3@hse.ie Phone: 087-9704990 Abstract: Tobacco use remains Ireland’s leading cause of preventable death, with lung cancer the number one cause of cancer-related death in the country. Despite excellent progress through the Tobacco Free Ireland Programme (TFIP)— including the Tobacco 21 legislation and universal access to nicotine replacement therapy—smoking prevalence persists at 17%, and youth vaping rates are rising. National initiatives like Quitline, Quit4Youth, and We Can Quit have expanded cessation access, yet challenges remain in mental health settings, illicit supply, and youth uptake. While Ireland has achieved global recognition in tobacco control, intensified enforcement and innovative strategies are essential to realise a truly tobacco-free future.

Dr Eimear Foley

Introduction The evidence remains stark, with the WHO highlighting the following statistics; Tobacco use is the leading cause of preventable death in Ireland with 4,500 smokers dying each year from tobacco-related diseases.1 Tobacco kills up to half of users who do not quit.2,3,4 Tobacco is responsible for over 7 million deaths annually, including an estimated 1.6 million non-smokers who are exposed to second-hand smoke as well as disability and longterm suffering from tobaccorelated diseases.5 The younger you are when you start smoking, the more likely you are to smoke for longer and to die early from smoking.6

Dr David Breen

Despite the glaring data and devastating consequences of smoking-related lung damage, the tobacco epidemic continues to be one of the biggest public health threats faced by society. The 2024 Healthy Ireland (HI) survey reports that 17% of the Irish population are current smokers, of which 14% are daily and 4% occasional smokers.

Smoking rates remain highest among the 25 to 34 age group at 20%, However it must be noted that this is a significant decline from 32% reported in the first Healthy Ireland Survey in 2015.

Cigarette smoking remains the most common form of tobacco use worldwide but there is growth in the industry of electronic cigarettes - the most common form of electronic nicotine delivery systems (ENDS), commonly referred to as ‘vaping’. Multiple forms exist including disposable vapes, pod systems, pen-style

PHARMACYNEWSIRELAND.COM

vapes and box mods. These contain varying amounts of nicotine and additional harmful emissions. The World Health Organisation (WHO) state that there is no safe level of tobacco use and calls for comprehensive bans on flavoured tobacco and nicotine products to prevent youth addiction. The current evidence reveals that these products are harmful to health, however unfortunately it is too early to provide clear data on the longterm impacts.

The overall objectives of the TFIP are to support people in smoking cessation and treat tobacco dependence as a healthcare issue, prioritising the protection of children and contributing to the de-normalisation of tobacco use for future generations. As we approach the end of the current Tobacco free Ireland policy in 2025, we will critically appraise the areas addressed to highlight the key successes to date and offer an outlook on the next steps for efficient tobacco control in Ireland.

Overall 8% of our Irish population currently use e-cigarettes either daily (5%) or occasionally (3%) – this figure has not declined since 2023. Most concerningly, the central statistics office reported in 2024 that 9.3% of our young people aged 15-19 years of age use e-cigarettes daily, a staggering increase from 4.7% reported in 2022, having peaked at 12.3% in 2023. The prevalence of nicotine pouches which are strongly linked to oral cancer was as high as 8.1% in the Irish population in 2024.7

Legislative Compliance and Regulating the Retail Environment

In 2004, Ireland became the first country to pass a smoke-free law, and furthermore in 2021 the WHO recognised Ireland as a global leader in tobacco control due to its innovative policies.

The HSE’s Tobacco Free Ireland Programme (TFIP) Implementation Plan for 2022–2025 set a national target to be tobacco free (i.e. with a smoking prevalence rate of less than 5%) by the year 2025. This policy focuses on a number of key pillars in smoking cessation and lays out a robust, multi-dimensional path toward achieving their goal by integrating governance, policy, clinical practice and public engagement Nationally.

Firstly it must be acknowledged that there are significant gains obtained from the major law changes delivered as part of the TFIP nationwide implementation plan. Under the Public Health Tobacco Amendment Act 2024; Ireland is increasing the minimum legal age for the sale of tobacco products from 18 to 21, thus becoming the first EU country to implement such a policy. US studies indicate that Tobacco 21 laws reduce both smoking rates among 15–20 year-olds and limit social supply, therefore this legislation which was passed by Dail Eireann in November 2024 (and taking effect from February 1st 2028), is seen nationally as a gamechanger in protecting our children and future generations from tobacco addiction.

These law changes are predicted to have a major beneficial effect on our society. It has been shown that people who start smoking at a younger age are more likely to continue to smoke through their adult life.6 In addition, the 2024 Eurobarometer report

19

Tobacco Free Ireland

15-19 year olds now vaping daily in Ireland, the need to protect our youth from tobacco addiction has never been more important. Childprotection and denormalisation steps have advanced significantly with the legislation changes outlined above.

The implementation plan has also rolled out an awareness training programme for youth workers on nicotine addiction, the prevention of E-cigarette and smoking initiation – for example, the HSE Youth Prevention Toolkit and the Quit4Youth 7 week programme provide behavioural support from advisors and other participants to promote vaping and smoking cessation. The tobacco free Ireland team have engaged with mental health service Spunout who actively highlight and link young people with these available supports.

The HSE's Tobacco Free Campus Policy has mandated that smoking by employees, patients, visitors and any other parties is prohibited on all HSE campuses since December 2015 (9). However, compliance with this policy is poor with a recent audit showing that up to 11% of people observed on hospital grounds had a cigarette in their hand.

demonstrated that children in Ireland start smoking at a younger age than the European average.8 In addition, the Public Health Tobacco Products and Nicotine Inhaling Products (TPNIP) Act 2023 has introduced phased commencements. The first measure, implemented in December 2023 introduced a ban on selling tobacco products and ENDS to individuals under 18. In addition the legislation restricts advertising near schools and on public transport.

Vending machines are consistently more accessible to minors than over-the-counter sales. To combat this, the Act has implemented (in September 2025) a ban on selfservice sales of these products from vending machines. At the time of writing, 2/3 of signatories to the WHO Convention have already banned the sales of tobacco products from vending machines, with Scotland, England, Wales and Northern Ireland introducing the ban over 10 years ago.

A national licensing regime was announced by Minister Donnelly in January 2025 - strengthening compliance leverage - and will come into operation in February 2026 with annual licences legally

required for the sale of tobacco and nicotine inhaling products for each premises from which either product is sold. The law prohibits the issue of licences for temporary or mobile premises including festival popups, emphasising that a product that kills one out of every two of its users is not to be treated like other consumer products.

These legislations will have a knock-on effect in prohibiting ease of tobacco access for the younger population and preventing the start of a lifelong habit.

Challenges remain in the form of illicit supply, which undermines price-based deterrence and compliant retailing. A survey from the Irish Revenue in 2024 found that 26% of cigarettes packs held by smokers were illegal and a further 11% were non-Irish duty paid. The ability of under21s to source tobacco through informal and illegal channels will indeed blunt demand-reduction and compliance gains unless enforcement and cross-border controls keep pace.

Denormalisation of Tobacco Use and Promotion of Tobacco-Free Environments With 9.3% (almost 1 in 10) of our

In addition, Tobacco-free campus compliance is uneven - in particular, there is major difficulty in inpatient mental-health settings reported in the literature.

Tobacco Free Campus policy implementation across the Mental Health service is vital as smoking rates are disproportionately high throughout all areas of the mental health service with the highest rates in people with substance use disorders.10 Implementing strategies such as smoking cessation becoming a routine part of psychiatric care plans will not only have a positive impact on quality of life; both the physical and mental health needs of our patients, but also has the potential to realise significant cost savings for the HSE.10 Further work is required with Mental Health Services to advocate for and support the development of on-site smoking services for acute and community mental health services. In addition, tobacco-free campuses must be properly enforced. This should include the removal of designated smoking areas and active policies to support patients to take up nicotine replacement therapy (NRT) and ultimately to quit smoking.

HSE Leadership in Treating Tobacco Dependence as a Healthcare Issue The TFIP implementation plan, developed in 2022, outlines a clear national clinical framework

for smoking cessation In Ireland.

The National Clinical Effectiveness Committee’s (NCEC) Stop Smoking Clinical Guideline 2022 is a document that sets out best practice for treating tobacco addiction in the Irish healthcare system. This guideline focuses on health professionals to improve interventions for the general adult population, especially pregnant women and those with mental health issues as mentioned. It recommends an approach which combines pharmacological support and enhanced behavioural support services, with the goal of increasing successful quit attempts by providing evidence-based strategies and resources for smokers.

All of the commercially available forms of NRT are effective as part of a strategy to promote smoking cessation, with proven increased quit rates by 50-70% regardless of setting with NRT compared to no treatment.11 Interventions that combine pharmacotherapy with behavioural support also increase smoking cessation success at 6 months or longer compared with no support.12 This effect is consistent across trials.

The clinical guideline framework encourages all healthcare professionals to utilise the proven ASK–ADVISE–ARRANGE approach when assessing smoking status, advising on the best way to quit and finally recommending suitable medications while referring patients to specialised behavioural support services / a HSE stop smoking advisor.

As smoking cessation without professional help is achieved only in 3-5% of smokers in the longterm, this guideline is key in providing our health system with a common strategy to establish sustained cessation.

The development of an effective smoking cessation framework in the acute hospital setting has been proven by the Ottawa Model in Canada and the CURE project in the UK. A Smoking Cessation Proforma as part of the patient admission bundle was introduced on a pilot ward in Galway University Hospital in 2023. Supported by a poster campaign, the simple interventions included the introduction of a standardised approach to identification of smoking status and an optout referral of active smokers to smoking cessation services. Patients were easily identified this way with 19.7% of audited inpatients active smokers. During the 5 week pilot programme, smoking documentation rate increased from 64.4% to 85.7%, and 95% of tobacco users were referred to

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20

Smoking Cessation awareness of the importance of smoking eradication and in normalising cessation efforts.

However, this outreach now needs to be sustained. These campaigns should be tested and tailored for different demographic groups, especially younger adults, where smoking remains high and multiplatform approaches including utilisation of young influencers on social media may enhance reach to this cohort.

Conclusion As we approach the final quarter of 2025 and the end of the current plan, it must be acknowledged that there have been massive structural wins to celebrate from the TFIP implementation plan - primarily in terms of our legislative reforms.

As mentioned, TPNIP 2023, Tobacco 21 - 2024 and retail licensing laws launching in 2026 all show a clear commitment to continuing to denormalise tobacco and vaping by reducing their appeal and accessibility of products, particularly to young people.

local smoking cessation services, a significant improvement from the reported pre-intervention results (13%). These policies can be implemented successfully throughout Irish hospitals.

HSE Quit Resources now include the National Quit website, the Quitline (1800 201 203), open 7 days a week, and the successful provision of free NRT. These services are all standardised with national Quality Assurance (QA) standards and implemented across settings; digital QUIT plans and advisor-led programmes continue to attract users. The HSE moved to provide free NRT through stop-smoking services from 2023, with ongoing promotion and operational guidance in 2024–2025 focussed on providing universal access to pharmacotherapy in the form of gum, sprays, inhalers, lozenges and patches. Early evaluations have indicated increased NRT uptake, with record numbers of people using the QUIT service since it began providing free NRT in 2023. The HSE reported a 50% increase in NRT use among people using their service.

Another successful service is the ‘We Can Quit' Programme, delivered by community partners under the auspices of the Sláintecare Healthy Communities Initiative. This programme is a free, community-based, group support programme run by the HSE and partners to aid smoking cessation. They run for between 7–12 weeks, offering weekly group sessions and free NRT, with one-to-one facilitators providing

encouragement and advice in a non-judgemental environment.

Numerous groups are run by community organisations in every county throughout the country, focusing on community health inequalities, with further sites continuing to be developed.

Smoking in pregnancy is a leading public health challenge with both national and international studies highlighting the urgent need to improve stop-smoking care in pregnancy. This care gap was highlighted in the National Maternity Strategy (2016–2026) and an evidence-based care pathway was established in the 2022 new National Stop Smoking Clinical Guidelines.

A pilot implementation of the new care pathway was undertaken in two Irish maternity hospitals and found that 691 women were referred to a specialist Stop Smoking Midwives. Referrals were accepted by 81.6% of women and 23.4% set a quit date, with 14.5% of women delivering a smoke-free baby. This qualitative research highlights the importance of a non-judgemental approach in recruitment and engagement with women in the programme throughout the country, an important initiative which again should be targeted as an area we can continue to make important gains.

Monitoring Tobacco Prevalence and Evaluating Effectiveness of All Interventions The HSE Health & Wellbeing Reports have maintained smoking cessation activity on the radar

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via a suite of key performance indicators developed to monitor the impact of HSE funded tobacco control interventions. For example at the end of quarter 1 of 2024; HSE metrics show that nationally 5,909 smokers received intensive cessation support from a cessation counsellor which is -5.4% below the target of 6,246 but +8.3% ahead of the same period in 2023. The HSE has provided accountability via the QUIT Service Monitoring reporting quarterly and annual outputs (QUIT plan activations, advisor sessions delivered, NRT provision).

Ongoing surveillance of tobacco and e-cigarette use through the HSE Tracker Survey, Healthy Ireland Survey, Health Behaviour in School Children Surveys and the European School Survey Project on Alcohol and Other Drugs have been vital implementation tools to monitor where we stand.

Regular, transparent prevalence tracking works well to monitor progress, however, despite these interventions, the overall smoking prevalence is not on a trajectory to reach the eradication goal of <5% by 2025. The 2024 HI Survey provides up-to-date national data on smoking rates in Ireland. The data shows that 17% of the Irish population continues to smoke and the reality remains that Ireland won’t meet the desired target without extra measures.

The TFIP rollout included additional plans to develop and produce new media & public campaigns such as the QUIT TV and Radio campaigns which were revamped in 2023. Media outreach is a vital cornerstone in raising

In addition, service access has undoubtedly improved, most notably with universal access to free NRT which continues to support the reduction of smoking rates, alongside many other innovative services including We Can Quit, Quit4Youth, the National QUIT website and a 7 day-a-week Quitline. The clinical guideline dissemination and QA framework align well with the National Implementation Plan.

These strategies implemented to date highlight the commitment of the Tobacco Free Ireland team to enforcing smoking cessation, saving preventable deaths and taking a significant step towards achieving a Tobacco Free Ireland.

However, the data unfortunately shows a definite loss of momentum in that we are not reaching the perhaps overambitious target of a tobacco-free Ireland by the end of this year.

Meeting this goal in the near future will be dependent on accelerating the progress of our smoking cessation programs across all healthcare settings. Additional challenges have arrived including the evolving smoking habits of Irish people with the increasing popularity of ENDS, which will require ongoing adaptation of current smoking cessation practice and legislation. It is worth remembering that some of the aforementioned legislation announced will not come into practice until as late as 2028 and it will require additional time to fully bear the fruits of these new laws.

Unfortunately significant challenges remain. The annual HI Surveys suggest

Atorvastatin Teva Pharma replaces Atorvastatin Teva

Same GMS codes apply: 41990 (10 mg), 41991 (20 mg), 41992 (40 mg), 41993 (80 mg) Indications 10 mg, 20 mg, 40 mg and 80 mg film-coated tablets Hypercholesterolaemia Atorvastatin Teva Pharma is indicated as an adjunct to diet for reduction of elevated total cholesterol (total-C), LDLcholesterol (LDL-C), apolipoprotein B, and triglycerides in adults, adolescents and children aged 10 years or older with primary hypercholesterolaemia including familial hypercholesterolaemia (heterozygous variant) or combined (mixed) hyperlipidaemia (corresponding to Types IIa and IIb of the Fredrickson classification) when response to diet and other non-pharmacological measures is inadequate.

Atorvastatin Teva Pharma is also indicated to reduce total-C and LDL-C in adults with homozygous familial hypercholesterolaemia as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) or if such treatments are unavailable.

Prevention of cardiovascular disease Prevention of cardiovascular events in adult patients estimated to have a high risk for a first cardiovascular event, as an adjunct to correction of other risk factors.

Atorvastatin Teva Pharma Film-Coated Tablets Abbreviated Prescribing Information. Presentation: Each film-coated tablet contains 10mg, 20mg, 40mg and 80mg atorvastatin (as atorvastatin calcium). Indications: Hypercholesterolaemia: Atorvastatin Teva Pharma is indicated as an adjunct to diet for reduction of elevated total cholesterol (total-C), LDL-cholesterol (LDL-C), apolipoprotein B, and triglycerides in adults, adolescents and children aged 10 years or older with primary hypercholesterolaemia including familial hypercholesterolaemia (heterozygous variant) or combined (mixed) hyperlipidaemia when response to diet and other nonpharmacological measures is inadequate. Atorvastatin Teva Pharma is also indicated to reduce total-C and LDL-C in adults with homozygous familial hypercholesterolaemia as an adjunct to other lipid-lowering treatments (e.g.

LDL apheresis) or if such treatments are unavailable. Prevention of cardiovascular disease: Prevention of cardiovascular events in adult patients estimated to have a high risk for a first cardiovascular event, as an adjunct to correction of other risk factors. Dosage and administration: For oral administration. Adults: Usual starting dose is 10mg once a day, with adjustment of dose made at intervals of 4 weeks or more. Maximum dose is 80mg once a day. Primary hypercholesterolaemia and combined (mixed) hyperlipidaemia: Majority of patients are controlled with Atorvastatin Teva Pharma 10mg once a day. A therapeutic response is evident within 2 weeks, and the maximum therapeutic response is usually achieved within 4 weeks.

Heterozygous familial hypercholesterolaemia: Patients should be started with Atorvastatin Teva Pharma 10mg daily. Doses should be individualised and adjusted every 4 weeks to 40mg daily. Thereafter, either the dose may be increased to a maximum of 80mg daily or a bile acid sequestrant may be combined with 40 mg atorvastatin once daily. Homozygous familial hypercholesterolaemia: Limited data available. The dose of atorvastatin in patients with homozygous familial hypercholesterolemia is 10 to 80mg daily.

Atorvastatin should be used as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) in these patients or if such treatments are unavailable.

Prevention of cardiovascular disease: In the primary prevention trials the dose was 10mg/day. Higher doses may be necessary in order to attain (LDL-) cholesterol levels according to current guidelines. Children aged 10 years and above for Heterozygous Familial Hypercholesterolemia: Recommended starting dose is 10mg per day which may be increased to 80mg daily, according to the response and tolerability. Elderly: Efficacy and safety in patients older than 70 using recommended doses are similar to those seen in the general population. Renal impairment: No dose adjustment required.

Hepatic impairment: Atorvastatin Teva Pharma should be used with caution in patients with hepatic impairment. Atorvastatin Teva Pharma is contraindicated in patients with active liver disease Contraindications: Atorvastatin Teva Pharma is contraindicated in patients with: hypersensitivity to the active substance or to any of the excipients; active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal; during pregnancy, while breast-feeding and in patients of child-bearing potential not using appropriate contraceptive measures; treated with the hepatitis C antivirals glecaprevir/pibrentasvir.

Precautions and warnings: Liver function tests should be performed before the initiation of treatment and periodically thereafter. Patients who develop any signs or symptoms suggestive of liver injury should have liver function tests performed. Atorvastatin Teva Pharma should be used with caution in

Teva Pharmaceuticals Ireland, Digital Office Centre Swords, Suite 101 - 103, Balheary Demesne, Balheary Road, Swords, Co Dublin, K67E5AO, Ireland.

Freephone: 1800 - 201 700 | Email: info@teva.ie

Prescription Only Medicine.

patients who consume substantial quantities of alcohol and/or have a history of liver disease. For patients with prior haemorrhagic stroke or lacunar infarct, the balance of risks and benefits of atorvastatin 80mg is uncertain, and the potential risk of haemorrhagic stroke should be carefully considered before initiating treatment. Atorvastatin may in rare occasions affect the skeletal muscle and cause myalgia, myositis, and myopathy that may progress to rhabdomyolysis, a potentially life-threatening condition characterised by markedly elevated creatine kinase (CK) levels (> 10 times ULN), myoglobinaemia and myoglobinuria which may lead to renal failure. There have been very rare reports of an immune-mediated necrotizing myopathy (IMNM) during or after treatment with some statins. IMNM is clinically characterised by persistent proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment, positive anti-HMG CoA reductase antibody and improvement with immunosuppressive agents. In few cases, statins have been reported to induce de novo or aggravate pre-existing myasthenia gravis or ocular myasthenia. This medicinal product should be discontinued in case of aggravation of symptoms. Atorvastatin should be prescribed with caution in patients with pre-disposing factors for rhabdomyolysis. A CK level should be measured before starting statin treatment. The risk of treatment should be considered in relation to possible benefit, and clinical monitoring is recommended. If CK levels are significantly elevated (> 5 times ULN) at baseline, treatment should not be started. Exceptional cases of interstitial lung disease have been reported with some statins, especially with longterm therapy. Presenting features can include dyspnoea, non-productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued. Some evidence suggests that statins as a class raise blood glucose and in some patients, at high risk of future diabetes, may produce a level of hyperglycaemia where formal diabetes care is appropriate. Patients at risk (fasting glucose 5.6 to 6.9mmol/L, BMI>30kg/ m2, raised triglycerides, hypertension) should be monitored both clinically and biochemically according to national guidelines. Interactions: Please refer to the SmPC for a comprehensive list of drug interactions (including the effect of medicinal products on atorvastatin, and the effect of atorvastatin on other co-administered medicinal products). Risk of rhabdomyolysis is increased when atorvastatin is administered concomitantly with potent inhibitors of CYP3A4 or transport proteins (e.g. ciclosporin, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole, letermovir and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, tipranavir/ritonavir, etc).

The risk of myopathy may also be increased with the concomitant use of gemfibrozil and other fibric acid derivates, antivirals for the treatment of hepatitis C (HCV) (e.g. boceprevir, telaprevir, elbasvir/grazoprevir, ledipasvir/ sofosbuvir), erythromycin, niacin, or ezetimibe. If possible, alternative (noninteracting) therapies should be considered instead of these medicinal products. In cases where co-administration of these medicinal products with atorvastatin is necessary, the benefit and the risk of concurrent treatment should be carefully considered. When patients are receiving medicinal products that increase the plasma concentration of atorvastatin, a lower maximum dose of atorvastatin is recommended. In addition, in the case of potent CYP3A4 inhibitors, a lower starting dose of atorvastatin should be

considered, and appropriate clinical monitoring of these patients is recommended. The risk of myopathy and/or rhabdomyolysis may be increased by concomitant administration of HMG-CoA reductase inhibitors (e.g. atorvastatin) and daptomycin. Consideration should be given to temporarily suspend Atorvastatin Teva Pharma in patients taking daptomycin unless the benefits of concomitant administration outweigh the risk. If co-administration cannot be avoided, CK levels should be measured 2-3 times per week and patients should be closely monitored for any signs or symptoms that might represent myopathy. Atorvastatin must not be coadministered with systemic formulations of fusidic acid or within 7 days of stopping fusidic acid treatment. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving fusidic acid and statins in combination. The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness. Statin therapy may be re-introduced seven days after the last dose of fusidic acid. In exceptional circumstances, where prolonged systemic fusidic acid is needed, e.g. for the treatment of severe infections, the need for co-administration of Atorvastatin Teva Pharma and fusidic acid should only be considered on a case-by-case basis and under close medical supervision. Pregnancy and lactation: Patients of childbearing potential should use appropriate contraceptive measures during treatment. Atorvastatin Teva Pharma is contraindicated during pregnancy.

Atorvastatin Teva Pharma should not be used in patients who are pregnant, trying to become pregnant or suspect they are pregnant. Treatment with Atorvastatin Teva Pharma should be suspended for the duration of pregnancy or until it has been determined that the patient is not pregnant.

Patients taking Atorvastatin Teva Pharma should not breast-feed their infants. Atorvastatin is contraindicated during breast-feeding. Effects on ability to drive and use machines: Atorvastatin Teva Pharma has negligible influence on the ability to drive and use machines. Adverse reactions: Thrombocytopenia, anaphylaxis, peripheral neuropathy, myasthenia gravis, hearing loss, pancreatitis, hepatitis, hepatic failure, cholestasis, angioneurotic oedema, dermatitis bullous including erythema multiforme, StevensJohnson syndrome and toxic epidermal necrolysis, myopathy, myositis, rhabdomyolysis, muscle rupture, lupus-like syndrome, immune-mediated necrotizing myopathy, gynaecomastia, peripheral oedema. Common: Nasopharyngitis, allergic reactions, hyperglycaemia, headache, pharyngolaryngeal pain, epistaxis, constipation, flatulence, dyspepsia, nausea, diarrhoea, myalgia, arthralgia, pain in extremity, muscle spasms, joint swelling, back pain. Consult the Summary of Product Characteristics in relation to other side effects. Overdose: Specific treatment is not available for atorvastatin overdose. Should an overdose occur, the patient should be treated symptomatically and supportive measures instituted, as required.

Liver function tests should be performed and serum CK levels should be monitored. Due to extensive atorvastatin binding to plasma proteins, haemodialysis is not expected to significantly enhance atorvastatin clearance. Legal category: POM. Marketing Authorisation Number: PA1986/125/001-004. Marketing Authorisation Holder: Teva B.V., Swensweg 5, 2031GA Haarlem, Netherlands. Job Code: MED-IE-00099. Date of Preparation: July 2025

Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie.

Adverse events should also be reported to Teva UK Limited on +44 (0) 207 540 7117 or medinfo@tevauk.com

Date of Preparation: August 2025 | Job Code: GEN-IE-00149 Further information is available on request or in the SmPC. Product Information also available on the HPRA website.

22

Smoking Cessation nationwide providing continuity.

Publicising seizures to deter illicit supply may also be necessary.

that denormalisation among adolescents/young adults is not yet decisively improving despite the best efforts of the National Implementation programme. The overall population prevalence remains concerningly static at 17% and youth vaping with e-cigarettes remains at 8%.

Of Note, the UK government has placed a complete ban on the sale of disposable / single-use vapes, implemented in June 2025, with e-cigarettes and e-liquids also subject to these regulations, including restrictions on the

maximum nicotine strength – a policy that should now be strongly considered in Ireland.

Further progress can also be made with an increased focus on high-prevalence groups including tailored supports as discussed for both mental health and maternity sites. Campaigns utilising social media and influencers can target the under-25 population.

Smoking cessation policies should be implemented throughout our Irish hospitals, in line with the successful international Ottawa and CURE projects. Mandatory

Hseland training on smoking cessation for all healthcare staff across the board should be instated to emphasise the importance and remind us of the fact that it is all of our duties as healthcare professionals to continue to Ask-Advise-Arrange on a daily basis.

Expanding our Slaintecare communities is vital as is integration of the GP Healthlink IT system to provide direct referrals to the QUIT service, so that patients are prescribed NRT and swiftly linked with the available counsellors

In conclusion, we have much to be proud of as a leader in global tobacco control. However, despite admirable progress and unquestionable accountability from the HSE TFIP, the end of the epidemic of smoking-related harm in Ireland is not yet in sight.

Tobacco use still remains the leading cause of preventable death in Ireland with a staggering 4,500 smokers dying each year from tobacco-related diseases. Lung cancer remains Ireland’s leading cause of cancer-related death in both sexes with 1950 deaths per annum, accounting for 19.5% of cancer deaths in women and 20.6% in men.13 The reach, intensity and enforcement of the TFIP simply must be accelerated—especially in particular groups such as youth, disadvantaged groups, and hardto-regulate environments such as the illicit tobacco trade and inpatient settings.

It is vital to maintain and grow these initiatives if - both as a society and a health service - we want to close the gap and obtain the desired goal of a Tobacco Free Ireland.

References available on request

News

Understanding Diabetes AstraZeneca in Ireland has announced the launch of a new national campaign ‘Be the Informed Type’, supported by Diabetes Ireland. The initiative encourages people with diabetes to take charge of their health and become informed of the potential complications and how to reduce the risk of developing them.

In Ireland, it is estimated that 308,000 people in Ireland have Type 1 or Type 2 diabetes.

Research shows people with diabetes are four times more likely to develop heart failure and almost 24% of people with diabetes aged over 50 develop chronic kidney disease.

Helping to launch the campaign was Pharmacist Oonagh O’Hagan who explained her reason for collaborating on the initiative, “Seeing first hand, every day, the importance of proactive care for diabetes is what motivated me to get involved in this campaign.

Without proper care, diabetes can lead to serious complications like kidney disease or even heart failure.”

Speaking about the importance of the campaign Senior Dietitian, Education and Support Co-Ordinator with Diabetes

Ireland, Sinéad Powell explained, “The purpose of this campaign is to empower people with diabetes to become more informed on understanding the impact that diabetes complications can have on their body. Even with regular care and best efforts to manage diabetes, changes in the body can still happen over time. This is why staying connected with your healthcare professional is so important, early action can help manage symptoms and slow progression.”

The campaign also encourages the importance of being informed when speaking with your healthcare professional. Medical terminology can sometimes be hard to understand, so people should not be afraid to ask their healthcare professional to explain something again or even to use simpler language if there’s something they don’t understand.

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Further information on diabetes complications – including risk factors and symptoms associated with heart failure or chronic kidney disease – can be found at https:// betheinformedtype.ie/.

Kieran O’Leary, CEO Diabetes Ireland, Oonagh O’Hagan, Pharmacist, and Alex Wilkes, CEO AstraZeneca, photographed at the launch of the ‘Be the Informed Type’, a campaign developed by AstraZeneca and supported by Diabetes Ireland to help people with diabetes better understand the broader health implications of their condition. Further information can be found at https:// betheinformedtype.ie/

SMOKING CRAVINGS? CHOOSE FAST RELIEF *

TRY OUR CITRUSY PUNCH! 4mg only. NiQuitin Mini Mint and Mini Citrus Lozenges contains nicotine. Stop Smoking Aid. Requires will power. Always read the leaflet. MAT-10671

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NiQuitin Mini 2mg/4mg Citrus Lozenges contain nicotine and 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 2 mg are suitable for those 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. In heavy smokers, those who have relapsed after NRT, or when one NRT is not enough to control cravings, NiQuitin Minis may be used in combination with NiQuitin patches (refer to the package leaflet for dosing guidance). 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.

Should not quit with a combination NRT regimen. 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, susceptibility to angioedema & urticaria, renal/hepatic impairment, phaeochromocytoma & uncontrolled hyperthyroidism, GI disease & seizures.

Side effects: Nausea, mouth/throat and tongue irritation, irritability, anxiety, insomnia, sleep disorders, dizziness, headaches, cough, sore throat, vomiting, diarrhoea, upper abdominal pain, GI and oral discomfort, flatulence, hiccups, heartburn, dyspepsia, dry mouth, constipation, ulcerative stomatitis, pharyngitis, pharyngolaryngeal pain, nervousness, depression, palpitations, heart rate increased, dyspnoea, rash, angioedema, pruritus, erythema, hyperhidrosis, urticaria, fatigue, malaise, asthenia, chest pain, anaphylactic reactions, hypersensitivity, tremor, dysgeusia, paresthesia mouth, seizures & epilepsy, dysphagia, eructation, salivary hypersecretion, influenza like illness. Product not subject to medical prescription. PA 1186/018/017 & PA 1186/018/012 MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. Date of preparation: Dec 2023.

SPC: https://www.medicines.ie/medicines/niquitin-mini-2mg-mint-lozenges-35237/spc https://www.medicines.ie/medicines/niquitin-mini-4mg-mint-lozenges-33091/spc

24

Eczema

The Role of the Pharmacist in a Patient's Journey with Eczema Atopic eczema is an inflammatory dermatological skin condition, characterised by the presence of dry, red, and intensely itchy skin lesions. The skin barrier is weakened in patients with eczema, which results in loss of moisture from the skin, and entry of allergens and irritants through the skin.

Written by Eimear O’Reilly, Pharmacist

It is a common, chronic skin condition, the severity of which ebbs and flows throughout the course of a patient’s life. Patients can experience periods of remission, where symptoms settle significantly, followed by episodic flares, which sees symptom severity worsen considerably.

Flares can arise as a result of certain triggers, for example

periods of stress or illness, however, some flares can occur without the identification of any obvious cause.

Itch is the predominant symptom of ezcema, so much so that its presence is considered essential in the diagnosis of the condition. If a patient presents with a non itchy skin rash, healthcare professionals

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can be reasonably confident that the diagnosis is unlikely to be eczema. Eczema is often known as “the itch that rashes”, and the characteristic rash associated with eczema occurs primarily as a result of skin damage caused by scratching the itchy skin (i.e. the rash is secondary to the itch).

This scratching further worsens skin symptoms and can lead to skin thickening, known as “lichenification”, and increased pigmentation over time. The itch can be so strong that sleep can be negatively impacted, resulting in increased irritability and decreased quality of life for patients.

Eczema predominantly arises in childhood (70-90% of cases), however it is possible for the condition to arise for the first time later in life (10-30%). Presentation of the rash and the body sites impacted vary depending on the age of the patient.

Eczema most commonly begins between the ages of 3 to 6 months. Presentations in children aged between 0 to 24 months tend to be found on the face, especially the cheeks, and the extensor surfaces, namely the elbows and

knees. The rash can also extend to the trunk. The napkin area is generally spared; rashes in this area could be indicative of irritant contact dermatitis.

Children aged 2 to 16 years will display the characteristic rash on flexural folds, namely the insides of the elbows, behind the knees, the neck, the axilla, and the groin.

The presentation may remain unchanged into adulthood or the rash may become more diffuse.

The Irish Skin Foundation estimates that 1 in 5 children and 1 in 10 adults in Ireland suffer with Atopic eczema. Given the high prevalence of this skin condition, its chronicity, and its propensity to relapse and remit over a patient’s lifetime, there are numerous points in the patient journey where they will likely interact with their pharmacist. Each interaction represents an opportunity for pharmacists to educate and support patients living with eczema in the effective management of their condition.

Taking time to explain the treatment regimen to patients

E45 knows how to support skin E45 cream is used for treating dry skin conditions such as dry/flaky skin, eczema, dry psoriasis, dermatitis and sunburn. Suitable for the whole family. Apply 2-3 times daily for best results*.

E45 Cream is a medicinal product not subject to medical prescription, containing White Soft Paraffin 14.5% w/w, Light Liquid Paraffin 12.6% w/w and Anhydrous Lanolin 1.0% w/w. Suitable for use from 1 month of age. Always read the leaflet before use. Marketing Authorisation Number: PA 22650/007/001.

Distributed in Ireland by Ocean Healthcare Ltd. Date of preparation: May 2025. *E45 SPC. Available at: https://www.medicines.ie/medicines/e45-cream-31954/spc.

Tel: 01 2968080 orders@oceanhealthcare.ie www.oceanhealthcare.ie

26

Eczema “Apply sparingly to the affected area” or “Apply a thin layer to the affected area”. Caution should be exercised with these directions as they can potentially lead to under treatment of inflamed skin by patients, which can prolong flares and further damage skin.

The guiding principle of topical steroid treatment is to use sufficient quantity of an appropriate potency topical steroid for an adequate duration of time to bring inflammation associated with a flare under control, followed by step wise tapering of the steroids. Patients should be told to use enough of a strong enough topical steroid for long enough to control the flare, before beginning to wean down.

(or their parents in the case of children) who have been diagnosed with eczema, will aid understanding and has been shown to increase compliance to prescribed therapy.

Importance of emollient care The mainstay of eczema treatment is regular and fastidious use of emollients. Emollients restore and repair the skin barrier. Water loss through the skin is reduced and penetration of the skin barrier by irritants is prevented with the use of emollients.

Practical advice for patients with respect to emollient care: • Liberally and frequently apply emollients. Apply at least twice daily, and more if experiencing a flare of ezcema.

• Use emollients as a soap substitute in bath or shower.

Plain water can lead to drier skin, while soaps can irritate the skin.

• Bath or shower in tepid water.

Water that is too hot can strip the skin of natural oils, drying the skin and exacerbating skin barrier dysfunction • Pat skin dry after a bath or shower.

• Apply emollients in a downward, gentle motion. Follow the direction of the hair growth.

• Continue to use emollients even when skin has improved.

Emollients are the foundation of eczema care.

The role of Topical Corticosteroids in flare management Sudden worsening of eczema symptoms following a period of relative calm is known as a “flare”. Irritants, illnesses such as a cold or flu, teething, and stress can all cause eczema to flare however, the root cause of a flare may not always be known. The gold standard treatment for the management of an eczema flare is topical corticosteroids.

Topical corticosteroids are widely recognised as a safe and effective treatment for the inflammation and itching associated with active eczema flares. Negative commentary online has lead to misconceptions and apprehension among some patients regarding the use of topical steroids in the management of their condition.

It is vitally important that pharmacists address patients concerns and correct any misinformation that patients may have encountered online.

Practical advice for patients with respect to topical steroid application: • Ointments are preferred to cream based steroid preparations. Greasier ointments retain moisture in the skin and have fewer excipients such as preservatives and emulsifiers, which can irritate the skin. They also have a greater ability to penetrate lichenified areas of skin.

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• Different areas of the body will require use of different potency steroids. Mild steroids will be used on more delicate skin while more potent steroids will be used on areas of thicker skin.

Ensure patients are clear on which steroid should be used on which area if multiple body sites are impacted and multiple products have been dispensed.

• Avoid “dotting” of steroids i.e. small amounts of steroid placed on the skin and spread over large areas. This leads to insufficient application and ineffective treatment of the flare.

The Fingertip Unit (FTU) if useful when explaining to patients the amount of topical steroid that should be used in a given area.

The amount of topical steroid that covers the tip of the finger to the first crease is equal to 1 FTU. This amount of steroid will cover an area twice the size of the palm of the hand. This gives patients guidance to ensure sufficient topical steroid is being applied to the affected area.

• Patients should be advised to apply the ointment such that it leaves a visible shiny layer on the skin. The skin should “glisten” after application.

• Apply topical steroids to the affected area before emollients.

Allow the steroid to absorb for 15 to 30 minutes before emollients are applied.

Standard practice in community pharmacy is to dispense topical steroids with directions such as

To avoid the risk of rebound flares occurring, topical steroid therapy should not be abruptly discontinued. Tapering of the topical steroids through reduced frequency of application or use of lower potency steroids reduces the risk of recurrence of flares.

An example of a topical steroid regimen that could be expected for the management of a flare would see daily application of the steroid for a defined time for example one to two weeks, reducing to alternate day application, and subsequently reducing to twice weekly application. Twice weekly application can be two consecutive days, which is sometimes known as “weekend therapy”. Patients may be advised to continue this weekend therapy for several months at a time to proactively prevent recurrence of flares. If patients commence tapering of their topical steroids and note recurrence of the rash, they should be advised to step back up their treatment and only recommence the taper once skin is clear again.

Topical Calcineurin inhibitors (TCIs) such as Tacrolimus (Protopic® 0.03% and 0.1%) are an alternative to topical steroids and are used on areas of the body which are more susceptible to side effects from topical steroid use, such as the face. They are typically used more in the maintenance phase of eczema management in practice as they can cause a stinging/ burning sensation when applied to areas of active eczema. It is important to advise patients to use SPF when using TCIs. Summary As trusted and accessible healthcare professionals who will meet patients at many points on their journey with eczema, pharmacists can provide evidence based, practical advice to ensure symptoms are managed, flare ups are minimised and overall quality of life is enhanced.

Adex Gel has been shown to improve atopic eczema from moderate to mild in 2 weeks without corticosteroids1 Adex Gel also improved: Quality of life1 Total eczema area2 Redness2 Dryness2 Sleeplessness2 Itch2

Specially formulated with a high level of oils (30%) and an ancillary anti-inflammatory, nicotinamide (4%) which is a form of vitamin B3, to help reduce inflammation.

Recommended for use as long as necessary, all over the body including on the face, hands and flexures.

Available at your local pharmacy. For patients aged 1 year+

Scan the QR code for more trial information

Adex Gel

does not contain corticosteroids

Product name: Adex™ Gel. Key ingredients: Isopropyl myristate 15%, liquid paraffin 15%, nicotinamide 4%. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Package sizes: 100g tube and 500g pump pack.

Further information is available from: Dermal Laboratories Ltd, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. ‘Adex’ is a trademark.

SCORAD, SCORing Atopic Dermatitis. CDLQI, Children’s Dermatology Life Quality Index.

Adverse Events/Incidents should be reported. Reporting forms and information can be found at www.hpra.ie. Adverse Events/Incidents should also be reported to Dermal.

Scan for Adex Gel essential information and adverse event/ incident reporting.

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ADXPR365/I/JUL25

References: 1. Gallagher J. et al. Evaluation of an Emollient with Nicotinamide in Managing Moderate Atopic Eczema in Paediatric Patients: A RealWorld GP Study. Data presented at the European Academy of Dermatology and Venereology (EADV) Spring Symposium, May 2025, Prague, Czech Republic. 2. Gallagher J. et al. Impact of an Emollient Containing Nicotinamide on Moderate Atopic Eczema and Quality of Life in Paediatric Patients.

Data presented at the European Academy of Dermatology and Venereology (EADV) Spring Symposium, May 2025, Prague, Czech Republic.

28

Migraine

More than a Headache Migraines are one of the most common neurological disorders worldwide, affecting up to 12% of the population, yet it remains underdiagnosed, undertreated, and often misunderstood. For many patients it is far more than “just a headache” — it is a debilitating condition that disrupts daily life, work, and wellbeing. Over the past three decades, major advances such as triptans, CGRP-targeted therapies, and neuromodulation devices have transformed the treatment landscape, but access to care and persistent misconceptions continue to challenge both patients and clinicians.

We sat down with Dr. Edward O’Sullivan, Director of the Headache & Migraine Clinic at Cork University Hospital, to discuss the evolution of migraine management in Ireland, the pressures facing specialist services, and where the next opportunities for improvement lie.

Dr. Edward O’Sullivan

migraine, and the rising demand for specialist input.

What misconceptions about migraine still affect patient care?

The biggest misconception is that migraine is “just a headache.”

When patients present to emergency departments or are admitted to hospital, once a secondary cause has been ruled out, concern for the patient often diminishes. This can lead to suboptimal care.

Could you tell us about your background and how you came to lead the Cork Headache & Migraine Clinic?

I was appointed Director of the Headache/Migraine Clinic within the Department of Neurology, Cork University Hospital, in September 2000. The clinic runs two outpatient sessions each week, on Tuesdays and Fridays, and is fully supported by registrars, SHOs, a clinical nurse specialist and clerical staff. We also have ready access to diagnostic services, particularly radiology and laboratory testing.

My own interest in headache began in my junior hospital doctor days during a neurology rotation.

Even after moving into general practice I maintained that interest.

Towards the end of the 1990s, as triptan therapies began to emerge, awareness of migraine as a serious and debilitating disorder grew. Around the same time the Migraine Association of Ireland was founded by Audrey Craven, who has been a tireless advocate for patients for decades.

I became medical advisor to the Association and increasingly

involved in the evolving landscape of migraine management.

The Association lobbied for the establishment of dedicated migraine clinics in hospitals. The first was set up in Beaumont Hospital, followed soon afterwards by the Cork clinic which I now direct.

How do you approach diagnosis in the clinic?

Migraine is a recurrent clinical disorder, and accurate diagnosis depends first and foremost on a comprehensive history and examination. The International Headache Society has helped bring uniformity with internationally adopted diagnostic guidelines.

One crucial element is recognising “red flag” symptoms that suggest possible secondary causes of headache. In those cases we order appropriate neuroimaging or laboratory investigations. For follow-up, we ask patients to keep headache diaries, which provide invaluable information and help us to refine management.

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The management of migraine has become increasingly complex.

There is now a wide variety of acute and preventative therapies available, and patients being considered for newer treatments such as CGRP antagonists must meet specific clinical criteria. The most challenging group are those with chronic migraine—defined as more than 15 headache days per month. These patients now represent the largest proportion attending our clinic.

How common is migraine, and what does that mean for clinics like yours?

Migraine affects around 10–12% of the population, but those who attend specialist headache or neurology clinics represent only the tip of the iceberg. The majority of people with migraine remain undiagnosed in the community, or assume that little can be done.

At the clinic our challenge is triage: identifying those with the highest levels of disability and poorest quality of life. Even with triage, our waiting lists are long. This reflects the sheer prevalence of

All too often patients are prescribed compound analgesics such as paracetamol with codeine, or even narcotics, despite guidelines recommending triptans as the first-line treatment for acute attacks. Many of these patients should also be considered for a preventative therapy.

These barriers have been difficult to break down. Greater education—both for healthcare professionals and for patients— remains essential.

How did triptans change the management of migraine?

The first targeted specific acute migraine therapies, the triptans, 5HT1B/1D receptor agonists have been available since the late 1990’s and are listed in fig 1.

Fig: 1 Triptans: 5HT1B/1D Receptor Agonists 1. Sumatriptan 50mg, 100mg, Nasal: 10mg, 20mg.

2. Zomitriptan 2.5mg 3. Frovatriptan 2.5mg 4. Eletriptan 40mg 5. Naratriptan 2.5mg 6. Almotriptan 12.5mg

29 The arrival of triptans (5HT1B/1D receptor agonists) in the late 1990s represented a milestone in migraine therapy and our understanding of pathophysiology. Today we have six oral triptans available (sumatriptan, zolmitriptan, frovatriptan, eletriptan, naratriptan and almotriptan), as well as intranasal formulations.

Despite proven efficacy in numerous clinical trials, triptans remain under-prescribed. A recent meta-analysis published in the BMJ (September 2024) showed that only 20–25% of migraine patients in Western societies have ever been prescribed a triptan. The authors concluded that triptans should be first-line for acute migraine, ahead of simple or compound analgesics and NSAIDs. Can you explain the role of CGRP and the development of targeted therapies?

Pivotal research in the late 1980s

by Goadsby and Edvinsson demonstrated that calcitonin gene-related peptide (CGRP) was elevated in jugular venous blood during migraine attacks. CGRP is concentrated in the trigeminal system, and its release activates the trigeminovascular pathway.

This scientific breakthrough lead to investment in drug development which specifically targeted C.G.R.P. and ultimately lead to the approval of C.G.R.P. monoclonal antibody antagonists and small molecule ‘’gepants’’. Fig 2. These advances have brought us to a new era in migraine management with recommended guidelines and best practice changing and evolving all the time.

Fig: 2 CGRP ANTAGONISTS 1. CGRP MONOCLONAL ANTIBODIES: PREVENTATIVE THERAPIES ERENUMAB 70MG OR 140MG MONTHLY S.C INJECTION FREMANEZUMAB 225MG MONTHLY S.C INJECTION GALCANEZUMAB 200MG LOADING AND 100MG S.C MONTHLY INJECTION EPTINEZUMAB 100MG IV INFUSION EVERY 3 MONTHS 2. SMALL MOLECULE GEPANTS: RIMEGEPANT 75MG BOTH AS ACUTE AND PREVENTATIVE THERAPY ALTERNATE DAYS ATOGEPANT 30MG AND 60MG DAILY AS PREVENTATIVE THERAPY

Are the current restrictions on prescribing CGRP antagonists fit for purpose?

“The management of migraine has become increasingly complex. There is now a wide variety of acute and preventative therapies available, and patients being considered for newer treatments such as CGRP antagonists must meet specific clinical criteria” Today we have two categories: • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) used as preventatives, administered by injection or infusion.

stimulators (Cefaly), external vagal nerve stimulation (gammaCore), and transcranial magnetic stimulation are available. These can be used both acutely and preventatively, particularly for patients who fail to respond to drug therapies.

• Small molecule “gepants” (rimegepant and atogepant) which can be used both acutely and preventatively.

However, they are not reimbursed by the HSE. Patients must pay out-of-pocket, which limits access

These advances mark a new era in migraine care, with clinical guidelines evolving rapidly.

How are these new therapies impacting services?

What are the eligibility requirements for these therapies in Ireland?

In Ireland, CGRP antagonists are available only through neurology departments under the HSE’s Medicines Management Programme. Patients must meet strict criteria: • For monoclonal antibodies: diagnosis of chronic migraine (>15 headache days/month, including 8 migraine days) and documented failure of at least three conventional preventatives (such as propranolol, amitriptyline, topiramate, candesartan, venlafaxine, pizotifen, or botulinum toxin).

Supporting documentation from the patient’s dispensing pharmacist is required.

• For gepants: approved in episodic migraine (>4 migraine days/month) as well as chronic migraine, but patients must also have failed three preventatives.

These hurdles take time, create delays, and add pressure to already stretched neurology services.

Are devices also part of modern management?

Yes. Neuromodulation devices such as trigeminal nerve

The arrival of CGRP antagonists has led to a surge in referrals.

GPs and patients are aware of the real-world data showing these therapies are superior to conventional preventives.

However, because prescribing is restricted to neurology, the pressure on Headache/Migraine Clinics has increased dramatically.

With current resources, clinics cannot meet demand. This leaves many eligible patients unable to access therapies that could transform their quality of life.

Beyond medications, how important are multidisciplinary approaches?

Migraine is the second leading cause of disability worldwide, and management is rarely just about tablets. Multidisciplinary input is vital: physiotherapy, cognitive behavioural therapy, stress management, and lifestyle interventions all play a role.

Clinical nurse specialists are an essential part of this team. In some centres they manage follow-up patients, increasing clinic capacity, and act as a vital contact point between appointments. They explain medications, side-effects, trigger management, and provide reassurance. Their role significantly enhances patient care and should be expanded.

In my view, no. The restrictions imposed by the Medicines Management Programme are at odds with best clinical practice.

International evidence consistently demonstrates the safety and effectiveness of CGRP therapies.

Meanwhile, many of the conventional preventives have significant drawbacks. Sodium valproate and topiramate are teratogenic and require contraception in women of childbearing age. Beta-blockers and candesartan may cause hypotension and dizziness. In many cases, patients are forced to try medications with more risk and less efficacy before being allowed access to targeted therapies.

What changes would improve services for patients?

The appointment of more clinical nurse specialists with expertise in migraine would make an immediate difference, increasing capacity, supporting patients between appointments, and helping reduce waiting times.

Longer term, we need to revisit prescribing restrictions. Broader access to CGRP antagonists— supported by evidence and patient outcomes—would align policy with best practice and ease the pressure on neurology clinics.

Looking back, how do you see the progress in migraine care?

From the early days of triptans to the new generation of CGRP therapies, progress has been remarkable. Patients who once had few options now have access to highly effective, targeted treatments.

The challenge is no longer a lack of therapies, but ensuring equitable access, adequate resourcing, and education—both for clinicians and for the public—to overcome the misconceptions that still surround migraine.

In summary: migraine remains one of the most common and disabling neurological disorders.

But with targeted treatments, better service structures, and multidisciplinary care, outcomes for patients in Ireland can continue to improve. As Dr. O’Sullivan stresses, the science has brought us far—the next step is ensuring patients can benefit.

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30

News

RSV Risks Among Older People A new study has found that awareness of Respiratory Syncytial Virus (RSV) is very low among key interest groups, despite the virus being a major cause of hospitalisations each winter. The findings highlight a lack of public health awareness among older adults and their carers, despite being the cohort who face a higher risk of serious illness from RSV. A new study into the awareness of RSV from Ipsos B&A, commissioned

by Pfizer, was launched recently and found: • RSV has an awareness issue in Ireland, with just 18% of respondents claiming to know a lot about the condition, potentially putting vulnerable groups at risk.

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• Two in five (41%) have either never heard of RSV, or have only ever heard the name.

• There is a significantly higher level of awareness about Flu and Covid.

• While age is a key risk factor for RSV, just one in four respondents who care for an older adult indicated that they know a lot about RSV. • Despite limited knowledge of RSV, 76% of respondents who care for older adults would be concerned if they were to contract an infection.

• While awareness of the existence of RSV vaccines is low at just 18% there is strong support for them, with 85% of people believing they should be free of charge if available.

Those responding to the survey are significantly more concerned about long-term conditions such as cancer and heart disease, with only 3% saying they are more concerned about acute illnesses like pneumonia and RSV. Although awareness of RSV is limited, the study found that people do perceive it as a risk, with 85% of respondents stating their concern that an RSV infection for an older adult in their care could become severe.

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Cough, Cold & Flu

31

Merchandising Cough, Cold & Flu It’s no coincidence that more people get ill over the holiday period than any other time of year. Parties, late nights, bad weather, over-indulgence in food and drink, not to mention concerns about the bank balance, all take their toll on people’s bodies.

With the winter season just around the corner, now is the time for community pharmacists and their teams, to be promoting the message that consumers should visit them first, for advice and treatment of common winter ailments.

Research shows that 18% of GP appointments are for minor ailments. Community pharmacists are in fact, best placed to advise on these conditions and over-the-counter available and appropriate medications.

Furthermore, the winter months provide the perfect opportunity for pharmacy to drive home the Self-Care message and ease the pressure on GP surgeries and A&E departments.

The Government has previously stated that the range of medicines provided without a prescription will continue to expand as part of the drive towards a National

Health Service that promotes Self-Care and greater public choice. However, self-medication may not be appropriate for every patient in view of preexisting medical conditions or because of interactions with other prescription and non- prescription medications. This reinforces the importance of pharmacists, who have been trained to ask the right questions so they can give appropriate advice.

It has been previously revealed that treatment results for common ailments such as coughs and sore throats were equally good regardless of whether patients were treated at a pharmacy, A&E or GP practice, highlighting community pharmacy as a solution to the increasing burden on a stretched health service.

Community pharmacy can have an extremely positive impact on the health of the communities it

serves due to the engagement pharmacy teams have with their patients every day. Pharmacists will offer advice on conditions and medications, and if appropriate, they will refer a patient to their GP if they feel it necessary.

Emphasis of Self-Care Research indicates that, despite good intentions, many people do not know how to self-treat conditions such as coughs and colds and therefore visit their GP or A&E for advice.

Visiting pharmacy as an alternative could save up to 950,000 GP consultations every year. Pharmacies need to be aware of the crucial role they can play in educating customers about relieving symptoms of minor winter ailments.

Self-Care is a healthcare philosophy which emphasises the role of ordinary people in taking

ownership of their health and wellbeing and includes taking actions to prevent and decrease the likelihood of disease and to restore health after illness or injury.

It is the first step and first choice for Irish people who are taking an increasingly active role in their healthcare and looking to improve their health and wellbeing.

Research from Behaviour & Attitudes confirms that there is a clear desire from the majority of people (92%) to be involved in decisions about their own health and medication, with 80% expressing their view that they see their pharmacist as a key partner in maintaining their health.

The role of community pharmacists is pivotal to the successful development of Self-Care and its more widespread adoption, according to the Irish Pharmacy Union (IPU) and the Irish Pharmaceutical Healthcare

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32

Cough, Cold & Flu

Association (IPHA), who, at the end of last year, launched a Self-Care awareness campaign, entitled ‘Be Well this Winter – Think Pharmacy’.

The campaign was rolled out through the extensive deployment of social media, as well as a series of posters displayed nationwide in retail pharmacies.

Engage with those ‘at-risk’ Using Self-Care and targeted campaigns as a tool to drive footfall to the pharmacy also gives you the perfect opportunity to engage with those people who are most at risk of flu.

Winter campaigns are frequently run on an annual basis by many major pharmaceutical companies, encouraging customers to SelfCare when suffering from colds, flu, sore throats and other associated symptoms. It is important therefore that pharmacists are aware of these and educated in the key, core messages.

For people aged 65 and over and those with long-term health conditions, including diabetes and kidney disease, flu can be particularly dangerous. If you feel that a customer falls into one of those categories, it might be worth advising them to book in for a flu jab as soon as possible to reduce their risk. Remind them that your pharmacy can offer this service, particularly if they are eligible for a free vaccine.

Preparing monthly displays about particular subjects, or a dedicated winter health display could be a perfect opportunity to promote Self-Care for colds, coughs and other winter ailments. Look out for printed leaflets and booklets that can be displayed on a healthy living pharmacy display table and handed out to customers or attached to prescription bags.

Although the World Health Organisation works to produce timely vaccines based on information available at the time, if the strain of flu mutates it may not be as effective. That’s why it’s also important that you take the time to advise people on how to tell the difference between symptoms of flu and symptoms of a common cold, so that they can treat

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themselves accordingly with the right OTC medicines if they fall ill.

If someone has a lot of symptoms and asks for advice on what medicines to take, it might be worth recommending an OTC medicine that can treat a number of symptoms e.g. temperature and muscle aches at once. However, it’s important to remind them not to ‘double dose’ on paracetamol or ibuprofen if the flu medication also contains these.

Efficient Merchandising The cough and cold season could also provide the perfect opportunity to reorganise fixtures in your pharmacy with a clear merchandising plan featuring beacon brands in both the P and GSL sections.

You really need to think about the winter season and make a proper planogram, that provides a merchandising tool on a tablet, so that any member of staff can scan the fixture and see what it should look like. Make sure that you feature the national bestsellers, as these beacon brands act as visual

clues for customers and direct them to the products they are looking for.

There needs to be some offers that make the pharmacy look competitive and it is crucial that staff are trained to provide advice on seasonal ailments and OTC products.

Staff should also deliver public health messages by reminding customers to have a flu jab (see Panel) and, for example, when selling cough medicine finding out if the customer is a smoker and whether they would like help to quit. They won’t necessarily think the water tablets they are taking for their blood pressure are important but they could react with the decongestant in a cold remedy and cause problems. This could be a cue for the pharmacist to check through their medication records to ensure they are getting appropriate advice.

Ailment Overview Common Cold The common cold is a condition that is prevalent in the community

34

Cough, Cold & Flu

and is associated with a variety of symptoms. Typically, it is an acute, self-limiting viral infection of the upper respiratory tract that is most frequently caused by rhinoviruses.

Symptoms commonly associated with the common cold include coughing, nasal congestion, low-grade fever, and fatigue, usually presenting 1 to 2 days after exposure. Generally, most symptoms subside within 7 to 10 days, although some symptoms can persist for up to 3 weeks.

The common cold is often mistaken for the flu. The flu is caused by the influenza virus, classified as type A, B, or C. Types A and B affect humans, with type A generating more severe symptoms. The influenza virus can be dangerous in older people and in those patients who are immunocompromised.

Nevertheless, people with influenza are sicker than those experiencing common cold symptoms and commonly manifest such signs and symptoms as temperatures greater than 102°F, chills, headaches, myalgia, and malaise.

Sore Throat Sore throat is a hallmark symptom of both viral and bacterial infections of the upper respiratory tract. Sore throat is a self-limiting complaint, resolving within three days in 40% of sufferers and within one week in 85% of people - even in those cases with a bacterial aetiology. The key symptom of sore throat is pain at the back of the mouth, which can vary from localised mild discomfort to intense pain on swallowing.

For sore throat sufferers presenting in pharmacy, regular use of paracetamol or ibuprofen-based products can be recommended to relieve pain (soluble analgesics can be gargled to provide targeted pain relief). Customers can also be advised to use simple mouthwashes at frequent intervals (e.g. warm, salty water) until the discomfort and swelling subsides.

Sucking pastilles or lozenges stimulates saliva secretion, which lubricates the throat, and many throat sweets also contain soothing ingredients, such as glycerine and honey, to help relieve irritation.

Nasal Congestion Nasal congestion is a blocked, stuffy or bunged-up feeling in the nose. Depending on the cause, it can last a short while (a few days) or can be persistent. In adults and children it is usually an annoying symptom rather than a

serious one. In babies, however, a blocked-up nose may make it difficult to breathe or feed.

Some of the causes of nasal congestion include: • Infections: the common cold and other respiratory tract infections, including influenza (flu) and sinusitis.

• Allergies, including hay fever.

• Persistent rhinitis.

Sinusitis The sinuses are small, air-filled spaces inside the cheekbones and forehead which drain into the nose.

Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by an infection. Most cases of sinusitis are acute (lasting 1-4 weeks) but some may go on to a more persistent (chronic) sinusitis.

The symptoms of sinusitis are mainly nasal congestion, and pain in the area of the affected sinus.

This is most commonly in the forehead or cheeks on one or both sides of the nose. The pain may be worse on bending down. Other symptoms which may occur are dizziness and fever.

Sinusitis is usually treated with painkillers and decongestants.

Indigestion The holidays aren’t the holidays without an overload of food.

Indigestion can cause heartburn, nausea and discomfort or even pain in the chest shortly after eating. Over-the-counter remedies can relieve the pain, but those getting regular bouts or experiencing other symptoms such as loss of weight, persistent vomiting, difficulty swallowing or blood in their vomit or stool, should be referred.

Alcohol Consumption The festive season often means endless parties, catching up with old friends, eating and drinking.

Research has found people drink much more than the annual monthly average during December.

Regularly drinking above the daily unit guidelines during Christmas can cause temporary effects, such as headaches, sickness, diarrhoea and may also negatively affect mood, weight and sleep.

Frequently consuming alcohol can also lead to liver damage.

Advise on drinking responsibly, staying within the safe daily unit guidelines , to drink water or soft drinks between each alcoholic drink and to eat a filling meal before alcohol consumption.

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MEDICATION SUMMARY: Decongestants - These help to reduce nasal congestion by constricting the dilated blood vessels in the nasal mucosa.

This reduces swelling and oedema of the nasal mucosa, making it easier to breathe.

Decongestants are not suitable for pregnant and breast-feeding women and patients with hypertension.

Nasal sprays and oral tablets should not be used concurrently.

Oral analgesics Analgesics and antipyretics help to reduce pain and fever associated with sore throats and colds. Ibuprofen also reduces inflammation, which can help if sinuses are inflamed. Paracetamol and ibuprofen can be used in conjunction with one another but should be taken two to three hours apart for maximum benefit.

Combination products - Can contain ingredients such as a decongestant, analgesic, cough suppressant, antihistamine or an expectorant. These can be used up to their maximum dose for up to seven days unless they contain sedating antihistamines, when they should only be used for up to three days. Antihistamines work by drying up nasal secretions and should be used with a decongestant as they are relatively ineffective on their own. They can also cause drowsiness, so are often found in combination products to aid insomnia associated with having a cold.

Inhalants, vapour rubs and saline products - Inhalants work by helping to clear the nasal passages, while steam inhalation will help ease nasal congestion by loosening mucus. Saline preparations relieve congestion by helping to liquefy mucous secretions. Inhalants, rubs and saline products can be used daily until symptoms are cleared. They can be used as an alternative by patients who cannot tolerate decongestants.

Sore throat treatments - Most sore throats are caused by a viral rather than a bacterial infection, so don’t need antibiotics. Medicated lozenges or anaesthetic sprays can help relieve the symptoms of sore throat.

Gargling regularly with an antibacterial mouthwash or warm, salty water can reduce any swelling and inflammation, while sucking pastilles or lozenges will stimulate saliva secretion to lubricate the throat and help relieve irritation.

Cold sore treatments Cold sores usually clear up without treatment within seven to 10 days but antiviral creams, such as aciclovir or penciclovir, can be used to ease symptoms and speed up the healing time. Antiviral tablets are generally more effective than creams at treating severe cold sores, but are usually only prescribed in more intractable cases. Patches that contain a hydrocolloid gel can be placed over the cold sore to hide the affected area while it heals.

36

Footcare

First Steps in Footcare: A Pharmacist’s Guide Feet are often neglected; many people don’t pay their feet and legs much attention until they notice something isn’t quite right. Many people simply don’t know whether they have a wart, a verruca, a corn, or even know the source of the pain at all.

Despite the high prevalence of various foot ailments, because many are unable to distinguish the source of the problem, they may use the wrong products or don’t treat at all. So it is important that pharmacists are able to advise customers on key foot care issues, recommend the correct treatment solution and refer them to a GP or podiatrist if required.

Those at Risk • Age: Feet flatten and widen with age, the fat padding the sole of the foot wears down and skin becomes drier. Foot pain in older people may be an early sign of age-related illnesses such as diabetes, arthritis and circulation issues.

• Occupation: Foot problems, including arthritis in the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot and tarsal tunnel syndrome, have been attributed to repetitive use at work..

• Activity: Sports players and people who take part in vigorous exercise. Women are at higher risk of stress fractures than men.

Common Foot Conditions Corns and Callouses - Corns (which usually appear on the tops or sides of toes) and calluses (found on the soles of feet) are areas of hard, thickened skin that

develop when the skin is exposed to excessive pressure or friction.

Problems can be prevented by wearing well-fitting shoes and using protective gel pads or strips to reduce pressure.

Hardened skin can be gently removed with a pumice stone or foot file. OTC products containing salicylic acid are available to treat established corns or calluses, but severe cases or people with diabetes or circulation problems should be referred to a podiatrist.

Cracked Heels - Cracked heels are often caused by open-backed shoes such as sandals or flipflops striking the heel. Older people are most at risk of cracked heels, as well as those who stand for prolonged periods. Limiting unsupportive footwear can help to prevent the problem arising, while regularly applying a moisturising foot cream can help keep feet smooth and soft. A pumice stone or foot file can be used to remove hard skin; these are particularly effective when used after a bath or shower.

Athletes Foot - Athlete’s foot is contagious via skin to skin contact and indirectly if one uses the same towel as a person with the condition. Athlete’s foot, a common fungal infection that usually develops between the toes, most commonly affects teenagers and young adults. The infection usually clears up within days or

weeks with antifungal treatment.

Customers can choose between fungicidal products that kill the fungus and fungistatic products, which slow down its growth until it stops. A low-potency steroid cream may be recommended if the skin is very sore.

Athlete’s foot is highly infectious, as the fungi multiply quickly in warm and humid environments, such as swimming pools, showers and changing rooms. Good foot hygiene can help to reduce the spread of an infection and involves drying the feet thoroughly, particularly between the toes, wearing clean cotton socks, rotating footwear and avoiding walking barefoot in changing rooms.

Symptoms of Athlete’s foot include: • An itchy, red rash, which often starts in between the 4th and 5th toes, before spreading to the other toes.

• Scaling or cracking of the skin may occur.

• Blisters can occur. If these burst, they can cause pain & swelling.

Verrucas - A verruca is a wart on the sole of the foot caused by infection with the human papilloma virus (HPV), which is picked up from contaminated floors in changing rooms or around swimming pools.

The affected skin is usually white and may have a black spot in the centre. Verrucas may clear up naturally, but treatment is advisable to prevent the infection spreading. Several treatment options are available OTC, including salicylic acid gels, creams, plasters and paints, cryotherapy sprays containing dimethyl ether propane and silver nitrate. To make verrucas more susceptible to treatment, the affected area should be soaked in warm water for a few minutes and gently filed with a pumice stone or emery board. Waterproof plasters are available to protect the verruca and prevent the infection from spreading.

Diabetic Foot Care Diabetes can cause nerve damage and blood vessel disease in the feet. This may cause skin and tissue breakdown, which can develop into non-healing wounds (ulcers), which are at risk of infection. This may even result in limb amputation.

Structural deformity leaves bony prominences exposed to increased external pressure on the skin, leaving it at risk of being damaged.

Identification of patients at risk of diabetic foot disease allows early intervention of preventative measures to be taken, and thus reduces the risk of further complications.

As the number of type 2 diabetes (T2D) cases continues to escalate each year, pharmacists are likely to encounter patients inquiring about proper diabetic foot care.

Foot problems are very common in patients with T2D, accounting for a significant portion of diabetesrelated complications and health care costs. Pharmacists are in a pivotal position to educate patients with a new diagnosis of diabetes about their care.

Conducting a daily skin inspection and adhering to daily skin care, especially foot care, is imperative for all patients with diabetes.

Pharmacists should seize every opportunity to stress the importance of maintaining tight glycaemic control and remind patients how proper and routine foot care is critical to decreasing the incidence of foot ulcers and amputations. It is estimated that nearly 85% of amputations are preventable with education and early intervention.

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Topic Team Training – Emergency Contraception Following on from the September issue Continuing Professional Development on the Pharmacy Role in Emergency Contraception, this 5-Minute Learning Module is designed to enhance the community pharmacy team understanding and ask further questions as to how you can support and advise patients.

After completing this module, you should recognise the different types of emergency contraceptives available, indications and suitability for patients that may present to the pharmacy and appropriate advice and counselling to be given for each.

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.

This module focuses on the three main methods of EHC: ulipristal acetate, levonorgestrel, and the copper intrauterine device (Cu-IUD).

1. Ulipristal Acetate (UPA) – eg ellaOne® How it works: A selective progesterone receptor modulator, UPA delays ovulation even if the LH surge has already begun, giving a longer window of effectiveness than LNG. Dose and timing: • 30 mg single oral dose • Effective up to 120 hours (5 days) post-UPSI • Repeat dose if vomiting within 3 hours Effectiveness: • Maintains consistently high efficacy across the full 5-day window • More effective than LNG between 72–120 hours post-UPSI • Less impacted by body weight, though some data suggest modest reduction in higher BMI 2. Levonorgestrel (LNG) – NorLevo® How it works: A synthetic progestogen, LNG prevents or delays ovulation by blocking the luteinising hormone (LH) surge.

It only works if taken before ovulation; it does not affect an existing pregnancy.

Dose and timing: • 1.5 mg single oral dose • Licensed up to 72 hours postUPSI (most effective within 12 hours) • Repeat the dose if vomiting occurs within 3 hours Effectiveness: • About 84% overall; best within the first 12 hours • Reduced efficacy in women with BMI ≥26 kg/m2 or weight >70 kg – UPA or Cu-IUD may be more suitable 3. Copper Intrauterine Device (Cu-IUD) How it works: Copper ions impair sperm motility and viability, preventing fertilisation. If fertilisation has already occurred, implantation may also be inhibited.

Timing: • Can be fitted up to 5 days after UPSI or up to 5 days after the earliest possible ovulation date Effectiveness: • Over 99% – the most reliable option for emergency contraception Advantages: • Provides long-term contraception (5–10 years) • Hormone-free, suitable for those who cannot use hormonal methods • Works regardless of BMI or timing in the cycle Counselling Priorities for Pharmacists For pharmacists, counselling priorities around emergency hormonal contraception (EHC) focus on several key considerations. Timing is critical, as the sooner EHC is taken, the

Consider: Reflect on the following in assessing your own knowledge and your team’s training:  Is your knowledge up to date on all methods of emergency contraception?  Are you aware of all cases where referral to GP or sexual health clinic are required?  Do you know what advice should be given to all patients provided with emergency contraception?  Have you details of sources for further support that may be required, either for STIs or crisis situations?  Are you confident explaining the options for ongoing contraception?

38 | PHARMACYNEWSIRELAND.COM

more effective it will be. The choice of method depends on a range of factors, including the time since unprotected sexual intercourse (with ulipristal acetate [UPA] being most effective after 72 hours), cycle timing (UPA is preferred when closer to ovulation), and BMI or weight (where a copper IUD or UPA is recommended if BMI is ≥26 kg/m2 or weight exceeds 70 kg). Breastfeeding status should also be taken into account, as levonorgestrel (LNG) is preferred in this situation, and potential drug interactions should be considered, with a copper IUD being the best option for those taking enzyme inducers.

3. Side effects – mostly mild and short-lived. Nausea is common with LNG; insertion discomfort with Cu-IUD. 4. Contraceptive cover afterwards: o After LNG: start/continue contraception immediately; condoms for 7 days (9 for Qlaira®). o After UPA: delay hormones for 5 days, then use condoms until effective.

5. STI protection – remind patients that EHC does not prevent infections; offer screening referral.

6. Confidential, supportive environment – especially important for younger patients.

Special Considerations • Free contraception scheme: Available to patients aged 17–35 Key Points:  Always refer requests for emergency contraception directly to the pharmacist – no exceptions.  Be able to explain the consultation process clearly if patients ask what to expect.  Understand the differences between the emergency contraception options available and when each is most appropriate.  Be familiar with the relevant SOP sections that cover emergency contraception supply.  Maintain strict confidentiality at all times when handling requests for EHC.  Communicate with professionalism, empathy, and sensitivity in every patient interaction.

(or with medical card).

• Aged under 17: Pharmacists must consider consent and safeguarding obligations.

• Drug shortages: Always check HPRA/IPU updates. If UPA unavailable, consider LNG (if within 72h) or refer for Cu-IUD. Common Causes of EHC Failure • Delayed use after UPSI • Ovulation already occurred • Further UPSI after taking EHC • Enzyme-inducing drugs reducing efficacy • High BMI (LNG particularly affected) • Vomiting within 3 hours without repeating the dose Key Takeaway for Teams Pharmacists play a pivotal role in preventing unintended pregnancies through timely supply of EHC. Successful consultations rely on: • Prompt access • Accurate method selection • Clear, non-judgmental counselling • Awareness of supply schemes and shortages Encourage your team to rehearse scenarios, stay familiar with counselling points, and create a supportive environment for every patient.

Actions:  Keep your knowledge current on all methods of EHC that can be supplied from the pharmacy.  Review contraindications, drug interactions, and side effects regularly so you can advise confidently.  Know the decision points for recommending one method over another (e.g., time since UPSI, BMI, drug interactions, breastfeeding).  Deliver and document regular team training on EHC, with assessment to confirm understanding.  Have a clear SOP in place and ensure all staff follow it consistently.  Use a structured consultation tool – such as a questionnaire or assessment form – to guide patient discussions and ensure key safety questions are covered.

*Based on IQVIA sales data MAT June 2025. ~ Glasier AF, et al. Lancet. 2010;375(9714):55 5 62. Erratum in Lancet. 2014;384(9953):15 and ellaOne EU SmPC PRODUCT INFORMATION ellaOne® 30 mg film-coated tablet (ulipristal acetate). Refer to the SmPC for further information. INDICATION: Emergency contraception (EC) within 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure. DOSAGE: one 30mg tablet taken orally as soon as possible, but no later than 120 hours (5 days) after unprotected intercourse or contraceptive failure. Another tablet should be taken if vomiting occurs within 3 hours of intake. Can be taken at any time during the menstrual cycle. Not recommended for women with severe hepatic impairment. CONTRAINDICATIONS: Hypersensitivity to the active substance or excipients. SPECIAL WARNINGS AND PRECAUTIONS: Occasional use only. Use reliable barrier method after use until next menstrual period. If next menstrual period is delayed >7 days or is abnormal or suggestive symptoms occur then perform pregnancy test. Consider ectopic pregnancy. If pregnancy confirmed, woman should contact their doctor. Concomitant use with EC containing levonorgestrel not recommended.

Does not contraindicate the continued use of regular hormonal contraception but reliable barrier method should be used until next menstrual period. Not recommended in severe asthma treated by oral corticosteroids. Concomitant use of CYP3A4 inducers [e.g. barbiturates (including primidone and phenobarbital), phenytoin, fosphenytoin, carbamazepine, oxcarbazepine, herbal medicines containing Hypericum perforatum (St. John’s wort), rifampicin, rifabutin, griseofulvin, efavirenz, nevirapine] not recommended (may decrease efficacy of ellaOne). Long term use of ritonavir not recommended. Not recommended for women who have used enzyme-inducing drugs in the past 4 weeks. Non-hormonal emergency contraception (i.e. a copper intrauterine device (Cu-IUD)) should be considered. Contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. Contains less than 1 mmol sodium (23 mg) per vial, essentially ‘sodium free’. FERTILITY, PREGNANCY AND LACTATION: Not intended for use during existing or suspected pregnancy. Limited human data does not suggest safety concern. Does not interrupt existing pregnancy. No teratogenic potential was observed; animal data insufficient with regard to reproduction toxicity. Marketing Authorisation Holder maintains a pregnancy registry (www. hra-pregnancy-registry.com) to monitor outcomes of pregnancy in women exposed to ellaOne®. Patients and health care providers are encouraged to report any exposure. Ulipristal acetate is excreted in human breast milk; breastfeeding is not recommended for one week after intake. Breast milk should be expressed and discarded. A rapid return of fertility is likely following ellaOne use; regular contraception should be continued or initiated as soon as possible; subsequent acts of intercourse should be protected by reliable barrier method until next menstrual period. UNDESIRABLE EFFECTS: Always consult the SmPC before prescribing. Only the most common side effects and those which are rare but may be serious are listed below. Most commonly reported adverse reactions: headache, nausea, abdominal pain and dysmenorrhea. Common (≥1/100 to <1/10): mood disorders, dizziness, vomiting, abdominal discomfort, myalgia, back pain, pelvic pain, breast tenderness and fatigue. Rare (≥1/10,000 to <1/1,000): ruptured ovarian cyst. MARKETING AUTHORISATION HOLDER: Laboratoire HRA Pharma, 200 avenue de Paris 92320 Châtillon - France. MARKETED IN IRELAND BY: Chefaro Ireland DAC, The Sharp Building, 10-12 Hogan Place, Dublin 2, D02 TY74, Ireland. MARKETING AUTHORISATION NUMBER(S): EU/1/09/522/003. LEGAL CATEGORY: Medicinal product not subject to medical prescription. Adverse events should be reported. Reporting forms can be found at www.hpra.ie or email: medsafety@hpra.ie Reporting forms can be found at: www.hpra.ie or email: medsafety@hpra.ie Adverse events should also be reported to: Chefaro Ireland DAC on Freephone:+353 (0)1709 4190 or email: UKLOCustomerService@per rigo.com MAT 10672

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CPD: Sleep Disorders Continuing Professional Development

CPD

41

Written by Denis O’Driscoll, Superintendent Pharmacist, McCabes Pharmacy Group Denis O'Driscoll has 26 years’ experience in pharmacy. After spending most of his career as an addiction expert, Denis moved to the role of Superintendent Pharmacist for the McCabe’s Pharmacy group (formerly Lloyds Pharmacy).

He is responsible for the management and delivery of quality pharmacy services to the public.

Denis is also the voluntary independent chair of the Naloxone Advisory Group for the HSE Strategy on Overdose Prevention. Denis is a graduate of pharmacy from Trinity College Dublin and has a PhD in Biopharmaceutics (TCD).

Denis is a pharmacist appointee to the PSI Council and President of the PSI.

60 Second Summary Sleep is a universal human need, as essential as nutrition and physical activity. Yet, sleep disorders are common, underdiagnosed, and often poorly managed. Globally, it is estimated that up to 45% of the population experience at least one sleep-related problem during their lifetime. In Ireland, as in many other countries, surveys suggest that around one in three adults regularly suffers from poor sleep. This has profound implications—not only for individuals’ health and wellbeing, but also for the healthcare system, workplace productivity, and society as a whole.

Sleep disorders are remarkably common across the population, with epidemiological studies consistently showing that they affect a substantial proportion of both adults and children. Among these, insomnia stands out as the most prevalent condition.

Surveys indicate that around 30% of adults experience occasional episodes of insomnia, while between 10–15% meet the criteria for chronic insomnia, defined as sleep difficulties occurring at least three nights per week for three months or longer.

Beyond the direct burden on individuals, sleep disorders collectively impose a considerable economic cost.

Although precise Irish data are limited, international research indicates that insufficient sleep costs economies billions of euro annually through lost productivity, workplace absenteeism, accidents, and increased healthcare utilisation.

The development of sleep disorders is rarely attributable to a single cause; rather, it results from a complex interplay of biological, psychological, and social factors.

Demographic characteristics play an important role, with sleep problems more frequently reported in older adults, women, and during key life stages such as pregnancy and menopause.

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

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

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

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

3. PLAN - If I have identified a

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

4 previous steps, log and record your findings.

Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author. Nytol has no editorial oversight of the CPD programmes included in these modules.

Sleep: A Universal Need Management and Treatment of Sleep Disorders Sleep is a universal human need, as essential as nutrition and physical activity. Yet, sleep disorders are common, underdiagnosed, and often poorly managed. Globally, it is estimated that up to 45% of the population experience at least one sleep-related problem during their lifetime. In Ireland, as in many other countries, surveys suggest that around one in three adults regularly suffers from poor sleep. This has profound implications—not only for individuals’ health and wellbeing, but also for the healthcare system, workplace productivity, and society as a whole.

Pharmacists occupy a unique position in tackling sleep disorders. As one of the most accessible healthcare professionals, pharmacists are often the first point of contact for patients reporting sleep difficulties. They are trusted to provide advice, triage, and safe supply of medicines. Moreover, their expanding role in medication reviews, deprescribing initiatives, and primary care collaboration means pharmacists increasingly contribute to sleep health management across settings.

This CPD article provides an up-to-date overview of common sleep disorders, with a focus on equipping pharmacists to:

• Identify and differentiate between sleep conditions.

• Support patients with non-pharmacological and pharmacological management.

• Recognise red flags requiring referral.

• Reflect on their professional responsibilities in safe supply, deprescribing, and monitoring.

Prevalence, Risk Factors, and Impact of Sleep Disorders Sleep disorders are remarkably common across the population, with epidemiological studies consistently showing that they affect a substantial proportion of both adults and children. Among these, insomnia stands out as the most prevalent condition.

Surveys indicate that around 30% of adults experience occasional episodes of insomnia, while between 10–15% meet the criteria for chronic insomnia, defined as sleep difficulties occurring at least three nights per week for three months or longer. Insomnia is often under-reported and undertreated, with many individuals normalising their symptoms or attributing them to stress, ageing, or lifestyle pressures. The condition is not only distressing in itself but also strongly associated with the development of anxiety,

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An aid to the relief of temporary sleep disturbances in adults. For further information, ask your doctor or pharmacist. Always read the leaflet.

Another significant contributor to the sleep health burden is obstructive sleep apnoea (OSA).

It is estimated to affect between 5–10% of adults, though the true prevalence is likely much higher, as up to 85% of cases remain undiagnosed. OSA occurs when the upper airway repeatedly collapses during sleep, leading to fragmented rest and intermittent hypoxia. The prevalence of OSA is rising in parallel with the obesity epidemic, and it is strongly associated with hypertension, type 2 diabetes, and cardiovascular morbidity. Left untreated, it not only impairs quality of life but also significantly increases the risk of road traffic accidents due to excessive daytime sleepiness.

Restless legs syndrome (RLS) is another relatively common condition, affecting 5–10% of adults, with symptoms typically becoming more pronounced with advancing age. Women are disproportionately affected, and prevalence is particularly high during pregnancy. The syndrome is characterised by an uncomfortable urge to move the legs, often leading to difficulty initiating or maintaining sleep. While

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depression, and long-term health complications such as cardiovascular disease and metabolic dysfunction.

42

CPD: Sleep Disorders Table 1: Prevalence of Common Sleep Disorders

many patients experience mild, intermittent symptoms, severe RLS can be profoundly disabling and may be linked to iron deficiency, renal disease, or neuropathy.

Circadian rhythm disorders represent a different category of sleep disturbance, in which the timing of the body’s internal clock is misaligned with environmental or social demands. These disorders are relatively uncommon in the general population, affecting around 2–3%, but are particularly prevalent in specific groups such as shift workers. Among this population, studies suggest that up to 20% may develop clinically significant shift work sleep disorder, characterised by insomnia, excessive sleepiness, and impaired daytime functioning.

Adolescents and young adults are also especially vulnerable to delayed sleep–wake phase disorder, where difficulty falling asleep until the early hours leads to chronic sleep deprivation when social or occupational schedules require early rising.

Parasomnias, such as sleepwalking, night terrors, and REM sleep behaviour disorder, are less common overall, with a prevalence of around 4% in adults. However, they are much more frequent in childhood, where they can cause considerable distress to both children and their families. While many parasomnias are self-limiting and benign, some can persist into adulthood or present risks of injury to the patient or others. In the case of REM sleep behaviour disorder, prevalence increases with age and may act as an early marker of neurodegenerative conditions such as Parkinson’s disease.

Risk factors The development of sleep disorders is rarely attributable to a single cause; rather, it results from a complex interplay of biological, psychological, and social factors. Demographic characteristics play an important role, with sleep problems more frequently reported in older adults, women, and during key life stages such as pregnancy and menopause. Ageing is associated with changes in circadian rhythm, reduced slow-wave sleep, and increased prevalence of chronic illness, all of which contribute to fragmented rest.

Medical comorbidities are another significant risk factor. Conditions

Disorder Insomnia Obstructive Sleep Apnoea Restless Leg Syndrome Circadian Rhythm Disorders Parasomnias

Estimated Prevalence (adults) 30% occasional, 10-15% chronic 5-10% (up to 85% undiagnosed) 5-10% 2-3% general, up to 20% shift workers -4% adults, higher in children

Health impact

Key Notes Most common, often underrecognised Strongly linked to obesity, high CV risk More common in women; pregnancy ↑ risk Delayed sleep-wake phase common in adolescents Some persist into adulthood (e.g. REM behaviour disorder)

Table 1: Prevalence of Common serotonin reuptake inhibitors linked tohypertension, circadian rhythm disorders Physical health: Poor sleep is a recognised risk factor for obesity, Sleep•factors Disorders Risk and chronic sleep deprivation.

(SSRIs), can lead to insomnia. cardiovascular disease, impaired glucose metabolism, and reduced immunity. are known to to a single cause; rather, it results from a The development of sleep disordersBeta-blockers is rarely attributable Finally, genetic and familial suppress melatonin secretion influences be a overlooked. complex interplayhealth: of biological, psychological, anddreams socialand factors.

Demographic characteristics play • Mental Strongly linked to depression anxiety; poor sleepcannot is both cause and a and cause vivid or such as cardiovascular disease, Studies suggest a heritable nightmares.

Conversely, sedative an important role, with sleep problems more frequently reported in older adults, women, and during diabetes, consequence. chronic respiratory component to conditions such medicines used inappropriately disorders, depression, anxiety and aswith restless legs syndrome and key life stages such asand pregnancy menopause.

Ageing is associated changes in circadian can trigger rebound insomnia upon are strongly associated with poor • reduced Safety: Sleep deprivation contributes toprevalence road traffic accidents and occupational hazards. narcolepsy, while insomnia often rhythm, slow-wave sleep, and increased of chronic illness, all of which withdrawal.

Pharmacists must sleep. Painful musculoskeletal runs in families, potentially due to therefore remain vigilant when conditions and neurological contribute to fragmented rest. fatigue, irritability, reduced productivity, a mixture of genetic predisposition • Quality of life: Daytime and impaired relationships. conducting medication reviews to diseases, including Parkinson’s and shared behaviours. identify iatrogenic contributors to disease and multiple sclerosis, Medical comorbidities are anothersleep significant risk factor. Conditions such as cardiovascular disease, problems.

Health impact also contribute to disordered diabetes, chronic respiratory disorders, depression, and anxiety are strongly associated with poor sleep by disrupting both the Lifestyle factors also play an • Physical health: Poor sleep sleep.

Painful musculoskeletal conditions and neurological Parkinson’s disease initiation and maintenance of important role.

High caffeinediseases, intake, including is a recognised risk factor sleep.

Importantly, the relationship obesity, hypertension, excessive alcohol use, nicotine and multiple sclerosis, also contribute to disordered sleep by disruptingfor both the initiation and between sleep disorders and cardiovascular disease, impaired dependence, and late-night use maintenance of sleep.

Importantly, the relationship between sleep disorders and medical conditions medical conditions is bidirectional: glucose metabolism, and of electronic devices all contribute reduced immunity. itself is a forbidirectional: example, insomnia increasesinsomnia is for example, increases the risksocietal of depression, while depression to poor sleep. Modern the risk of cause depression, while trends, including 24-hour working common of insomnia.

• Mental health: Strongly linked depression itself is a common patterns and increased screen to depression and anxiety; poor exposure, create environments cause of insomnia. sleep is corticosteroids, both a cause and a Medications may also directly impact sleep quality. Stimulant drugs, including that make sleep disruption more consequence.

Medications may also directly decongestants, and certain antidepressants such as selective likely. Environmental conditionsserotonin reuptake inhibitors (SSRIs), impact sleep quality. Stimulant such as noise,to light, and poor can lead to insomnia.

Beta-blockers are known suppress melatonin secretion and cause vivid drugs, including corticosteroids, housing quality can also undermine Differentiating Common decongestants, and certain dreams or nightmares.

Conversely,sleep. sedative medicines used inappropriately can trigger rebound Occupational demands— Sleep Disorders antidepressants such as selective particularly shift work—are strongly insomnia upon withdrawal.

Pharmacists must therefore remain vigilant when conducting medication BOX - Differentiating Common Sleep Disorders

reviews to identify iatrogenic contributors to sleep problems.

Disorder Key clinical features Associated risks Lifestyle factors also play an important role. High caffeine intake, excessive alcohol use, nicotine dependence, and late-night useinitiating/maintaining of electronic devices allsleep; contribute sleep.

Modernreduced societal Difficulty early to poor Mood disorders, Insomnia trends, including 24-hour working patterns and increased screen exposure, create environments wakening; dissatisfaction with sleep daytime function that make sleep disruption more likely. Environmental conditions such as noise, light, and poor Loud snoring, sleep. witnessed apnoeas,demands—particularly excessive CV disease, road housing quality can also undermine Occupational shiftdiabetes, work—are OSA strongly linked to circadian rhythm disorders and chronic sleep deprivation. daytime sleepiness accidents

Finally, genetic and familial cannot Studies suggest a heritable Urge toinfluences move legs, worsebeatoverlooked. rest/evening, Iron deficiency, pregnancy, RLS component to conditions such as restless legs syndrome and narcolepsy, while insomnia often runs relieved by movement renal disease in families, potentially due to a mixture of genetic predisposition and shared behaviours.

Circadian Rhythm Sleep normal when allowed at “natural” times; Common in shift workers, Disorders mismatch with social demands adolescents Parasomnias

Injury risk; REM behaviour Abnormal behaviours during sleep disorder may precede (sleepwalking, nightmares, acting out dreams) Parkinson’s

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In practice, pharmacists may encounter patients presenting with non-specific complaints such as tiredness, difficulty sleeping, or daytime fatigue. The ability to distinguish between different types of *Based on IQVIA sales data MAT 05/2025. Nytol One-A-Night 50mg tablets contains Diphenhydramine hydrochloride. sleepFordisorders is therefore critical for effective An aid to the relief of temporary sleep disturbances in adults. further information, ask your doctor or pharmacist.

Always readadvice the leaflet.and referral.

43 • Safety: Sleep deprivation contributes to road traffic accidents and occupational hazards.

• Quality of life: Daytime fatigue, irritability, reduced productivity, and impaired relationships.

Beyond the direct burden on individuals, sleep disorders collectively impose a considerable economic cost. Although precise Irish data are limited, international research indicates that insufficient sleep costs economies billions of euro annually through lost productivity, workplace absenteeism, accidents, and increased healthcare utilisation.

Given the comparable prevalence of sleep disorders in Ireland, it is reasonable to expect a similar burden here. The societal impact is amplified by the strong association between sleep disorders and chronic conditions such as cardiovascular disease, diabetes, depression, and dementia. Furthermore, the risks to safety are significant, with sleeprelated impairment contributing to road traffic collisions and occupational injuries.

Differentiating Common Sleep Disorders In practice, pharmacists may encounter patients presenting with non-specific complaints such as tiredness, difficulty sleeping, or daytime fatigue. The ability to distinguish between different types of sleep disorders is therefore critical for effective advice and referral.

Insomnia remains the most commonly reported disorder.

Patients typically describe difficulty falling asleep, waking frequently during the night, or rising earlier than intended, often accompanied by feelings of irritability, poor concentration, and fatigue during the day. Insomnia can be short-term, triggered by stress, bereavement, or illness, or chronic, lasting for months or years. Unlike other conditions, the hallmark of insomnia is a persistent dissatisfaction with sleep quantity or quality despite adequate opportunity for rest.

In contrast, obstructive sleep apnoea (OSA) is characterised by loud snoring, nocturnal choking or gasping, and witnessed pauses in breathing during sleep. Patients may complain less about difficulty sleeping and more about feeling

excessively sleepy during the day, often falling asleep unintentionally at work, while reading, or even when driving. OSA is strongly associated with obesity and carries significant risks for cardiovascular health, making prompt recognition and referral essential.

Restless legs syndrome (RLS) presents differently. Patients usually describe an uncomfortable or tingling sensation in the legs, accompanied by an overwhelming urge to move. Symptoms are typically worse in the evening or at rest and may be temporarily relieved by walking or stretching.

RLS can severely delay sleep onset and cause frequent awakenings, leading to secondary insomnia. Its association with iron deficiency, pregnancy, and chronic kidney disease is an important clue to underlying causes.

Circadian rhythm disorders represent a misalignment between the body’s internal clock and external social or occupational demands. In delayed sleep–wake phase disorder, commonly seen in adolescents and young adults, patients find it difficult to fall asleep before the early hours, which results in insufficient sleep during the week. Shift workers are vulnerable to irregular sleep patterns, with up to one in five developing clinical symptoms of insomnia and excessive sleepiness. Unlike insomnia, the sleep itself is of normal quality and duration when permitted to occur at the “right” time.

Parasomnias are distinct in that they involve abnormal behaviours or experiences during sleep.

Non-REM parasomnias include sleepwalking and night terrors, typically arising in childhood but sometimes persisting into adulthood. REM parasomnias include vivid nightmares and REM sleep behaviour disorder, where patients physically act out dreams, sometimes violently.

These disorders can cause injury to the patient or bed partner and may signal underlying neurological disease.

To support differentiation, pharmacists may find validated tools useful. The Insomnia Severity Index can help measure sleep disturbance, while the Epworth Sleepiness Scale and STOP-BANG questionnaire are widely used to assess risk of OSA. Asking structured questions

about symptom onset, duration, pattern, and associated features provides critical clues to the underlying disorder.

Non-pharmacological management Non-drug strategies are considered first-line in nearly all sleep disorders, and pharmacists can play a pivotal role in reinforcing these approaches.

Sleep hygiene advice is the foundation of good sleep health.

Patients should be encouraged to establish regular sleep and wake times, even on weekends, and to create a relaxing pre-bedtime routine. Reducing stimulants such as caffeine and nicotine, limiting alcohol in the evening, and ensuring that bedrooms are cool, quiet, and dark are simple but effective steps. Avoiding electronic screens before bed is particularly important, as blue light exposure can suppress melatonin secretion and delay sleep onset.

Cognitive Behavioural Therapy for Insomnia (CBT-I) is considered the gold standard for managing chronic insomnia. Unlike pharmacological treatments, CBT-I addresses the behavioural and cognitive factors perpetuating poor sleep. Techniques include stimulus control, which strengthens the association between bed and sleep by limiting time spent awake in bed, and sleep restriction, which initially reduces time in bed to consolidate sleep before gradually increasing it. Cognitive restructuring helps patients challenge unhelpful beliefs about sleep, such as the idea that one must achieve a fixed number of hours to function.

Relaxation training, mindfulness, and breathing exercises are often incorporated. Evidence shows that CBT-I produces durable improvements that often outlast medication-based therapies. With the growing availability of digital CBT-I platforms, pharmacists can signpost patients to accessible, evidence-based resources, some of which are NHS-approved.

Other behavioural approaches are equally important for specific disorders. In OSA, lifestyle measures such as weight loss, positional therapy, and reducing alcohol or sedative use are essential alongside medical treatment. For RLS, correcting iron deficiency can significantly reduce symptoms, while avoiding triggers such as caffeine, antihistamines,

IRELAND’S NO.1

*Based on IQVIA sales data MAT 05/2025. Nytol One-A-Night 50mg tablets contains Diphenhydramine hydrochloride.

An aid to the relief of temporary sleep disturbances in adults. For further information, ask your doctor or pharmacist. Always read the leaflet.

Practical tip Pharmacists can use screening tools such as: • Epworth Sleepiness Scale (for OSA).

• Insomnia Severity Index.

• STOP-BANG questionnaire (OSA risk).

Non-Pharmacological Management Sleep hygiene Pharmacists should deliver consistent advice: • Maintain regular bed/wake times.

• Avoid caffeine, nicotine, alcohol late in the day.

• Reduce screen use before bed.

• Keep bedroom cool, quiet, and dark.

• Restrict bed use to sleep/sex only.

• Encourage physical activity, but not too close to bedtime.

Cognitive Behavioural Therapy for Insomnia (CBT-I) The gold standard for chronic insomnia.

• Stimulus control: Go to bed only when sleepy; leave bed if unable to sleep within 20 mins.

• Sleep restriction: Limit time in bed to actual sleep time, then gradually increase.

• Cognitive restructuring: Challenge negative beliefs (“I must get 8 hours”).

• Relaxation techniques: Progressive muscle relaxation, mindfulness, breathing exercises.

• Delivery: Face-to-face, group.

Other behavioural approaches • OSA: Weight loss, reduced alcohol/sedative use, positional therapy.

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and prolonged inactivity can also help. Circadian rhythm disorders may benefit from carefully timed light exposure or melatonin supplementation to reset the body clock, while parasomnias can often be managed through reassurance, stress reduction, and environmental safety measures such as locking doors and removing hazards from bedrooms.

44

CPD: Sleep Disorders • Early identification: Recognising red flags such as loud snoring/ apnoeas, severe daytime sleepiness, violent parasomnias.

• Safe supply: Ensuring hypnotics are used short term, with full counselling.

• Medication review: Identifying drugs contributing to insomnia (e.g., corticosteroids, SSRIs, stimulants).

• RLS: Correct iron deficiency, avoid triggers (caffeine, antihistamines).

depression, although robust evidence for their effectiveness remains limited.

• Circadian disorders: Timed light exposure, melatonin.

Over-the-counter sedating antihistamines, such as diphenhydramine and promethazine, are widely available in Ireland and may provide shortterm relief of sleep difficulties for some individuals.

• Parasomnias: Reassurance, safety measures, stress management.

Pharmacological Management Although non-pharmacological approaches remain the mainstay of treatment, pharmacological therapies are sometimes necessary, particularly when symptoms are severe, persistent, or when behavioural interventions alone prove insufficient.

For insomnia, benzodiazepines such as temazepam and loprazolam are effective short-term hypnotics, working by enhancing GABA-A receptor activity to promote sleep. However, they are associated with tolerance, dependence, and cognitive impairment, particularly in older adults, and guidelines recommend restricting use to no longer than four weeks. Non-benzodiazepine “Z-drugs” such as zopiclone and zolpidem act similarly, but are often preferred due to a slightly more favourable side-effect profile. Nevertheless, they carry comparable risks of dependence and next-day sedation, as well as rare but serious parasomnias such as sleep-driving.

In Ireland, melatonin is available only on prescription and is not routinely reimbursed under the HSE Primary Care Reimbursement Service, except in certain specialist indications such as paediatric neurodevelopmental disorders. While melatonin has a relatively benign side-effect profile and may be useful in circadian rhythm disorders, its efficacy is modest and the timing of administration is crucial for optimal benefit. Sedating antidepressants, including trazodone and mirtazapine, are sometimes used off-label for insomnia, particularly in the presence of comorbid

In OSA, continuous positive airway pressure (CPAP) remains the gold standard, with pharmacological treatment limited to select cases.

For example, modafinil, a wakepromoting agent, may be used in specialist settings for patients with residual daytime sleepiness despite optimal CPAP use.

For RLS, dopamine agonists such as ropinirole and pramipexole are effective but carry the risk of augmentation, where symptoms worsen and appear earlier in the day, as well as impulse control disorders. Alpha-2-delta ligands such as gabapentin and pregabalin are increasingly preferred, particularly in patients with comorbid pain or insomnia.

Correction of iron deficiency is fundamental if ferritin levels are below 75 µg/L, as this can alleviate symptoms without the need for long-term medication.

Circadian rhythm disorders may be managed pharmacologically with melatonin, administered at carefully timed intervals to shift the sleep–wake cycle. In shift work disorder, stimulants or wake-promoting agents may sometimes be used under specialist guidance, though these are not first-line. Parasomnias rarely require medication, but severe cases of REM sleep behaviour disorder may respond to clonazepam or melatonin under specialist supervision.

Pharmacist-Led Advice, Support, and Referral Pharmacists’ contribution includes: • Education: Providing accurate, accessible advice on sleep hygiene and therapies.

• Referral: o To GPs for diagnostic workup (sleep studies, iron studies, psychiatric assessment). o To sleep clinics such as Beaumont Hospital, Tallaght University Hospital, Cork University Hospital or Galway University Hospital for suspected OSA. o To HSE mental health services for comorbid anxiety/depression.

use tools such as sleep diaries or digital apps to help patients track progress. They should also consider the impact of other medicines that may worsen sleep and recommend alternatives where appropriate.

Finally, there are ethical and professional considerations.

Pharmacists must balance patient expectations—often for rapid, pharmacological solutions— with the longer-term benefits of behavioural interventions.

Supporting vulnerable populations, including older adults and patients with mental health conditions, requires sensitivity and adherence to professional standards.

Upholding PSI principles of patient-centred care, safety, and effective communication ensures that pharmacists provide the highest standard of support in managing sleep disorders.

CASE STUDIES

Professional Responsibilities

Case 1 Suspected OSA

Pharmacists carry significant responsibility in ensuring that sleep medicines are prescribed, supplied, and monitored safely.

Safe supply is critical, particularly given the risks of dependence and adverse effects associated with hypnotics. Pharmacists should ensure that these medicines are dispensed in line with local and national guidelines, accompanied by clear counselling on appropriate use, side effects, and risks such as driving impairment and interactions with alcohol or other central nervous system depressants.

A 52-year-old obese man reports constant fatigue and his partner notes loud snoring and pauses in breathing.

A major part of the pharmacist’s role is in deprescribing. Longterm use of benzodiazepines and Z-drugs remains common despite guidelines, especially among older adults. Pharmacists can identify such patients during medication reviews and work collaboratively with prescribers to support gradual withdrawal.

Tapering regimens, often involving dose reductions of 10–25% every one to two weeks, can minimise withdrawal symptoms and improve success rates. Crucially, deprescribing must be combined with non-pharmacological support, reassurance, and monitoring.

Monitoring is another professional obligation. Patients taking sleep medicines should be regularly reviewed for efficacy, adverse effects, and ongoing need.

Pharmacists should be alert to potential misuse or diversion and

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Case 2: Restless legs syndrome A 40-year-old woman reports tingling in her legs at night, making it difficult to sleep.

• Pharmacist’s role: Explore history, suggest iron studies via GP, advise on lifestyle measures, and discuss treatment options if confirmed.

Conclusion Sleep disorders are highly prevalent, significantly impacting health, wellbeing, and healthcare costs. Pharmacists are ideally placed to support patients through early identification, patient education, safe supply of medicines, and referral where appropriate. Non-pharmacological interventions such as CBT-I remain first-line, with pharmacological treatments used cautiously and short-term.

Reflecting on professional responsibilities—including safe supply, deprescribing, and monitoring—ensures pharmacists practise safely and add value to multidisciplinary management of sleep disorders.

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Adults: One tablet to be taken 20 minutes before going to bed, or as directed by a physician. Do not exceed the maximum dose of one tablet in 24 hours.

Elderly patients or patients with liver or kidney problems should consult their doctor before taking this medicine. Children under 18 years: Not recommended. The product should not be taken for more than 7 days without consulting a doctor. Contraindications: hypersensitivity to the active substance or to any of the excipients, stenosing peptic ulcer, pyloroduodenal obstruction, phaeochromocytoma, known acquired or congenital QT interval prolongation, known risk factors for QT interval prolongation. Special warnings and precautions: pregnancy/lactation, renal and hepatic impairment, myasthenia gravis, epilepsy or seizure disorders, narrow-angle glaucoma, prostatic hypertrophy, urinary retention, asthma, bronchitis, COPD. Patients should be advised to promptly report any cardiac symptoms. Tolerance and / or dependence may develop with continuous use. Do not take for more than 7 consecutive nights without consulting a doctor. Should not be used in patients currently receiving MAO inhibitors (MAOI) or patients who have received treatment with MAOIs within the last two weeks. Use in the elderly should be avoided. Avoid concomitant use of alcohol or other antihistamine-containing preparations. Do not drive or operate machines. Cases of abuse and dependence were reported in adolescents or young adults for recreational use and/or in patients with psychiatric dis-orders and/or history of abuse disorders. Contains lactose. May suppress the cutaneous histamine response to allergen extracts and should be stopped several days before skin testing. Interactions: Alcohol, CNS depressants, MAO inhibitors, anticholinergic drugs (e.g. atropine, tricyclic antidepressants), metoprolol and venlafaxine, CYP2D6 inhibitors, Class Ia and Class III anti-arrhythmics. Side effects: dry mouth, fatigue, sedation, drowsiness, disturbance in attention, unsteadiness, dizziness, thrombocytopenia, hypersensitivity reactions, confusion, paradoxical excitation, convulsions, headache, paraesthesia, dyskinesias, blurred vision, tachycardia, palpitations, thickening of bronchial secretions, gastrointestinal disturbance, muscle twitching, urinary difficulty, urinary retention. Product not subject to medical prescription. PA1186/016/001. MAH: Chefaro Ireland DAC. The Sharp Building. Hogan Place. Dublin 2.

Ireland. Date of preparation: Nov. 2023. SPC: https://www.medicines.ie/medicines/nytol-one-a-night-50-mg-tablets-34889/spc MAT-10247

46

News

Challenging Times for Older People The Irish Longitudinal Study on Ageing (TILDA) has released its ‘Wave 6’ findings which points to challenging times for Ireland’s older population.

Ireland is one of the fastest ageing countries in Europe, with the population aged 65 and over projected to double by 2051.

This demographic shift will place increasing pressure on public services particularly health and social care and will require significant planning and adaptation.

The latest findings released from The Irish Longitudinal Study on Ageing (TILDA), and their comparisons with their earlier ‘waves’ over the last 14 years may provide some answers.

TILDA observes patterns and changes in health social and economic characteristics of older adults in Ireland. By measuring the same information every two years, TILDA can reveal patterns, trends and cause -and - effect relationships that a single snapshot in time, like a cross-sectional study, might miss.

Drawing on 14 years of longitudinal data from over 8,000 adults aged 50 and older, the new report will highlight widespread unmet need in key areas such as cardiovascular disease prevention, falls and fracture care, osteoporosis treatment, chronic pain, and mental health. Early findings indicate that many older adults remain undiagnosed or inadequately treated, with serious consequences for wellbeing and

independence. The report will also address the ongoing burden of loneliness and emotional distress, showing that depression in later life is underdiagnosed, under-treated, and often not reported at all. It will also draw attention to the vital role of family carers, many of whom are older adults themselves providing more than 50 hours of care each week. This level of caregiving is associated with poorer mental health, particularly among women.

Regius Professor Rose Anne Kenny, Principal Investigator of TILDA, says, “This is the most comprehensive and wide-ranging report TILDA has produced to date. It's the first time we’ve brought together such an extensive, longitudinal view of the key issues shaping the lives of adults in Ireland. From loneliness and emotional wellbeing to healthcare access and the realities of caregiving, these are topics that matter deeply to the individual, but also to health and social care.

“What makes the Wave 6 findings so compelling is that the majority of the issues we’ve identified, like untreated hypertension, high cholesterol, chronic pain, and depression, are largely modifiable.

These are not inevitable aspects of ageing; they are challenges we can address with the right health and social care systems in place.

This study shines a light on where

immediate, evidence-based action can transform outcomes for older adults in Ireland.”

Key Findings There were four key areas of focus that the TILDA team examined in Wave 6. Their key findings are listed below.

1. Loneliness Loneliness has emerged as a persistent and powerful factor influencing the health and wellbeing of older adults. The study tracked how loneliness has affected older adults in Ireland over 14 years, including the impact of the COVID-19 pandemic.

2. Unmet Need The study explored the scale of undiagnosed and poorly managed health conditions among older adults, representing missed opportunities for prevention and intervention, with serious implications for wellbeing and health system efficiency.

3. 4Ms Framework Using the 4Ms—Mobility, Medications, Mentation, and What Matters— the study offers a comprehensive view of how ageing affects older adults over time.

• Ageing is non-linear and multidimensional: while mobility and cognitive function decline,

Quality of Life (QoL) can initially improve before declining in later years.

• Evidence supports the male– female health–survival paradox: women live longer but experience more healthrelated decline.

4. Caring The study examined the emotional and mental health impacts of caregiving, and makes the case for stronger policy supports to reduce caregiver strain and improve wellbeing.

• Carers who provide more than fifty hours of care each week report poorer mental health and reduced overall well-being, highlighting the emotional strain of high-intensity caregiving.

• Among these caregivers, women in particular were more likely to report increased symptoms of depression, pointing to a gendered impact of prolonged caregiving responsibilities.

Further information You can read the report TILDA Wave 6 Report – Shaping the Future: Longitudinal Trends and Opportunities for Transformation in Health and Social Care in Ireland at the following link: https:// tilda.tcd.ie/publications/reports/ W6KeyFindings/index.php.

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48

Women’s Health: Incontinence

Incontinence in Women Urinary incontinence is when the normal process of storing and passing urine is disrupted resulting in the involuntary leakage of urine from the bladder. It is a common problem that affects millions of women worldwide.

It can have a devastating impact on quality of life and affects women both physically and psychologically.

Written by Dearbhla Walsh, Lecturer in Pharmacy, South East Technological University

It is also possible for some women to suffer with a mix of stress incontinence and urge incontinence.

Risk Factors

bladder wall. The detrusor muscles relax to allow the bladder to fill with urine, then contracts to release urine. This muscle can contract involuntarily, even when the bladder is not full creating an urgent need to go to the toilet.

This can also be referred to as an overactive bladder. Contractions can occur due to urinary tract infections, inflammation, bladder stones or tumours. Excessive caffeine or alcohol consumption can also be a factor.

There are several types of incontinence some are acute while others may be long term.

Stress incontinence This occurs when the pressure inside the bladder, as it fills with urine, becomes greater that the strength of the urethra to stay closed. Any sudden increase in pressure due to activities, such as sneezing, coughing, laughing, heavy lifting or exercise. The amount of leakage can range from a few drops to large amounts.

Causes Stress incontinence mainly occurs when the urethra is unable to remain closed due to weakness of damage to the pelvic floor muscles and urethral sphincter.

Other common underlying factors include pregnancy, vaginal birth, hysterectomy, menopause or trauma.

These include advanced age particularly those patients over the age 80 years old. Postmenopausal women, multiple vaginal deliveries, previous pelvic or urological surgeries and family history of incontinence.

Medicines that may cause incontinence There are some medicines that can disrupt the normal process of storing and passing urine or increase the amount of urine produced leading to incontinence.

Overflow Incontinence

• ACE inhibitors.

This is a type of incontinence where the bladder may fill as usual but is unable to empty completely, leading to frequent or constant leakage of small amount of urine. It is also known as chronic urinary retention.

The patient may experience difficulty starting urination and a week or slow urine flow often without the sensation of urgency.

• Diuretics.

Causes Overflow incontinence may occur due to weak bladder muscles due to nerve damage or muscle weakness due to conditions such as diabetes Parkinson’s disease or MS. Other causes can include blockages or obstructions such as pelvic organ prolapse, bladder stones or tumours what prevent the bladder from emptying fully.

Patients with this particular type of incontinence are at risk of urinary tract infections due to residual urine in the bladder.

Urge Incontinence

Continuous or Total Incontinence

Characterised by a sudden urge to urinate. Leakage can occur before reaching the bathroom. Patients may awake up multiple times are night to urinate (nocturia). The urge to urinate can be triggered by a sudden change in position or even the sound of running water. Urge incontinence can also occur during sexual intercourse. The constant need to plan bathroom visits, can interfere with daily activities and quality of life.

The bladder cannot store any urine, causing urine to leak continuously.

Causes The main cause is the overactivity of the detrusor muscle in the

PHARMACYNEWSIRELAND.COM

• Some antidepressants.

• HRT. Treatment Urinary incontinence is often a highly treatable condition, particularly with early intervention and adherence to recommended life style and medical therapies.

Many women experience a significant improvement in quality of life.

Treatment options will depend on the type of urinary incontinence and severity of symptoms.

First line treatments include Life style changes Reduce caffeine intake, which is found in tea, coffee and soft drinks. It is important to drink the right amount of fluids each day.

Too much or too much can make incontinence worse. Pelvic floor exercises can help to strengthen the muscles around the bladder and the urethra to help control the flow or urine out of the bladder.

Medicines Medications can improve bladder contractions or relax bladder muscles.

Catheter use for Women A urinary catheter is a thin, flexible tube designed to drain the bladder and collect urine in a drainage bag when voluntary urination is not possible or practical. They are widely used in women for various medical indications such as urinary retention, incontinence and during and after surgical procedures. Female catheters are manufactured to accommodate a shorted length and anatomical differences for a female urethra.

The duration of catheterization depends on the underlying medical condition and the patients’ individual needs. Catheters are generally considered when other treatments for urinary incontinence have not been effective.

Catheters provide effective bladder drainage, reduce leakage and help prevent unfections.

Indications for use • Overflow incontinence – This occurs where the patient has an inability to empty the bladder. This could be due to nerve damage, arising from issues such as MS, Parkinson’s Disease, stroke or diabetes.

Anatomical issues such as blockages of the bladder neck or urethra.

• Urinary retention due to postsurgery due to anaesthesia, child birth, swelling or trauma.

• Urethral Catheter - Here the tube is Urinary catheters and usually inserted by a doctor or nurse.

Female catheters come in lots of shapes and sizes. What is right for your patient will depend on what is comfortable and lifestyle.

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50

Women’s Health: Menopause

Menopause and the Role of the Pharmacist Menopause is a natural stage in a woman’s life, usually occurring between the ages of 45 and 55. It marks the end of reproductive function, brought about when the ovaries cease producing reproductive hormones and stop releasing eggs. Natural menopause is defined retrospectively, once a woman has experienced twelve consecutive months without menstruation in the absence of any other underlying cause or clinical intervention. While it is a normal biological process, the hormonal changes associated with menopause can profoundly affect physical and emotional wellbeing, making it a critical period for healthcare intervention and patient support.

Written by Fatimah Kara, Superintendent Pharmacist, Reidy’s Pharmacy Rathcoole

The transition through menopause is highly individual. Some women report few or no symptoms, while others experience multiple and sometimes severe manifestations that significantly interfere with daily life. Hot flushes, or vasomotor symptoms, are perhaps the most recognised sign, often described as a sudden wave of heat spreading through the body.

Many women also experience night sweats or cold flushes, which can disrupt sleep and lead to fatigue. Genitourinary symptoms are common, particularly vaginal dryness, which may result in discomfort during sex, and urinary urgency or increased frequency.

Sleep disturbances, including insomnia, are widespread, often compounded by hormonal fluctuations, night sweats, and mood changes. Emotional shifts such as irritability, mood swings, or low mood can also appear during this time.

Beyond these core symptoms, menopause is associated with a spectrum of other complaints.

Women may report headaches, palpitations, joint and muscle aches, or cognitive difficulties

such as poor concentration and memory lapses. Weight gain, breast tenderness, and thinning of hair can occur, adding to the complexity of presentation.

Importantly, menopause carries broader health consequences beyond symptom management.

The decline in oestrogen levels alters body composition and cardiovascular risk, gradually eroding women’s relative protection against cardiovascular disease compared to men.

Pelvic support structures may weaken, leading to an increased risk of prolapse. Perhaps most significantly, bone density decreases, contributing to the higher rates of osteoporosis and fractures seen in postmenopausal women.

These multifaceted changes underscore why menopause is not simply a stage of ageing but a transition with wide-reaching health implications. For community pharmacists, this presents a clear opportunity and responsibility to support women, not only in managing symptoms but also in addressing long-term health risks.

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Hormone Replacement Therapy Hormone Replacement Therapy (HRT) remains the most effective treatment for managing menopausal symptoms. By replacing the hormones that decline during menopause— primarily oestrogen and progestogen—HRT addresses the root cause of many symptoms rather than simply treating them in isolation. These hormones are not only central to reproductive cycles, ovulation, and pregnancy but also play vital roles in bone health, cardiovascular function, and overall systemic balance.

The primary benefits of HRT are well established. It provides effective relief from vasomotor symptoms such as hot flushes and night sweats and alleviates genitourinary problems including vaginal dryness and discomfort.

HRT also plays a preventative role, reducing bone loss and significantly lowering the risk of osteoporosis-related fractures.

Evidence suggests it can help maintain muscle strength, though patients are still advised to exercise regularly to sustain mobility and resilience.

Formulations of HRT are varied and flexible, enabling treatment to be tailored to individual needs.

Options include tablets, patches, gels, sprays, vaginal oestrogen, and intrauterine systems.

This breadth of choice allows prescribers to personalise therapy, balancing efficacy, convenience, and tolerability. However, it is important to emphasise that HRT is not a uniform solution. Treatment plans must be individualised, with careful consideration given to age, symptom profile, and personal or family history of risk factors.

The benefits of HRT are most likely to outweigh risks in women under 60 who are experiencing symptoms and who commence treatment within ten years of their final menstrual period. Risks, such as those related to breast

cancer or blood clots, are generally small and depend on the specific type of HRT, duration of use, and underlying health factors.

These considerations should be openly discussed with the prescribing GP, with pharmacists contributing to ongoing counselling and monitoring.

Despite its benefits, HRT access remains a challenge. In recent years, product shortages have caused significant disruption, with women facing changes in their prescribed regimen or difficulty obtaining suitable alternatives.

This has understandably caused frustration and anxiety for patients.

Encouragingly, the inclusion of HRT in the GMS and DPS schemes has improved affordability and accessibility, but the supply chain remains a concern. Pharmacists often find themselves on the frontline of these issues, guiding patients through alternatives and ensuring continuity of care despite shortages. In many cases, collaboration between prescribers and pharmacists is key to achieving a satisfactory outcome.

Alternatives to HRT For some women, HRT is not appropriate. Contraindications such as a history of hormone-sensitive cancers, thromboembolic disease, or liver disease mean that alternative strategies are necessary. For others, personal preference leads them to decline HRT in favour of non-hormonal options. In these cases, a combination of lifestyle measures, complementary therapies, and non-hormonal medicines may be employed.

Lifestyle modifications play a powerful role in managing symptoms. Regular physical activity can help maintain bone density, muscle strength, and cardiovascular health, while also supporting mood and sleep quality.

A balanced diet rich in calcium and vitamin D contributes to skeletal health, while reducing intake of

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52

Women’s Health: Menopause

alcohol, caffeine, and spicy foods may alleviate hot flushes for some women. Smoking cessation is strongly encouraged, not only for general health benefits but also because smoking is associated with earlier menopause and more severe vasomotor symptoms.

Stress management and adequate rest are equally important, and simple measures such as wearing loose clothing and keeping bedrooms cool at night can make a meaningful difference for women struggling with night sweats.

Over-the-counter products also have a role in symptom management. Vaginal moisturisers and lubricants can help relieve vaginal dryness and improve comfort during intercourse. Many women turn to herbal remedies such as evening primrose oil, black cohosh, ginseng, or St John’s wort. While some find these helpful, caution is necessary due to the potential for interactions with prescribed medicines.

Pharmacists are well placed to provide evidence-based guidance, ensuring that patients are informed of both benefits and risks.

Nutritional supplementation is another area of interest. Calcium and vitamin D are the most widely recommended, helping to maintain bone structure and facilitating calcium absorption.

Magnesium has gained attention for its role in regulating cortisol, supporting mood and sleep, and contributing to bone and muscle health. B vitamins are essential

for energy metabolism, mood stability, cognitive function, and stress regulation, while omega-3 fatty acids provide cardiovascular, cognitive, and anti-inflammatory benefits. Phytoestrogens—plantderived compounds structurally similar to oestrogen—have been studied for their ability to reduce hot flushes and improve genitourinary symptoms. Though the evidence is mixed, many women report symptomatic improvement.

In all cases, pharmacists should take care to assess the full picture of supplement use, as patients may inadvertently overlap products or exceed recommended doses.

Conducting a comprehensive medication history and screening for interactions is vital before making recommendations.

The Pharmacist’s Role The role of community pharmacists in menopause care has never been more important. Pharmacists are accessible healthcare professionals who often act as the first point of contact for patients seeking advice. They provide continuity in care, bridging gaps between GP consultations and specialist services, and are uniquely positioned to offer both clinical and practical support.

Pharmacists can counsel women on what to expect during the menopausal transition, helping them to distinguish normal symptoms from those requiring further investigation. They can

PHARMACYNEWSIRELAND.COM

provide detailed guidance on how to take prescribed medication, offer reassurance about safety, and troubleshoot common problems with adherence. In the context of HRT shortages, pharmacists play a vital role in identifying suitable alternatives, liaising with prescribers, and ensuring patients continue to receive effective treatment.

The pharmacist’s expertise also extends to non-prescription options. By discussing lifestyle strategies, recommending suitable supplements, and advising on safe use of herbal remedies, pharmacists help patients make informed decisions tailored to their circumstances. Importantly, they can also recognise when symptoms or risk factors require referral back to the GP for further assessment.

Supporting women during menopause is not just about managing symptoms—it is about empowering them to make informed choices and promoting long-term health. For many patients, the pharmacist is a trusted, approachable professional who provides reassurance and continuity in a healthcare system that can sometimes feel fragmented.

Conclusion Menopause represents a major life transition, affecting not only reproductive function but also cardiovascular, skeletal, and psychological health. The wide

range of symptoms, from hot flushes and night sweats to cognitive changes and bone loss, underscores the need for comprehensive, individualised care. Hormone Replacement Therapy remains the most effective treatment for many women, but access challenges and contraindications mean that alternatives must also be considered. Lifestyle changes, nutritional support, and nonhormonal therapies all have a role in supporting women through this stage of life.

Community pharmacists are at the heart of this care. Positioned as accessible, knowledgeable, and trusted healthcare professionals, they play a critical role in counselling patients, supporting adherence, managing shortages, and advising on safe use of supplements. Their ability to provide personalised advice and continuity of care makes them invaluable in helping women navigate the challenges of menopause with confidence.

Ultimately, menopause is not just a biological event but a significant health milestone. With the right support, women can maintain quality of life, protect long-term health, and continue to thrive.

Pharmacists, as a key part of the healthcare team, are uniquely placed to empower women during this time—ensuring that they feel heard, understood, and supported every step of the way.

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Women’s Health: Breast Cancer

An Overview of Breast Cancer in Ireland Breast cancer is the most common cancer in women in Ireland (excluding Non-Melanoma Skin Cancer, NMSC). On average 1 in 11 Irish women up to the age of 75, will develop breast cancer in their life time.

Written by Bernie Carter, Assistant Director of Nursing, Marie Keating Foundation

• Having no children or late age pregnancy.

• Benign breast disease.4, 5, 6 What is BRCA? Everyone has BRCA 1 and BRCA 2 genes. They are important genes that stop the cells in our body from growing and dividing out of control. By doing this, the genes help to protect us from getting cancer. They are often referred to as tumour suppressor genes. Everyone has two copies of each of the BRCA 1 and BRCA 2 genes—one copy inherited from each parent.

The incidence of breast cancer in females is rising significantly since 2014.

1:11 Irish women will develop breast cancer (to the age of 75) and 1:7 in their life time.

3.587 female cases diagnosed each year.

753 women die from breast cancer annually.

However, more women are surviving breast cancer. Latest statistics from the national cancer registry in Ireland (NCRI) indicate that the 5 year survival for women with breast cancer is now 88%.

Early detection of breast cancer leads to better outcome so the earlier it is detected the better.1 Breast cancer is rare in men • About 30 men are diagnosed each year in the Ireland with breast cancer.

• Average of 8 men die yearly from breast cancer in Ireland.

• Invasive ductal carcinoma is the most common type of breast cancer in both women and men.

• Men can also develop rarer types of breast cancer, such as inflammatory breast cancer.

• More common in men over 60, but can occur in younger men.

• Men, as well as women, can inherit faulty genes that increase

their risk of breast cancer (BRCA1 and BRCA2).1, 2, 3 Risk Factors Modifiable risk factors: • Overweight or obesity particularly after the menopause.

• Being inactive.

• Alcohol intake - one standard alcoholic drink per day is associated with a 9% increased risk.

• Alcohol is responsible for 1 in 13 breast cancers in Ireland.

• Smoking – Small increased risk in women who smoke compared to those who have never smoked.

• Oral contraceptives – returns to normal 10 years after you stop taking it.

• HRT – risk is low but highest for those using combined HRT. Non-modifiable risk factors: • Getting older; 8 out of 10 cases occur in women over 50.

• A family history and inherited genes (BRCA 1 & BRCA 2).

• Early menarche (before age 12) or late natural menopause (after age 55).

• Dense breast - Risk of breast cancer is higher in women with the densest breasts compared to those with less dense breasts.

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Both men and women can inherit a faulty BRCA1 or BRCA2 gene from their father or their mother.

People who inherit a faulty BRCA1 or BRCA2 gene have an increased risk of developing different types of cancers including female breast cancer, ovarian cancer, prostate cancer and to a lesser degree male breast cancer and pancreatic cancer. They also tend to develop cancer at younger ages than people who do not have a faulty BRCA1 or BRCA2 gene.8, 9 Breast changes to look and feel for include the following: • Skin changes such as puckering, dimpling, a rash or redness of the skin.

• Orange peel appearance.

• Prominent veins.

• Nipple changes - inverted, change in direction or shape, flattened, discharge, rash, flaky or crusted skin.

• Change in size, shape or feel of the breast.

• Breast lump, swelling or thickening.

• Armpit lump.

Know what is normal for you and what changes to check for: One of the most important things that you can do for your health is to get to know your breasts. Know what is normal for you and know what changes to look out for. The best time to check your breast is several days after your menstrual period as the breast can be tender and lumpy at the time of the

menstrual period. It is important to check at the same time every month. If you have gone through menopause, do your exam on the same day every month.

We would suggest in the Marie Keating Foundation choosing your birthday date.

Please visit the Marie Keating foundation website, www.mariekeating.ie to view a short video on how to check your breasts for changes.

What to do if you find something not normal for you: • See your GP if you notice any new changes in your breasts, including nipple changes or new lumps or swellings in either of your armpits.

55 • Most breast lumps (90%) aren't cancerous, but it's always best to have them checked by your doctor.

• If necessary, your GP will refer you to a specialist breast centre for further tests & investigations.

• The earlier it's picked up the higher the chance of successful treatment.

Treatment for breast cancer

A Multi-Disciplinary Team (MDT), which is a team of doctors and other health professionals with expertise in a specific cancer, come together and discuss the best treatment plan for a specific patient.

Staging and Grading of Breast Cancer Doctors use the Stage and Grade of a cancer to help decide on the best treatment

Depends on the stage and grade of your cancer. Treatment may include one or combination of the following:

• Staging means the Size of the cancer and whether it has Spread

• Surgery -

• Grading describes what a cancer cell looks like under the microscope and whether they are similar or very different to normal cells

 Breast conserving surgery (Lumpectomy or wide local excision).  Mastectomy-removal of breast.

• Chemotherapy.

• Radiotherapy.

• Hormone treatment (Also called - Endocrine therapy).

• Targeted therapies.

• Breast reconstruction surgery.

Breast cancer is not something you have to go through alone.

The Marie Keating Foundation is here to support you. We have lots of valuable information on our website. www.mariekeating.ie . We offer a free ‘Ask The Nurse service’ that allows you to ask questions to a qualified senior oncology cancer nurse about any cancer related health issues you may have. We

have many services for those with a BRCA alteration so please do visit our website to find more information.

4. Cancer Research UK – breast cancer risk factors - https:// www.cancerresearchuk.org/ about-cancer/breast-cancer/ risks-causes/risk-factors

Our mission in the Marie Keating Foundation is to make cancer less frightening by enlightening and to achieve a world free from the fear of cancer.

5. HSE breast cancer - https:// www2.hse.ie/conditions/breastcancer-in-women/breast-cancerin-women-symptoms-diagnosisand-prevention.html

References:

6. HSE breast cancer risk factors – Alcohol - https://www2.hse. ie/healthy-you/alcohol-blogs/6facts-about-alcohol-and-cancerevery-woman-should-know. html#

1. National Cancer Registry 2024 report - NCRI_ AnnualStatReport_2024_ FINAL_14.pdf 2. Cancer Research UK – male breast cancer - https://www. cancerresearchuk.org/aboutcancer/breast-cancer/stagestypes-grades/types/malebreast-cancer# 3. HSE – male breast cancer https://www2.hse.ie/conditions/ breast-cancer-in-men/breastcancer-in-men-symptoms-anddiagnosis.html

7. Cancer Research UK – breast cancer symptoms - https://www. cancerresearchuk.org/aboutcancer/breast-cancer/symptoms 8. National Cancer Institute – 2024 - BRCA Gene Changes: Cancer Risk and Genetic Testing Fact Sheet - NCI 9. Cancer Research UK - Inherited genes and cancer types | Cancer Research UK

Irish Maternity Research A new research project, investigating consent to medical treatment in Irish maternity care, has received funding from Research Ireland under the COALESCE programme.

Research Ireland’s Collaborative Alliances for Societal Challenges (COALESCE) programme – now in its fifth cycle – supports excellent research across a broad range of disciplines, tackling national and international challenges.

The CONTENT Study (Consent for Medically Indicated Interventions in Childbirth) is one of 19 successful projects being funded under the current round of the programme. The project is being undertaken by Andrea Mulligan, School of Law and Joan Lalor, School of Nursing and Midwifery.

The team comprising two lawyers, a midwife, an obstetrician and an ethicist will investigate whether the legal principles that govern consent to treatment are applied in practice in Irish maternity care.

Dr Andrea Mulligan, School of Law, explained, “The objective of this project is to investigate the divergence between the legal requirements for consent to birth interventions and the reality of consent practices in Irish maternity services.

"The overarching research question is: are the legal requirements for informed and voluntary consent to birth interventions being met in Irish maternity practice? Ultimately, the project aims to deliver evidence-based outputs to improve consent practices.”

The team will survey and interview women, obstetricians and midwives, and examine the extent to which the legal requirements for provision of consent are being followed for women in childbirth.

The project aims to influence policy and practice in this area.

Professor Joan Lalor, School of Nursing and Midwifery, added, “Valid consent requires that a person is provided with all the information they need to make a decision and that the decision is truly voluntary, meaning that it is free from coercion of any kind.

Negative interactions with caregivers during birth are associated with suboptimal outcomes.

"Ensuring informed consent is given is one way to minimise negative birth experiences and to reduce the incidence of traumatic births and childbirth-related post traumatic stress."

PHARMACYNEWSIRELAND.COM

Anticoagulation therapy in the context of women’s health

56

Women’s Health: Thrombosis Written by Dr Katie Liston Haematology Specialist Registrar in Haematology and Dr Maeve Crowley Consultant Haematologist, Cork University Hospital

Anticoagulation therapy in the context of Background: Anticoagulants are frequently prescribed medications. In Ireland, direct oral anticoagulants are the anticoagulants of choice in most cases but vitamin K antagonists still have a women’s health vital role to play, especially in the management of patients with metallic heart valves and

antiphospholipidSpecialist syndrome. Registrar Anticoagulants remain high risk medications (https://ipu.ie/wpWritten by Dr Katie Liston Haematology in Haematology and Dr Maeve Crowley content/uploads/2022/03/high-risk-medicines.pdf).

Women face specific and evolving bleeding and Consultant Haematologist, Cork University Hospital thrombotic challenges throughout their lives (Figure 1.)

Background: Anticoagulants are frequently prescribed medications. In Ireland, direct oral anticoagulants are the anticoagulants of choice in most cases but vitamin K antagonists still have a vital role to play, especially in the management of patients with metallic heart valves and antiphospholipid syndrome.

Anticoagulants remain high risk medications (https://ipu.ie/wpdays and a median blood loss of 57ml/cycle. HMB is a loss of > 80mls/cycle or excessive menstrual content/uploads/2022/03/highrisk-medicines.pdf). Women face blood loss that interferes with a woman’s physical, social, emotional, or material quality of life. It is specific and evolving bleeding and important to identify if a woman has an underlying menstral disorder prior to starting them on thrombotic challenges throughout their lives (Figure 1.) anticoagulation as we know that anticoagulation is likely to make things worse. About 2/3 of women

Women and Iron deficiency: on anticoagulation and a median blood loss of almost 57ml/cycle. is aReplacement loss of 80mls/cycle or excess experience heavydays menstural bleeding and ¾ HMB of women on> rivaroxaban (De Figure 1. Bleeding and Thrombotic Challenges Faced

by Women.

HRT=Hormone Figure 1. Bleeding and Thrombotic Challenges Faced by Women.

The WHO estimate that ~half a blood loss that interferes with a woman’s physical, social, emotional, or material qua Therapy.

HRT=Hormone Replacement Therapy. et al. Thromb Res. 2015 Oct). billion women worldwide aged Crem N important to identify if a woman has an underlying menstral disorder prior to startin 15-49 are anaemic. In 2019 30% anticoagulation we know anticoagulation is likely to make worse. Abo Women and Iron deficiency: The WHO estimateas that ~halfthat a billion women worldwide agedthings 15-49 of non-pregnant women and Table 1. Clinical Features of Heavy Menstral Bleeding 37%of pregnant women in this on anticoagulation experience heavy menstural bleeding and almost ¾ of are anaemic. In 2019 30% of non-pregnant women and 37%of pregnant women in this age group women on age group were anaemic and Changing sanitary products more than every 2 Res. hours orOct). requiring double protection Crem N et al.

2015 were anaemic and the most common cause ofThromb this anaemia was iron deficiency (www.who.int/newsthe most common cause of this Leaking or soaking through clothing or needing to change sanitary products overnight anaemia was iron deficiency (www. room/fact-sheets/detail/anaemia). During this period, women have an increased requirement for Table 1. Clinical Features of Heavy Menstral Bleeding who.int/news-room/fact-sheets/ Periods lasting >7 days Changing Iron sanitary products more than every of 2 hours or requiring pro iron in the form of menstruation and pregnancy. supplementation outside dietary sources double is detail/anaemia). During this Passing clots >2.8cm (1.1 inch) Leaking or soaking through clothing or needing to change sanitary products o period, women have an increased not always easy to tolerate so once you become iron deficient, it can be difficult to resolve. This is requirement for iron in the form Periods lasting >7 days important in the– context of anticoagulation as if you know menstruating women are commonly extended survey 63% of these of menstruation and pregnancy.

Passing clotsimportant >2.8cm (1.1 inch) This is particularly women had diagnosed withon a treatment Iron supplementation outside of anaemic at been baseline, putting that leads toon increased and prolonged bleeding is only if a patient is going to be Wheniron trying to assess a women has an underlying menstrual disorder, Table 1 contains some deficiency or ironifdeficiency dietary sources is not always easy indefinite anticoagulation.

If a likely to but make things worse. only 46% had been to tolerate so once you becomethingsanaemia to ask women about. women has underlying menstrual When trying to assess if a women has an underlying menstrual disorder, Table 1 con prescribed supplementation. To Figure 2. Issues to address when iron deficient, it can be difficult to disorders, they may need further to ask women about. identify menstural menstrual problems, Heavy bleedingit’s(HMB):things HMB is common and can be caused by structural issues (e.g. starting a menstruating women resolve. This is important in the investigations such as imaging important to know whatwomen is normal.on anticoagulation: a menstruating It is good practice tryanovulatory to address 4 Heavy issues on to anticoagulation.

HMBcycles, = context of anticoagulation as if Starting you polyps, leiomyomas, malignancy or adenomyosis) or non-structural issues (e.g. or a review by a gynaecologist Starting a menstruating women on anticoagulation: It isMenstrual good practice to try to add normal cycle length is 21-35 Bleeding. know menstruating women arewhen A or haematologist.

Different starting a menstruating women on starting anticoagulation.

(Figure medications, coagulopathy); (Samuelson Bannow B et al. Res Pract 2.)

Thromb Haemost.(Figure 2021 2.)

Aug). days with each cycle lasting 2-7 when a menstruating women on anticoagulation. commonly anaemic at baseline, days and a median blood include loss putting on a treatment that leads to Consequences of HMB iron deficiency +/- anaemia, impaired quality of life, missing of 57ml/cycle. HMB is a loss increased and prolonged bleeding school/work, missed doses of anticoagulation due to fear of HMB and missing out on social activities of > 80mls/cycle or excessive is only likely to make things worse. menstrual lossEuropean that interferes and sport.blood A 2015 survey (Fraser IS et al. Int J Gynaecol Obstet. 2015 Mar) found that ~27% with a woman’s physical, social, Heavy menstural bleeding of the women surveyed had emotional, or material quality of experienced 2 or more HMB symptoms in the previous year; 46% of (HMB): HMB is common and can life. It iswomen important to identify if a be caused by structural issues (e.g. these had never consulted a physician about it. 7% of the respondents completed an woman has an underlying menstral polyps, leiomyomas, malignancy extended survey – 63% of these women had been diagnosed with iron deficiency or iron deficiency disorder prior to starting them on or adenomyosis) or non-structural anticoagulation as we know issues (e.g. anovulatory cycles, anaemia but only 46% hadthat been prescribed supplementation. To identify menstrual problems, it’s anticoagulation is likely to make medications, coagulopathy); important toAbout know2/3 what is normal. A normal cycle length is 21-35 days with each cycle lasting 2-7 things worse. of women (Samuelson Bannow B et al. Res Pract Thromb Haemost. 2021 Aug). on anticoagulation experience heavy menstural bleeding and Consequences of HMB include almost ¾ of women on rivaroxaban iron deficiency +/- anaemia, (De Crem N et al. Thromb Res. impaired quality of life, missing 2015 Oct). school/work, missed doses of anticoagulation due to fear of HMB When trying to assess if a women and missing out on social activities has an underlying menstrual and sport. A 2015 European survey disorder, Table 1 contains some (Fraser IS et al. Int J Gynaecol things to ask women about.

Obstet. 2015 Mar) found that ~27% of the women surveyed Starting a menstruating woman had experienced 2 or more HMB on anticoagulation: It is good symptoms in the previous year; practice to try to address 4 issues 46% of these women had never when starting a menstruating consulted a physician about it. 7% women on anticoagulation. of the respondents completed an (Figure 2.)

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Figure 2. Issues to address when starting a menstruating women on anticoagulation Menstrual Bleeding.

This is particularly important if a patient is going to be on indefinite anticoagulation. underlying menstrual disorders, they may need further investigations such as imagin

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58

Women’s Health: Thrombosis

anticoagulants have different risk of menorrhagia so agent choice is important. If a woman has always had HMB and sinister causes have been out-ruled, it is better to consider measures early to ameliorate the issue rather than risk the woman experiencing significant bleeding. Ensuring that women are iron replete is vital as you are lowering their bleeding threshold so you want to ensure they have some reserve. In general, a multifaceted approach works best.

risk of bleeding. The prescription of an anticoagulant may negate the need for an antiplatelet agent.

Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly prescribed antidepressant medications. Many of the haemostatic functions of platelets are mediated through serotonin so SSRIs potentially can make the haemostatic function of platelets less effective and increase the bleeding risk (Ann Med. 2022 Dec).

Over the counter medications such as non-steroidal anti-inflammatory drugs (NSAIDs) are also important to ask about as they also have an antiplatelet effect. It may not be possible to stop these medications but at least you can flag that the patient may be at a higher risk for bleeding and counsel them regarding this.

then their risk of recurrent VTE appears similar if they are on oestrogen containing therapies or no hormonal therapy (Martinelli I et al. Blood. 2016 Mar). Therefore, if a woman is remaining on anticoagulation, they can stay on the COCP but if they are stopping anticoagulation, an alternative needs to be found. Different modalities have different levels of efficacy in terms of contraception thrombosis risk and amenorrhoea rates (DeLoughery E et al.

Hematology Am Soc Hematol Educ Program. 2022 Dec).

Exploring these factors allows clinicians to counsel women about the most appropriate modality for them.

Anticoagulant choice: Rivaroxaban appears to be associated with the highest rates of menorrhagia, when compared with apixaban, dabigatran or Tranexamic acid (TXA): TXA is warfarin (Samuelson Bannow B et an antifibrinolytic agent which al. Res Pract Thromb Haemost. stops the breakdown of clots.

2021) – see Table 2. Quality of Hormonal therapy: The combined A Danish historical prospective life is also differently impacted oral contraceptive pill (COCP) is cohort study attempted to (Patel JP et al. Res Pract Thromb associated with an increased risk estimate the risk of thrombosis Haemost. 2023). The ongoing of venousthat thrombosis. in women 15-49, not on experiencing significant bleeding. womenWomen are ironarereplete is vital aged as you are lowering randomized MEDEA (Hamulyák EN Ensuring prescribed it for many reasons, anticoagulation with a standard et al.

Res Pract Thromb Haemost. their bleeding threshold so you want to ensure they haveHMB, some reserve. a multifaceted including contraception, risk In of general, thrombosis.

They looked at 2020 Dec) study will hopefully acne, endometriosis, polycystic data on 2 million women followed approach works best. provide further evidence to guide ovarian syndrome, dysmenorrhoea, for 13.8 million person years. The agent choice in the future. regulation. is importantwith theincidence of venous thrombosis Anticoagulant choice: Rivaroxabancycle appears to beItassociated highest rates of menorrhagia, Concurrent medications: It is to find out what the indication appeared to be increased but the when compared with apixaban, dabigatran or warfarin (Samuelson Bannow B et al.

Res Pract important to review a patients for the COCP was when you are number of women who needed regular medications look – forsee Table considering it should continue get a 5 day(Patel course to Thromb Haemost. to 2021) 2. Qualityif of life is also differentlytoimpacted JPofetTXA al. Res drug-drug interactions as well or be changed to an alternative. cause harm was >78,000 (Meaidi Pract Thromb Haemost.

TheWhatever ongoing their randomized MEDEA (Hamulyák EN et al. Res Pract as those that may increase 2023). the indication, it is A et al. EClinicalMedicine. 2021).

Thromb Haemost.

2020 Dec) will hopefully provide evidence guide agent choice bleeding risk.

Co-prescription of study reassuring the note that iffurther a women There to was no increased risk in antiplatelet is on therapeutic anticoagulation, of thrombosis in the high risk the future.agents increases the

Table 2. Relative risk of Heavy Menstrual Bleeding by choice of Anticoagulant.

Anticoagulant Incidence of uterine Relative risk CRNMB/MB Warfarin 4.5%-9.6% Reference Apixaban 5.4% 1.18 Edoxaban 9.0% 1.26 Rivaroxaban 9.5% 2.10* Dabigatran 4.7% 0.53*

*statistically significant , P<0.01. CRNMB= Clinically Relevant Non-Major Bleeding. MB=Major Bleeding. Adapted from *statistically significant , P<0.01. bleeding CRNMB= RelevantSamuelson Non-Major Bleeding.

MB=Major Am Bleeding.

Adapted ‘Management of heavy menstrual onClinically anticoagulation’ Bannow B. Hematology Soc Hematol Educ from ‘Management Program.

2020 Dec of heavy menstrual bleeding on anticoagulation’ Samuelson Bannow B. Hematology Am Soc Hematol Educ Program. 2020 Dec

patients recruited to the CRASH2 and WOMAN studies which is reassuring. It is frequently used in the prevention and management of bleeding in patients with bleeding disorders. It is not well studied in patients with thrombosis or on anticoagulation. A survey of clinicians’ prescribing habits showed that there is often a reluctance to use it in the acute setting, with 1/3 of those surveyed never prescribing it in the first 3 months and 46% very concerned with the risk of progression or recurrence. (Abdulrehman J et al.

Thromb Res. 2024 Jan).

Conclusion: It’s important to be both frank and open when starting a woman on anticoagulation.

Heavy Menstrual Bleeding is common, especially in woman on anticoagulation. Women are often reluctant to talk about it without prompting. Discussing where they are at present in terms of menstruation and their past experiences will help you predict how they will be on anticaogulation. If they are anaemic or iron deficient, this is a good time to address it.

Anticoagulation stewardship is an emerging movement focusing on the appropriate use of anticoagulants, which persist in being high risk medications despite the availability of newer agents. Choosing the correct agent, following consideration of patient and disease factors, at the correct dose, for an appropriate duration should ensure maximum efficacy with the minimal amount of harm.

Educational resource: The team in Kings College hospital have developed a short educational video for patients entitled ‘anticoagulants and your periods’ which is freely available on youtube https://youtu.be/ kAIirzFVFKc?si=IrSfQUGvygKQcZDS

Concurrent medications: It is important to review a patients regular medications to look for drugdrug interactions as well as those that may increase the bleeding risk. Co-prescription of antiplatelet agents increases the risk of bleeding. The prescription of an anticoagulant may negate the need for Ireland is urging Government to honour its Programme for(SSRIs) Government pledge to prescribed publish a National HIV Action Plan, warning that anHIV antiplatelet agent.the Selective Serotonin Reuptake Inhibitors are commonly without clear timelines and accountability, Ireland risks falling short of its goal to end new HIV transmissions by 2030. antidepressant medications. Many of the haemostatic functions of platelets are mediated through The call comes ahead of the HIV Ireland and Fast Track Cities UK & Ireland National HIV Conference, Towards a National Action Plan for HIV in serotonin so SSRIs canatmake the haemostatic function of platelets less effective and Ireland, which tookpotentially place recently the Aisling Hotel in Dublin. increase the bleeding risk (Ann Med. 2022 Dec). Over the counter medications such as non-steroidal HIV Ireland Executive Director Stephen O’Hare said, “We have the knowledge and tools to end new HIV transmissions. What we need now is anti-inflammatory drugs (NSAIDs) are also important ask about as they alsoand have an antiplatelet political will and leadership.

A National HIV Action Plan, to informed by both clinical community expertise, with specific targets and oversight, is the only way Ireland can meet its UNAIDS commitment to end new transmissions by 2030.” effect. It may not be possible to stop these medications but at least you can flag that the patient Thebe landmark conference together leadingthem experts from Ireland may at a higher risk forbrought bleeding and counsel regarding this.and the UK including UCD’s Centre for Experimental Pathogen and

NEWS - Calls for an HIV National Action Plan

Host Research led by Infectious disease specialist Professor Patrick Mallon, Sussex-based Irish Clinical Professor and Consultant in HIV

Medicine therapy: & Sexual Health Professororal Yvonne Gilleece andpill UK(COCP) Government advisor on HIVan and chair of the Hormonal The combined contraceptive is associated with increased riskHIV Action Plan Implementation Group for England Prof Kevin Fenton as well as people living with HIV and advocates. of venous thrombosis. Women are prescribed it for many reasons, including contraception, HMB, In June, Ireland published an updated National Sexual Health Strategy 2025-2035. The Strategy commits to developing a HIV Action plan and acne, endometriosis, polycystic ovarian syndrome, dysmenorrhoea, cycle regulation. It is important HIV Model of Care. A similar plan is in place in England, which was published in 2021. to find out what the indication for the COCP was when you are considering if it should continue or Professor Patrick Mallon added, “In recent decades, advances in testing, treatment and prevention have substantially changed the trajectory of beHIV changed to an Whatever indication, it is200 reassuring the note if a womenEnding is in Ireland.

Of alternative. the new cases identifiedtheir this year, fewer than will constitute newthat transmissions. new transmissions by 2030 is not but only if we redouble our efforts oninsurmountable, therapeutic anticoagulation, then their risk of now.” recurrent VTE appears similar if they are on oestrogen containing therapies or no hormonal therapy (Martinelli I et al. Blood. 2016 Mar).

Therefore, if a woman is remaining on anticoagulation, they can stay on the COCP but if they are PHARMACYNEWSIRELAND.COM stopping anticoagulation, an alternative needs to be found. Different modalities have different levels of efficacy in terms of contraception thrombosis risk and amenorrhoea rates (DeLoughery E et al.

60

Corporate Profile

Théa Pharma: Innovation, Partnership, and Leadership in Irish Eye Care In recent years, Théa Pharma has emerged as a leading force in Irish eye health, building trust with pharmacists, ophthalmologists, optometrists, and patients alike. At the heart of this success has been a clear strategy: combine clinically proven, preservative-free solutions with education, transparency, and genuine partnership with community pharmacy.

Diarmuid Gavin, Country Manager, Théa Pharma Ireland

“For me, 2025 is defining because it brings everything together: global innovation, Irish community pharmacy, and a growing patient need.”

and sustainable profitability. That combination is what makes us unique, and why Théa Pharma today is Ireland’s number one choice for eye health.”

Adapting to shifting market and patient needs The Irish healthcare landscape has changed significantly in recent years. Patients today are more informed and engaged than ever before. They enter pharmacies asking about preservatives, ingredients, and long-term safety.

At the same time, pharmacists are busier, juggling increasing responsibilities as the first port of call for many health concerns, including eye health.

According to Gavin, Théa Pharma’s response to these shifts has always started with one principle: listen first. “Pharmacists are on the front line every day, and they know what patients are asking.

By listening carefully, we can adapt quickly to meet both patient expectations and professional needs.”

This listening-led strategy has translated into several key initiatives:

As Diarmuid Gavin, Country Manager for Théa Pharma Ireland, reflects on the company’s milestones and shares his vision for the future, one message is consistent: Théa Pharma is here to empower pharmacists, strengthen their businesses, and improve outcomes for patients.

With 2025 shaping up to be a defining year for both Ireland and the global organisation, this is the story of how Théa has built a leadership position and where it is heading next.

portfolio meets the needs of both healthcare professionals and the people they serve. Thealoz Duo drops for dry eye and Blephaclean wipes for eyelid hygiene are two examples of products that pharmacists can recommend with confidence, knowing they are preservative-free, clinically tested, and patient friendly. These solutions have strengthened patient loyalty to pharmacies, as individuals return for treatments that truly work.

For Gavin, Théa Pharma’s greatest milestone in Ireland has been earning the trust of pharmacists.

“That didn’t happen overnight,” he notes. “It came from building real partnerships and consistently delivering clinically proven solutions that pharmacists and their patients can rely on.”

Another important milestone has been Théa’s commitment to education and training.

Recognising that eye conditions such as dry eye or blepharitis can often be misunderstood or underestimated by patients, the company has invested heavily in pharmacist education. Initiatives include a pioneering interactive training module, a series of webinars, and dissemination of clinical data in accessible formats.

From the beginning, the company has focused on making sure its

“The feedback we’ve had is that this support doesn’t just improve

Building trust through milestones

PHARMACYNEWSIRELAND.COM

patient outcomes,” Gavin explains.

“It also enhances the pharmacist’s role as a trusted expert in eye health. Patients leave with better understanding, and pharmacists feel more confident in the advice they’re giving.”

Profitability has also been central to Théa’s approach. Pharmacies are healthcare providers but also businesses that need sustainable margins. To address this, the company introduced a margin calculator — a transparent tool that helps pharmacies see exactly how Théa products contribute to their bottom line.

This initiative, alongside clear category management, means that recommending Théa is not only clinically responsible but also commercially beneficial.

Summarising these achievements, Gavin says: “We’ve become a partner that empowers pharmacists with three things: clinically proven solutions, continuous education,

• Product positioning that combines clinical robustness with practical benefits. For example, patients with dry, tired eyes need solutions that work across the full spectrum of dry eye symptoms, while pharmacists need evidence they can trust. Thealoz Duo provides both, bridging the gap between patient expectations and professional reassurance.

• Educational investment to support pharmacists as patient expectations grow. With conditions like dry eye and blepharitis increasingly managed at the pharmacy counter rather than in specialist clinics, pharmacists now carry a greater educational burden. Théa has responded by investing in webinars, interactive modules, and accessible data to equip pharmacists for these conversations.

• Brand Architecture and merchandising support to improve visibility and

NOT ALL DRY EYE DROPS HAVE CLINICALLY PROVEN EFFICACY

THEALOZ DUO DOES! Preservative-free Phosphate-free Hypotonic Thealoz® Duo relieves the signs and Osmoprotective

Relative change in Tear Film Thickness (%)

symptoms of Dry Eye Disease1

130

# # #

*

120

#

#

* 110

*

#

100 0 0

20

40

60

80

100

120

140

160

180

200 220 240

Timepoint (minutes) Thealoz ® Duo

# * Significant change from baseline

Sodium chloride

Sodium hyaluronate

p<0.0001 n=60 patients

See the difference:

EUROPE’S

1 drop of Thealoz® Duo lasts for up to 4 hours1 DRY EYE DROP2

The increase in TFT with Thealoz® Duo was significantly longer than with HA (p<0,01). With Thealoz® Duo the effect remained statistically significant over 240 min.

reatment of mild non-infectious allergic or inflammatory conjunctival diseases. Posology: The recommended dos of 14 days. Gradual tapering off up to one administration every other day may be recommended in order to avoid 150 years Products Educating bstance or to any glucocorticosteroid-induced that of are the 100%excipients; Known of knowledge & & empoweringocular hypertension and other forms of o preservative free expertise in eye care ept when combined with specific chemiotherapeutic agents forprofessionals herpes virus), conjunctivitis withour ulcerative let’s open eyes keratit vitis and purulent blepharitis, stye and herpes infection that may be masked or aggravated by anti-inflammatory glucocorticoids are excreted in breast milk and may cause suppression of growth or of endogenous corticosteroid Reference: 1. Schmidl D1, Schmetterer L et al. Tear film thickness after treatment with artificial tears in patients with moderate dry eye disease. Cornea. 2015 Apr;34(4):421-6. 2: 8. 2. IQVIA Consumer Health Customized Insights for the period 2024, volume and value sales in Euros PUB, limited to IQVIA CHC3 07A3 Artificial Tears and Ocular Lubricants, reflecting estimates of real-world activity in these countries: Austria, Belgium, Bulgaria, Croatia, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Netherlands, Norway, Poland, Portugal, Romania, Russia, Saudi Arabia, Serbia, Slovakia, Slovenia, South Africa, Spain, Sweden, Switzerland, UAE (United Arab Emirates), UK. Copyright IQVIA. All rights reserved. TP25015

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Corporate Profile

“We don’t just innovate, we prove. Every product in our portfolio carries clinical data, every one is preservative-free.” accessibility of the eye care category. By providing planograms and professional shelf layouts, Théa ensures that patients can easily navigate the eye care section, while pharmacists see improved category performance.

As Gavin explains, “Rather than one single strategy, it’s really been about evolving together — listening to pharmacists, understanding patients, and adapting in ways that

make everyone’s job a little easier and a lot more rewarding.”

2025: A defining year Looking ahead, Gavin sees 2025 as a year when Théa’s global leadership and Irish presence fully align. Internationally, Théa remains the number one ophthalmology group in Europe and a pioneer in preservative-free solutions. But in Ireland, the local story is equally compelling, shaped by growing patient demand and an enhanced pharmacy role.

“Patients here are more informed than ever, and conditions like dry eye, glaucoma, and blepharitis are now recognised as common, everyday concerns,” Gavin says.

“In fact, studies show that one in two people will experience dry eye symptoms at some point. That means pharmacists are increasingly the first person patients turn to for relief.”

This creates a unique opportunity for Théa’s clinically proven portfolio. Thealoz Duo is supported by numerous studies confirming its effectiveness across all dry eye symptoms, giving pharmacists the confidence that they are recommending a safe, preservative-free, and clinically robust product. Similarly, Blephaclean has established itself as Ireland’s number one

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daily eyelid cleanser, addressing a condition that often frustrates patients and leads to repeated pharmacy visits.

Beyond products, 2025 also marks an expansion of Théa’s Brand Architecture strategy, which will further enhance pharmacy eye care sections through planograms, merchandising, and transparency on margins. For patients, this means clarity when browsing shelves; for pharmacists, it means stronger category performance.

“For me, 2025 is defining because it brings everything together,” Gavin reflects. “Global innovation, Irish community pharmacy, and a growing patient need. It’s about empowering pharmacists with clinically proven solutions, education, and business support so that when one in two people walk into their local pharmacy with eye health concerns, Théa is right there as the partner that makes the difference.”

Drivers of sustained leadership Sustaining a leadership position across Europe and in Ireland requires more than good products — it requires a consistent set of values and actions. Gavin identifies five key drivers behind Théa’s success: 1. Innovation rooted in patient need. From its decision in 1994 to go 100% preservative-free — a bold and risky move at the time — Théa has consistently set new standards. Today, products like Thealoz Duo, Blephaclean, and Nutrof Total embody this philosophy, offering unique solutions to real patient needs.

2. Evidence and education. Trust is built on proof. By bringing pharmacists robust clinical data and innovative training resources, Théa ensures that recommendations are made with confidence, reinforcing the pharmacist’s role as an expert in eye health.

63 3. Partnership with pharmacies.

Recognising the central role of community pharmacies in Ireland, Théa has embedded itself as a genuine partner, offering not just products but also merchandising tools, profitability calculators, and hands-on support.

4. The Irish team. Gavin emphasises the role of the dedicated Théa Pharma Ireland team, describing them as small but passionate. “We’re on the ground, visiting stores, listening to concerns, and making sure eye care doesn’t get overlooked.

Pharmacists know us by name — and that matters.”

5. Consistency. Patients and professionals know what to expect from Théa: preservativefree innovation, clinical excellence, and unwavering partnership. This consistency has built loyalty, which in turn sustains leadership.

Differentiation in a competitive market The eye care market has become increasingly competitive, with new entrants and innovative solutions emerging regularly. Yet Théa continues to stand apart by combining clinical evidence, preservative-free safety, and a comprehensive product portfolio.

• Thealoz Duo: Europe’s leading dry eye drop, clinically proven to treat all dry eye symptoms while protecting against oxidative stress.

doesn’t happen in a clinic — it happens at the pharmacy counter,” he says.

• Blephaclean: Ireland’s number one eyelid cleanser, clinically shown to improve eyelid health, reduce inflammation, and relieve symptoms.

1. Confidence. Patients often arrive uncertain whether their discomfort is dry eye, blepharitis, or simple irritation.

Pharmacists, equipped with evidence-based, preservativefree solutions, can provide clarity and reassurance.

• Nutrof Total: Europe’s leading eye care supplement, uniquely formulated with 11 nutrients targeted to support retinal health and combat oxidative stress.

• Blephaderm: The latest addition, a preservative-free 5-in-1 cream for eyelids and periocular skin, clinically proven to soothe, repair, and hydrate even sensitive or atopy-prone skin.

“Our differentiation is clear,” Gavin states. “We don’t just innovate, we prove. Every product in our portfolio carries clinical data, every one is preservative-free, and every one gives pharmacists the reassurance that they are offering the best to their patients.”

Unlocking the potential of community pharmacy Ultimately, Gavin believes that the full potential of eye care in Ireland rests with community pharmacists.

“For many people, their first conversation about an eye concern

Unlocking this potential requires three things:

2. Visibility. Eye care is sometimes overlooked on pharmacy shelves. Théa’s Brand Architecture ensures that the category stands out, encouraging patient engagement and positioning the pharmacist as the expert guide.

3. Sustainable business support.

With tools like the margin calculator, pharmacists can see exactly how Théa products support their profitability, giving them the confidence to invest in patient care.

As Gavin concludes, “Community pharmacists are at the heart of every town and village in Ireland.

They are trusted like family, and their advice carries enormous weight. If they have the right tools, evidence, and support, they can truly transform how

patients manage their eye health.

Our promise at Théa Pharma is simple: to be there beside them — supporting their expertise, strengthening their business, and helping deliver the very best care for patients.”

Conclusion From bold innovation to genuine partnership with pharmacists, Théa Pharma has reshaped the landscape of eye care in Ireland.

By focusing on preservativefree, clinically proven solutions, investing in education, and providing transparent business support, the company has established itself as Ireland’s number one choice in eye health.

As 2026 approaches, Théa Pharma is poised to bring its global leadership and local expertise together in a way that will further empower Irish pharmacists and improve patient outcomes. With innovation, trust, and partnership at its core, Théa Pharma’s future looks every bit as defining as its past milestones.

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Eye Health

Managing and Treating Eye Conditions

Dry Eye Disease An estimated 10% to 30% of the population older than 40 years suffers from some degree of dry eye disease (DED). The condition tends to affect people above 60, and it is more common in women than men.

Around one in 13 people who are in their fifties experience dry eye syndrome, and the condition becomes more common with age.

Up to a third of people age 65 or older may have dry eye syndrome.

DED, which is also sometimes referred to as dry eye syndrome or keratoconjunctivitis sicca, is considered the most prevalent ophthalmic disorder that affects the anterior eye and is most often associated with the aging process, especially in postmenopausal women.

DED is a multifactorial disease of the tears and ocular surface that results in discomfort, tear film instability, and visual disturbance, with potential for damage to the ocular surface. DED can be

classified as chronic or temporary.

DED can be also attributed to Bell palsy, collagen disorders such as rheumatoid arthritis, corneal or eye lid defects, Sjögren syndrome, and thyroid-related eye disease.

Other medical conditions associated with DED include diabetes, lupus, and scleroderma.

Dry eyes can be caused by ordinary things that increase tear evaporation, such as looking at a computer screen too long; being outside in windy, dry conditions; or just being tired. Cigarette smoke may also cause dry eyes.

Other common causes of dry eye include: • Aging: Tear production tends to decline with age. Dry eyes are common in individuals older than 50 years.

• Gender: A deficiency of tears is more common in women, especially with hormonal changes caused by pregnancy, the use of birth control pills, or menopause.

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• The use of cold or allergy medicines, antidepressants, and drugs for high blood pressure; acne; birth control; and Parkinson’s disease.

• Wearing contact lenses.

• An eye injury or other problem with your eyes or eyelids.

• Diabetes.

• Thyroid disorders.

• Vitamin A deficiency.

Symptom Checker The symptoms of dry eye syndrome usually affect both eyes and may include: • feelings of dryness, grittiness or soreness, which get worse throughout the day.

• redness of the eyes.

• watering eyes, particularly when exposed to wind.

• eyelids that stick together when waking up .

These symptoms may get worse in smoky or hot environments.

When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors.

Briefly, this should include details of the signs and symptoms, duration of symptoms and exacerbating factors, such as the environment, changes in humidity or computer use.

It should also record details of topical and systemic medicines taken by the patient, whether the patient wears contact lenses and if the patient has any dermatological, inflammatory or other systemic diseases.

A differential diagnosis for other eye conditions (such as conjunctivitis, allergy and acute

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Eye Health

red eye) should be established because initial presentation may be similar.

Once dry eye syndrome develops, some people have recurring episodes for the rest of their lives. There is no cure for dry eye syndrome, but a range of treatments can control the symptoms. In rare cases, more severe cases of dry eye syndrome may require surgery.

The ultimate goal of dry eye treatment focuses on symptomatic relief, usually using tear supplements. Despite this, the underlying mechanism of symptomatic improvement with tear supplementation is still poorly understood. It is thought that increased tear volume, improved tear stabilisation, reduced tear osmolarity or a dilution of inflammatory biomarkers or a combination of these factors play a vital role.

Topical ocular lubricants are the mainstay of dry eye treatment, with the choice of tear substitute depending on the severity of the condition. Pharmacological interventions in all forms of dry eye conditions range in formulation, such as drops, sprays, gels and ointments.

For occasional or mild dry eye symptoms, OTC eyedrops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces. An indoor air cleaner to filter dust and other particles can help prevent dry eyes, as can a humidifier by adding moisture to the air, avoiding dry conditions, and allowing the eyes to rest when performing activities that require someone to use their eyes for long periods of time.

Pharmacologic agents that have anticholinergic properties—including antihistamines, decongestants, and antihypertensives such as antidepressants, beta-blockers, and diuretics—are common causes of DED. Additionally, DED may be caused or exacerbated by allergens and environmental conditions such as dry climates, failure to blink regularly when staring for long periods at electronic devices, smoke, and wind. Laser eye surgery may also cause temporary dry eye.

Blepharitis Eye irritation is among the most common—and most annoying—

conditions for patients. Itchy, swollen eyelids and a sensation of something in the eyes make patients miserable.

Most people with dry eye syndrome also have blepharitis, which is a common and usually mild condition where the edges of the eyelids become inflamed, red and swollen.

It is a common condition, accounting for an estimated 1 in 20 eye problems reported to GPs. Blepharitis can develop at any age, but is more common in people over 40.

Blepharitis, an overarching term, is a family of inflammatory eyelid diseases. Most often blepharitis is a waxing and waning chronic condition exacerbated by seborrheic dermatitis or meibomian gland dysfunction. Approximately 15% of patients have symptoms about half the time.

Blepharitis can also be acute; this type usually originates from allergen or irritant exposure.

Blepharitis is frequently associated with systemic diseases. Those who have anterior blepharitis, which is usually subdivided into staphylococcal and seborrheic variants, generally present with inflammation primarily around the eyelashes and follicles.

Patients who have posterior blepharitis have meibomian orifice involvement and telangiectatic vascular changes of the eyelid margin. Posterior blepharitis is usually less observable to the casual bystander as a cosmetic issue, but has more pronounced physical symptoms for the patient.

Patients with blepharitis may present with eyelash changes, watering, crusting and mattering around the lashes and canthus, photophobia, pain, and vision changes. The symptoms are usually worse in the morning, after a night of closed eyes has kept eyelids in contact with the ocular surface.

Patients’ visual function may decline pursuant to corneal damage and inflammation, scar formation, loss of surface smoothness, and clouded corneas.

If severe inflammation develops, corneal perforation can occur.

The normal progression may include eyelid damage to the lids with trichiasis, or entropion and ectropion (respectively, inward or outward turning lids that cannot close properly).

Ophthalmologists and opticians encourage blepharitis sufferers to establish a systematic, long-term commitment to eyelid hygiene, because management will require lifelong vigilance. The exact process varies. Antibiotic drops or

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ointments, or low-dose antibiotic courses should be considered if hygiene changes are ineffective.

Pharmacists should keep certain tips in mind when helping patients who have blepharitis. First, pharmaceutical preparations like ointments and gels will stay in contact with the lid margin longer than solutions. These are usually preferred for blepharitis, but drops are preferred for corneal disease because they spread evenly.

Pharmacists need to repeat one message to patients at every visit: when applying any ointment to lid margins, using a clean application device, such as a cotton swab or a clean fingertip, is critical, as is gentle eyelid handling.

A warmed wet towel or eyelidwarming mask can help to improve gland function. This is usually recommended for 10 minutes twice daily, but manufacturers’ instructions for eyelid-warming masks may vary.

Ensure that patients are aware that continued treatment is important. Even if the patient’s condition improves, continued management is important to ensure that any improvement is maintained.

Advise patients using antibiotic drops or ointment to avoid wearing contact lenses. The drops may build up behind the contact lenses and cause irritation.

The contact lenses may also be damaged by the medicines.

Eyelid Hygiene for Blepharitis For 5 minutes once or twice daily, apply a wet washcloth, soaked gauze pads, or flaxfilled mask, that has been warmed. This step softens gland secretions and promotes evacuation and cleansing of secretory passages.

Gently wash the eyelid margins while avoiding the lids or eye surface to remove adherent scurf (dead epidermal cells), collarettes (rims of thickened epidermis), and crusting. This also cleanses glandular orifices.

Although many clinicians recommend washing with water, some suggest adding a few drops of baby shampoo.

Apply an antibiotic ointment like erythromycin or sulfacetamide, but only for short courses of treatment (chronic use is contraindicated). Generally, ointments are applied at bedtime so blurry vision is not a problem.

Age-Related Macular Degeneration Age-related macular degeneration (AMD) is a chronic disease leading to progressive central vision loss.

The symptom of central vision loss is due to the fact that the damaged macula is in the centre of the retina. Patients with AMD may be unable to recognise faces, read, or drive a vehicle.

AMD is the most common cause of sight loss in people over the age of 50 in Ireland and it's estimated that 7% of Irish people over 50 years of age are living with AMD. On account of our ageing population, the number of people in Ireland affected by this condition is expected to increase.

Symptoms of AMD include decreased central vision, central scotoma, and metamorphopsia.

Scotoma is an area of partially diminished vision surrounded by a field of normal or well-preserved vision. Metamorphopsia is a visual defect that causes people to see objects in a distorted manner; straight objects appear wavy or curvy. Patients will complain of distorted vision, lack of bright colours, or blurred vision.

There are 2 types of macular degeneration: dry and wet. All AMD begins as “dry.” In some cases, it progresses to “wet,” which is a more severe form characterised by abnormal blood vessel growth that produces fluid in the retina. Wet age-related macular degeneration (wet AMD) is the leading cause of severe vision loss and legal blindness in people over the age of 65 in North America, Europe, Australia and Asia.

Dry macular degeneration, also known as the nonexudative form, is more common and found in approximately 90% of AMD patients. The onset of dry AMD is subacute. Management of dry AMD includes attempts to prevent progression to and frequent monitoring for the development of wet macular degeneration.

Wet (also known as exudative or neovascular) macular degeneration occurs in about 10% of AMD patients. It is the more acute form and more likely to cause vision loss.

Wet AMD (age-related macular degeneration) is a chronic, degenerative condition characterised by abnormal blood vessels that grow underneath the retina. The condition gets worse as these faulty blood vessels leak fluid in the back of the eye. This may lead to swelling and damage of the macula, the part of the retina that lets you see colour and maintain sharp vision.

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Eye Health

A healthy retina is a dry retina. If this fluid isn’t controlled, central vision will gradually get worse, leading to difficulty doing everyday activities such as reading, recognising faces and driving.

The leaky blood vessels are caused by an excess of a tiny protein called vascular endothelial growth factor (VEGF). Most eye doctors agree that the best way to control these tiny proteins is with an anti-VEGF treatment.

Treatments that help control fluid and stop blood vessels from leaking may slow the progression of wet macular degeneration.

Because the exact causes of AMD are not yet known, some people may develop AMD even in the absence of these risk factors.

Age-Related Studies (AREDS1 and AREDS2) have shown that a combination of vitamins and antioxidants may help reduce the risk of progression of Early AMD to late-stage AMD. The recommendations include supplements containing vitamins C and E, zinc, copper, lutein and zeaxanthin.

Treatment for Wet AMD is most often through a series of injections into the eye using a drug called anti-VEGF (anti-vascular endothelial growth factor). This

treatment works by reducing the growth of new blood vessels.

Response to this treatment is usually better in the early stages of Wet AMD, although even later stages can be stabilised. In some cases, individuals may notice improvements in their vision.

It is important to remind patients at risk for AMD to have regular eye exams, even when they are symptom-free. Patients complaining of a recent or chronic loss or change of vision should be urged to see an ophthalmologist immediately. A healthy lifestyle may help prevent AMD. This includes not smoking, eating a healthy diet, and being physically active.

Following the recommended guidelines and the use of appropriate pharmacologic agents may help patients with AMD slow vision loss progression, increase visual acuity, and experience a greater quality of life.

Conjunctivitis Conjunctivitis is one of the most common causes of ‘red eye’ and one that presents very often in the pharmacy. The term ‘conjunctivitis’ refers to an inflammatory condition that affects the conjunctiva, which is the thin transparent mucous membrane covering the white of the eye. It can become inflamed due to a variety of reasons and

is normally subdivided into origins that are either infective or non-infective in nature. This can be further divided into acute or chronic conjunctivitis.

• Allergies, like dust, pollen, or a special type of allergy that affects some contact lens wearers are described in more detail below.

There are various causes of conjunctivitis and these can be wide ranging including:

Symptoms and Treatment

• Viruses: Conjunctivitis results from the viruses that cause a common cold. Just as a cold must run its course, so must this form of conjunctivitis, which usually lasts from four to seven days.

Red and watering eyes are the main symptoms of conjunctivitis.

If you have Infective conjunctivitis you may also have: • a burning sensation in your eyes.

• a feeling of grit in your eyes.

• a sticky coating on the eyelashes.

• Bacteria: Conjunctivitis can also be caused by the bacteria resulting from the STDs gonorrhea or chlamydia. If a patient has conjunctivitis, ask about their sexual health. This form will need antibiotics to clear.

• an enlarged lymph node in front of the ear.

• Irritants: For conjunctivitis caused by an irritating substance, the patient should use water to wash the substance from the eye for five minutes.

The patient’s eyes should begin to improve within four hours. If the conjunctivitis is caused by acid or alkaline material such as bleach, the eyes should be rinsed immediately with lots of water and the patient should proceed to A&E to prevent eye damage.

Contact dermatoconjunctivitis and giant papillary conjunctivitis are frequently caused by contact lenses and lubricating eye drops. Eye drops that contain a preservative agent, commonly benzalkonium chloride, are long established irritants. Hence, patients that present with symptoms of irritation that can be linked to onset of use of eye drops should be advised to switch to preservative-free formulations.

Most cases of infective conjunctivitis do not require medical treatment and will clear up in one to two weeks.

Once the cause of the allergic symptoms has been identified, patients should be advised to avoid the allergen to control symptoms and avoid future flare-ups.

If a patient is suffering from conjunctivitis, the following measures should be employed to prevent its spreading. The patient should: • Not touch or rub the infected eyes.

• Wash their hands often with soap and warm water.

• Wash any discharge from the eyes several times a day using a fresh cotton ball or paper towel, and rewash hands.

• Wash bed linens, pillowcases, and towels in hot water and detergent.

• Avoid wearing eye make-up.

• Wear eyeglasses instead of contact lenses. Throw away disposable lenses or be sure to clean extended-wear lenses and all eyewear cases.

• Avoid sharing common articles such as unwashed towels and glasses.

• Wash their hands after applying eye drops or ointment to the eye.

• Not use eye drops that were used for an infected eye in a non-infected eye.

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Call for papers: make your contribution to Irish Pharmacy News  Articles  Research Papers  Reviews  Programme Descriptions  Reports Case Reports  Letters to editor  In-depth review articles critique fundamental concepts, issues, and problems that define a field of research or practice and support advanced practitioners as well as aspiring early-year pharmacists.  Practice reports share innovations on any area of practice, including delivering clinical services, pharmacy administration, or new approaches to inform and engage with patients with the aim to improving pharmacy practice.  Perspective articles focus on a specific field or discipline and discuss current advances or future directions, and may include original data as well as expert insight and opinions.

Contact: Kelly Jo Eastwood at: kelly-jo@ipn.ie or Robyn Maginnis robynmaginnis@ipn.ie

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70

Hepatitis B

Community prevalence of blood‑borne viruses (hepatitis B and HIV) in Ireland Written by P. Aiden McCormick1, Marie O’Grady2, Paul Holder3, Cillian F. De Gascun3, John S. Lambert4, Orla Crosbie5, Susan McKiernan6, Maeve Skelly7, Garry Courtney8, Brian Hennessy9, Kevin Walsh10, Roisin Twohig3, Kate Browne3, Tessa O’Gorman11, Vivion Crowley6, Seán J. Costelloe5, Roz O’Byrne7, Orla Gildea9 and Noreen Montgomery10 1 National Hepatitis C Treatment Program HSE, Liver Unit, St Vincent’s University Hospital and UCD, Elm Park, Donnybrook, Dublin 4 DO4 T6F4, Ireland 2 National Hepatitis C Treatment Program, HSE, Dublin, Ireland 3 National Virus Reference Laboratory, UCD, Dublin, Ireland 4 Mater and Rotunda Hospitals and UCD, Dublin, Ireland 5 Cork University Hospital and UCC , Cork, Ireland 6 St James’s University Hospital, Dublin, Ireland 7 University Hospital Limerick, Limerick, Ireland 8 St Luke’s Hospital, Kilkenny, Ireland 9 University Hospital Waterford, Waterford, Ireland 10 Sligo University Hospital, Sligo, Ireland 11 Mater Misericordiae University Hospital, Dublin, Ireland

Abstract Background: Chronic infection with hepatitis B virus and HIV causes significant morbidity and mortality. Effective antiviral treatment is available for both. Ireland has historically been considered a low prevalence country. However, with increasing inward migration and diversity, this may be changing.

Aims: The aim of this study was to measure the community prevalence of hepatitis B virus and HIV infections in Irish resi-dents born between the years 1965 and 1985.

Methods: Anonymised residual serum samples from blood tests ordered by community general practitioners and tested in eight general hospital laboratories, spread across Ireland, were analysed for the presence of Hepatitis B surface antigen and antibodies to HIV. Results: A total of 6080 samples were analysed for hepatitis B surface antigen including 2993 males, 2807 females and 280 samples for which gender was not recorded. HBsAg was detected in 28/6067 samples giving an estimated prevalence of 0.46% (95% CI 0.32–0.67%).

Antibodies to HIV were identified in 18/6064 giving an estimated prevalence of 0.33% (95% CI 0.19–0.47%). The prevalence of both hepatitis B and HIV was significantly higher in Cork (Southwest Ireland) than other centres: hepatitis B (12/1050 vs 16/5017, p = 0.014) and HIV (11/1049 vs 7/5015, p < 0.001).

Conclusions: The prevalence of hepatitis B virus and HIV infections in this cohort appear to be higher than previously esti-mated. In addition, their prevalence in the Cork area appears particularly high. Whether this represents a true prevalence or a chance finding will require confirmatory studies.

Keywords: Cirrhosis · Hepatitis B · Human immunodeficiency virus · Migration Introduction Blood-borne viruses hepatitis B (HBV), hepatitis C and human immunodeficiency virus (HIV) cause serious illness and significant morbidity and mortality. Effective treatment is now widely available for all three viruses. Hepatitis C virus can be eliminated with a short course of oral anti-viral medication. Conversely, while neither chronic hepatitis B nor HIV can be cured, they can be controlled with long-term oral antiviral therapy, thus preventing further end-organ damage. It is also important to diagnose and treat individuals with these viral infections, from a public health perspective, to prevent onward transmission. Accurate information on community prevalence and transmission patterns is essential for designing appropriate screening and treatment strategies. The epidemiology of these infections is likely to change as a result of migration patterns and other social and cultural trends.

We previously reported that the community prevalence of hepatitis C in Ireland was much lower than previously reported, approximately 0.1% compared to previous estimates of about 1%.1 This study was performed on anonymised routine biochemistry blood samples sent by general practitioners to general hospital laboratories. Individuals born between 1965 and 1985 were included as public health notification data suggested 70% of those infected were in this age cohort. The population prevalence of both hepatitis B and HIV is believed to be low in Ireland at between 0.1 and 0.2%.2, 3 We now report results for hepatitis B and HIV in the same birth cohort previously studied for hepatitis C. Methods This study looked at residual serum samples from general practitioner-requested blood tests from eight general hospitals, three of which were in Dublin.

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These hospitals included St Vincent’s University Hospital, Mater Misericordiae University Hospital, St James’s Hospital, Cork University Hospital, University Hospital Limerick, University Hospital Waterford, St Luke’s Hospital Kilkenny and Sligo University Hospital (Fig. 1). All patients were in the birth cohort (born in years 1965–1985) and the study included equivalent numbers of males and females.

Residual samples were anonymised, batched, and sent to the National Virus Reference Laboratory in UCD for analysis.

The only information retained on the samples was the sex of the patient. These samples were initially tested for the presence of hepatitis C virus antibody.

If positive, the samples were checked for the presence of hepatitis C antigen. Ethical permission was then obtained to test residual samples for HBV and HIV from the research ethics committees in St Vincent’s

University Hospital, Mater Misericordiae University Hospital, St James’s Hospital, University Hospital Limerick, Cork University Hospital and University Hospital Waterford. Sligo University Hospital and St Luke’s Hospital Kilkenny accepted the ethics approval from St Vincent’s University Hospital.

Laboratory methods HIV status was determined using the Abbott Architect HIV Combo Ag/Ab assay (Abbott Diagnostics, Wiesbaden, Germany). Specimens exceeding the manufacturer’s signal to cut-off (S/Co) ratio of 1.0 were tested using the Biomeriéux HIV DUO Ultra assay (MarcyL’Etoile, France). Persistently reactive samples were further investigated using the Fujirebio INNO-LIA HIV I/II Score assay (Fujirebio Europe N.V., Ghent, Belgium) to determine the true anti-HIV status of the sample and determine the HIV type.

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72

Hepatitis B Fig. 1 Geographic distribution and number of samples from eight general hospitals participating in the epidemiological study

p < 0.01) and HIV antibody in 11/1050 (prevalence 1.05%, CI 0.53–1.87%, p < 0.01). None of the samples in any of the hospitals was positive for both HBsAg and HIV antibody. One patient had hepatitis C antibodies and HBsAg (male) and one had hepatitis C antibodies and was anti-HIV positive (female). Both patients were in the Cork cohort.

The proportion of females with hepatitis C antibodies was higher in Cork than in the other centres (6 female/3 male vs 3 female/16 male, p < 0.05).

Discussion

HBV status was determined

1. There wasusing insufficient initially the Abbottvolume HBsAg for Qualitative sAg andArchitect 16 samples HIV antiII assay (Abbott Diagnostics, mmarised in TableGermany).

1. HBsAg was Wiesbaden, Specimens

Version 3 assay (DiaSorin Italia

in Fig. 1. There was insufficient

identified in 28/6067 (18 male, 1013female) giving S.p.A UK Branch, Dartford, samples UK) to volume to test samples for determine the trueprevalence HBsAg statusof 0.46% HBsAg(95% and 16CI samples for an estimated 0.32–0.67%). of the sample.

HIV antibody. The results are HIV antibody was identified insummarised 18/6064 samples male, in Table 1. (11 HBsAg

Statistical analysis generating a S/Co ≥ 15 were was identified in 28/6067 samples directly investigated for HBV (18 male, 10 female) giving an Differences between groups were markers using the following estimated prevalence of 0.46% evaluated using the chisquare (and assays, Abbott Architect HBeAg (95% CI 0.32–0.67%). HIV Fisher’s test using the Prism Site Number of exact) Anti-HCV (m/f) HCV Ag HBsAg (m/f) Anti-HIV (Abbott Diagnostics, Wiesbaden, antibody was identified in 18/6064 10 statistical program (GraphPad samples (m/f)giving Germany), Abbott Architect samples (11 male, 7 female) Software Inc., California, USA).

Anti-HBe (Abbott Diagnostics, an estimated prevalence of 0.3% Confidence intervals (95%) for StWiesbaden, Vincent’s Hospital, 982 the estimated 2 (2/0) 0 2 (2/0) 0 Germany),Dublin Abbott prevalence in each (95% CI 0.19–0.47%). Hepatitis sample were calculated using Architect antiHBc IgM (Abbott C antibodies were detected in Mater Hospital, Dublin 1018 3 (2/1) 0 5 (3/2) 4 (2/2) the Clopper-Pearson method Diagnostics, Wiesbaden, Germany) 28/6080 (19 male and 9 female), Limerick 500 [ref1] implemented 2 (1/1) in the R 1 (1/0) but of 1these, (1/0)hepatitis C 0antigen and Abbott Architect anti-HBc II 4 (Abbott Diagnostics, Wiesbaden, 531 package epitools. was detected Waterford 1 (1/0) 0 1 (0/1) in only 2/28 0 (7%) Germany). Weakly reactive HBsAg (1 male, 1 female). The Sligo 500 Results 2 (2/0) 0 1 (1/0) 1 (1/0) samples using the Architect assay geographical distribution of Kilkenny 0 0 samples was nonrandom.

0 (generating HBsAg result above 500 A total of 6080 positive samples were 0 the manufacturer’s S/Co of 1.0 1050available for Cork 9* analysis, (3/6) including 1 (0/1) The prevalence 12** (9/3)of both virus 11** (6/5) but less than 15.0) or HBeAg and infections was significantly 2993 males, 2807 females and Stanti-HBe James’sAb Hospital, 999 280 samples 9 (8/1) 0 1 (1/0) negativeDublin samples higher6in(3/3) Cork. HBsAg was for which gender was were further investigated using 6.080 12/1050 samples not recorded.

The geographical2 (1/1) present Total 28 (19/9) 28in(19/9) 17 (10/7) distribution of samples is shown the Murex HBsAg Confirmatory (prevalence 1.14%, CI 0.59–2.0%,

*p < 0.05. **p < 0.01; Cork prevalence vs other centres combined

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In this study, we found the prevalence of hepatitis B surface antigen was 0.46% and the prevalence of HIV antibodies was 0.3% in this community-based cohort of individuals born between 1965 and 1985. These figures appear higher than previously published estimates. As would be expected, approximately twothirds of those infected were male.

A surprise finding was that the prevalence rates of both hepatitis B and HIV were significantly higher in Cork than the other centres combined. We are not aware of a reason for this and it may represent a chance finding.

Nevertheless, further investigation is warranted to confirm or refute this finding.

There are limited data on the epidemiology of hepatitis B and HIV in the community in Ireland.

A recent publication from the European Centre for Disease Control (ECDC) and Bristol University suggested a population prevalence of 0.21% for HBsAg and a prevalence of 0.26% among prisoners.5 All pregnant females in Ireland are offered screening for hepatitis B and HIV. The Coombe maternity Hospital in Dublin reported 6974 babies born in 2023.

All expectant mothers are checked for hepatitis B, HIV and hepatitis C. Seven were HBsAg positive (0.1%), 18 had HIV (0.26%), 10 had antibodies to hepatitis C but

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Ag and 16 samples for HIV antimarised in Table 1. HBsAg was 74

Hepatitis B

an estimated prevalence of 0.46% (95% CI 0.32–0.67%).

HIV antibody was identified in 18/6064 samples (11 male,

Site

Number of samples

Anti-HCV (m/f)

HCV Ag

HBsAg (m/f)

Anti-HIV (m/f)

St Vincent’s Hospital, Dublin Mater Hospital, Dublin Limerick Waterford Sligo Kilkenny Cork St James’s Hospital, Dublin Total

982 1018 500 531 500 500 1050 999 6.080

2 (2/0) 3 (2/1) 2 (1/1) 1 (1/0) 2 (2/0) 0 9* (3/6) 9 (8/1) 28 (19/9)

0 0 1 (1/0) 0 0 0 1 (0/1) 0 2 (1/1)

2 (2/0) 5 (3/2) 1 (1/0) 1 (0/1) 1 (1/0) 0 12** (9/3) 6 (3/3) 28 (19/9)

0 4 (2/2) 0 0 1 (1/0) 0 11** (6/5) 1 (1/0) 17 (10/7)

*p < 0.05. **p < 0.01; Cork prevalence vs other centres combined Table 1 Results of testing for hepatitis B surface antigen (HBsAg), HIV antibodies, hepatitis C antibodies and hepatitis C antigen (HCV Ag) in 6080 community sourced birth cohort samples (born 1965–1985)

none was PCR positive.6 The Rotunda Hospital delivered 8442 babies in 2023. Thirtytwo had HBsAg (0.38%) and 25 (0.3%) had antibodies to HIV.7 The prevalence of HBsAg in first time blood donors in Ireland (1999–2022) was very low at 0.009% (monthly donation testing report, UK Health Security Agency). These figures are for donors born in Ireland or the UK, but would constitute a special population as individuals with risk factors are discouraged from donating.

International protection applicants in Ireland are offered blood-borne virus screening as many are from high prevalence countries.

Uptake is variable but the national reception centre for international protection applicants, in Balseskin, Dublin, reported that of those tested in 2023, 2.2% were HBsAg positive, 4.3% were HIV positive and 0.3% had chronic hepatitis C infection.8 The UNAIDS program estimates the prevalence of HIV infection in the general adult population in Ireland in 2023 was 0.3%.9 All pregnant females are offered antenatal testing for HIV. The national prevalence for 2023 was 0.2%.10 Only 14% of these were new diagnoses suggesting high rates of previous diagnosis, awareness and treatment in this cohort.

The strengths of this study are that it was community based, with a wide geographical spread and was not targeted at

higher risk groups. The major limitation is that the samples were anonymised so we have no clinical information about the infected individuals. It is possible that chance over-representation from higher risk groups may have skewed the results, particularly with regard to Cork, in the southwest of the country.

This study suggests that the epidemiology of hepatitis B and HIV infections is changing in Ireland and that the community prevalence of both is higher than previously estimated. This has implications for screening and service provision. It highlights the importance of up-todate epidemiological studies, particularly in societies affected by large-scale migration and social changes.

Acknowledgements We would like to thank Dr David McConnell, Senior Statistician, National Center for Pharmacoeconomics (NCPE), for providing statistical assistance.

Funding Open Access funding provided by the IReL Consortium.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if

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changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creativecommons.org/licenses/ by/4.0/.

References 1. McCormick PA, O’Grady M, De Gascun CF and others (2024) Hepatitis C community prevalence is over-estimated: a prospective, birth cohort study.

Ir J Med Sci 193:1257–1260 2. Nardone A, Anastassopoulou CG, Theeten H and others (2009) A comparison of hepatitis B seroepidemiology in ten European countries.

Epidemiol Infect 137:961–969 3. Tuite H, Horgan M, Mallon PW and others (2015) Patients accessing ambulatory care for HIV-infection: epidemiology and prevalence assessment. Ir Med J 108:199–202 4. Aragon T (2020) Epitoole: epidemiology tools. R package version 0.5–10.1. http:// CRAN.R- proje ct. org/ packa ge= epito ols

5. Trickey A, Bivegete S, Duffell E and others (2023) Estimating hepatitis B virus prevalence among key population groups for European Union and European Economic Area countries and the United Kingdom: a modelling study.

BMC Infect Dis 23:457 6. The Coombe Hospital. Annual Report 2023. Available at: https:// www. coombe. ie/ annual- report. (Accessed 31/12/2024) 7. Rotunda Hospital Dublin Annual Report 2023. Available at: https:// rotun da. ie/ rotun da- hospi tal- annual- report2023. (Accessed 31/12/2024) 8. (2023) Health Screening, National Reception Centre, Balseskin. Annual Report.

Health Service Executive 9. UNAIDS HIV and AIDS estimates for Ireland 2023.

Available at https:// www. unaids. org/ en/ regio nscou ntries/ count ries/ irela nd.

(Accessed 31/12/2024) 10. Antenatal HIV testing in Ireland. Health Protection Surveillance Centre. Available at https:// www. hpsc. ie/a- z/ hivan daids/ anten atalh ivtes ting/. (Accessed 24/12/2024) Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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HIV and Viral Hepatitis

Advances and Challenges in the Care of HIV and Viral Hepatitis in Ireland The landscape of care for people living with HIV and viral hepatitis has changed dramatically in recent decades. Yet despite scientific breakthroughs, challenges remain in diagnosis, access, and stigma. We spoke Professor Eoin Feeney, Consultant in Infectious Diseases, St. Vincent's University Hospital and Tara Ramsbottom, ID SpR, about where Ireland stands today—and what the future may hold.

Professor Eoin Feeney

But challenges remain. Specialist centres are concentrated in large urban hospitals, which means many patients face long journeys to appointments. Even once they attend, access to allied health services—physiotherapy, occupational therapy, clinical psychology—is limited. That’s a particular concern for our ageing HIV population, many of whom are living with multiple comorbidities and the impact of stigma or past trauma. Care is still largely hospitalbased rather than being integrated into community services.

What recent advances have had the most impact?

“Timely diagnosis remains a real issue. In 2023, almost 40% of new HIV diagnoses in Ireland were late, with a CD4 count under 350. Many clinicians still don’t think of HIV when faced with indicator conditions like recurrent shingles, unexplained weight loss, or bacterial pneumonia” How would you describe the current state of care for people living with viral hepatitis and HIV in Ireland?

Prof. Feeney: In many respects, Ireland has made excellent progress. If a patient receives a diagnosis of HIV or viral hepatitis today, they can usually be seen in a specialist clinic very quickly.

Antiviral therapy for HIV and hepatitis C is provided free of charge, which is hugely important.

In the case of hepatitis C, short oral courses of direct-acting antivirals (DAAs) achieve cure rates above 95%. That’s an

extraordinary change from the era of interferon, when treatment lasted a year, caused significant side effects, and cured less than half of patients.

Dr. Ramsbottom: Communitybased care is also developing.

Some patients with hepatitis C can now be treated outside hospitals, which improves access.

Inclusion health initiatives have made a real difference too— supporting patients experiencing homelessness or those in international protection who often face the greatest barriers to care.

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Prof. Feeney: For HIV, the concept of undetectable equals untransmissible (U=U) has been transformative. The knowledge that people with a suppressed viral load cannot transmit HIV to their partners is empowering and destigmatising.

Dr. Ramsbottom: Treatment itself has also changed. We now have two-drug regimens instead of traditional triple therapy, which means fewer side effects for many patients. Long-acting injectable therapies—currently given every two months—are available in Ireland, though still resourceintensive. They can be lifechanging for people who struggle with daily tablets, whether due to adherence issues, pill burden, or difficulties storing medication in shared accommodation.

For hepatitis C, DAAs have completely altered the landscape.

What was once a debilitating and often unsuccessful treatment journey is now short, simple, and curative for almost all patients. That’s reduced not just prevalence, but also the downstream complications we used to see regularly—cirrhosis, hepatocellular carcinoma, and liver transplantation.

And for hepatitis B, new guidelines from the European Association for the Study of the Liver and WHO recommend treating patients earlier, at the first

signs of fibrosis or inflammation.

While HBV is rarely curable, suppressive oral therapy can prevent long-term complications.

Where are the biggest gaps when it comes to early diagnosis?

Prof. Feeney: Timely diagnosis remains a real issue. In 2023, almost 40% of new HIV diagnoses in Ireland were late, with a CD4 count under 350. Many clinicians still don’t think of HIV when faced with indicator conditions like recurrent shingles, unexplained weight loss, or bacterial pneumonia.

Dr. Ramsbottom: There have been positive steps. The SH24 online programme allows people to order postal test kits for HIV, hepatitis B and C, which has improved access. Antenatal screening now routinely includes hepatitis C as well as HIV and HBV. But gaps remain. Optout screening isn’t consistently offered in busy emergency departments, prisons, drug treatment centres, or international protection accommodation.

Socioeconomic factors are also crucial. People who inject drugs or who come from endemic countries are among those least likely to seek asymptomatic screening, even if they have risk factors or symptoms. So, while the tools exist, reaching those most at risk remains challenging.

How well is Ireland doing in terms of equitable access to treatment?

Prof. Feeney: Broadly speaking, Ireland is performing well. A 2023 audit by the Health Protection Surveillance Centre showed that 90% of people living with HIV know their status, 99% of those are on treatment, and 99% of treated patients are virally suppressed. That puts us in a strong position internationally.

Dr. Ramsbottom: But we mustn’t overlook inequities. Patients outside major cities face difficulties

79 travelling to tertiary centres, particularly if they’re working, have limited English, or are financially constrained. And while HIV and hepatitis C therapies are free, patients with hepatitis B must pay for their medications, which are often lifelong. That inconsistency creates avoidable barriers.

Stigma continues to be raised as an issue. What is the situation today?

Dr. Ramsbottom: Stigma is still a daily reality for many patients. HIV and hepatitis disproportionately affect groups who already experience social exclusion— gay and bisexual men, people who inject drugs, migrants from endemic areas. Misconceptions about transmission remain common, and not everyone knows that U=U or that treated patients can live full, healthy lives.

Prof. Feeney: Unfortunately, stigma isn’t limited to the general public. A survey from the RCSI found that 75% of healthcare workers had witnessed stigmatising remarks about patients with infectious diseases.

That’s concerning. In our hospital we make a point of marking World AIDS Day and Sexual Health Awareness Day with education campaigns, stands, and social media posts to challenge stigma within healthcare. Campaigns like You, Me and HIV are also helping shift the narrative by sharing real patient stories.

How are treatment strategies evolving?

Prof. Feeney: For hepatitis C, the next challenge is eradication. DAAs have given us the means, but

success will depend on expanding testing and decentralising treatment. Other countries have shown that community pharmacies and outreach services can deliver effective test-and-treat models, and that’s something we need to look at more seriously.

Dr. Ramsbottom: For HIV, injectables are the biggest innovation right now. Cabotegravir and rilpivirine are already in use in Ireland as two-monthly injections.

While they bring challenges—site reactions, more frequent clinic visits, and increased resource needs—they offer a valuable alternative. Longer-acting agents, such as lenacapavir, which could reduce dosing to just twice a year, are particularly exciting.

How do you approach coinfections in practice?

Prof. Feeney: Integrated care makes all the difference. In St. Vincent’s, we run combined infectious diseases and hepatology clinics, which allow us to streamline visits, manage complex drug-drug interactions, and reduce pill burden. For example, tenofovircontaining regimens can treat both HIV and hepatitis B effectively.

Dr. Ramsbottom: Supportive care is also key. We try to address the risk factors that led to infection in the first place—providing opiate substitution therapy, needle exchange programmes, vaccinations, condoms, and routine sexual health screening.

Co-infected patients often face a double layer of stigma, so referral for psychological support is sometimes just as important as the prescriptions we write.

Are we on track for the WHO hepatitis C elimination targets?

Prof. Feeney: Encouragingly, yes.

Notification rates for hepatitis C have halved since 2012, down to 9 per 100,000 in 2024. The WHO elimination goal is fewer than 5 per 100,000 by 2030, so we’re within touching distance.

Dr. Ramsbottom: The WHO also targets ≥90% of patients diagnosed and ≥80% treated.

Around 70% of people with chronic HCV in Ireland have already been treated. To reach the remainder, we’ll need to broaden testing strategies—optout screening in EDs, targeted programmes in prisons and drug services, and outreach in international protection centres.

Reinfection risk in high-risk groups also needs ongoing attention, with harm reduction and repeat testing.

Looking ahead, what innovations are you most hopeful about?

Prof. Feeney: Long-acting HIV therapies are particularly exciting. At CROI 2025, phase II data showed six-monthly lenacapavir plus broadly neutralising antibodies maintained suppression in 96% of patients.

If longer-acting agents become standard, they’ll significantly ease treatment burden.

Dr. Ramsbottom: Cure research is ongoing for both HIV and hepatitis B, though we’re not there yet.

The few HIV “cures” so far have only been possible with stem cell transplants for malignancy—too risky for widespread use. But progress is being made with novel antivirals and immunotherapies.

In the shorter term, what gives us the most hope is scaling up testing, breaking down barriers to access, and addressing stigma.

Those steps will have the biggest impact in the next decade.

Finally, what lessons have you learned from your own practice that you’d like colleagues to bear in mind?

Prof. Feeney: Adherence challenges are rarely about patients being careless. More often, they reflect underlying problems—unstable housing, addiction, stigma, or mental health issues. Recognising those challenges, and offering support rather than judgement, can make all the difference.

Dr. Ramsbottom: Compassion and patient-centred care are as important as the drugs we prescribe. When patients feel heard, respected, and supported, adherence improves, outcomes improve, and stigma is reduced.

At a time when treatment options have never been stronger, the challenge is ensuring every patient—regardless of background—has equal access to care, and that stigma is replaced by understanding.

As Professors Feeney and Ramsbottom emphasise, science may provide the tools, but it is compassion and inclusivity that will drive real progress.

References: 1. HSE-Health Protection Surveillance Centre. HIV Slideset 2023. Dublin: HPSC; November 2024 2. British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV Testing Guidelines 2020 3. HIV Treatment Audit 2023 and progress towards UNAIDS 95-95-95 targets, Ireland. HSE. November 2024. Dublin.

4. HSE-Health Protection Surveillance Centre.

Epidemiology of hepatitis C in Ireland; Trends from 2004 to 2024.

5. A Study of Teropavimab and Zinlirvimab in Combination With Capsid Inhibitor Lenacapavir in Virologically Suppressed Adults With HIV-1 Infection ClinicalTrials.gov ID NCT05729568

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80

Clinical Profiles

ALEXION, ASTRAZENECA RARE DISEASE WELCOMES VISITORS TO HUB Alexion, AstraZeneca Rare Disease has welcomed government officials, academic leaders, and industry partners to its hub in Cork, reinforcing the company's commitment to productive partnerships and collaborative relationships within Ireland's life sciences sector.

Alongside established global operations in Dublin and Athlone, the Cork hub demonstrates Alexion’s dedication to building enduring connections across Ireland. The country continues to play a vital role as a global supply chain hub, delivering life-changing rare disease therapies worldwide—a complex mission that depends on strong collaboration to ensure quality, safety and timely access for patients in need.

Cork serves as a base for senior technical roles in manufacturing, supply chain, quality, and technical operations, positioning Alexion and AstraZeneca as active contributors to a vibrant regional life sciences community. Cork and the wider Munster region boast a robust talent pool and leading academic institutions, which enables shared innovation and professional development.

Across Dublin, Athlone, and Cork, Alexion and AstraZeneca employ approximately 1,400 people in development, manufacturing,

Shane Doyle, Senior Vice President, Global Operations and Sustainability, Alexion, AstraZeneca Rare Disease, Sylvia Kiely, VP, Global Supply Chain and Product Strategy Lead, Alexion, AstraZeneca Rare Disease and Michael Lohan, CEO of IDA Ireland

supply, and commercial roles, working together with colleagues, partners, and educational experts to advance solutions for rare disease patients.

Shane Doyle, Senior Vice President, Global Operations and Sustainability, Alexion, AstraZeneca Rare Disease, commented: “Ireland has long stood as a cornerstone of our global network, and our partnerships here reflect both our confidence in the country's talent, infrastructure, and supportive business environment, and our shared commitment to collaboration. Working closely within the Irish life sciences community allows us to enhance specialist capabilities in supply chain and technical operations, ultimately delivering our lifechanging medicines to more patients around the world.”

Sylvia Kiely, VP, Global Supply Chain and Product Strategy Lead, Alexion, AstraZeneca Rare Disease, said: “Cork represents a convergence of talent and academic excellence, and we look forward to deepening our relationships across Munster’s educational institutions and life sciences ecosystem. By working together, we nurture future talent and build on the region’s strengths through ongoing collaboration and shared purpose.”

Michael Lohan, CEO of IDA Ireland, added: “I would like to congratulate Alexion, AstraZeneca Rare Disease on establishing its operations hub in Cork. Their presence here underscores Ireland and indeed Cork’s reputation as a key hub for the life sciences sector.

With its well-established talent base, robust infrastructure, and pro-business environment, Ireland continues to attract strategic investments from world-leading companies. I would like to wish Alexion every success in the coming years.”

HSE LAUNCHES NEW STROKE PUBLIC AWARENESS CAMPAIGN The HSE today launched a new national TV, radio and digital campaign called ‘Every Second Counts’ highlighting that the second you suspect a stroke is the second you dial 999 or 112. The campaign reinforces knowledge and understanding of stroke symptoms while focusing on the importance of quick action when a stroke is suspected. It was developed with the support of stroke survivors alongside voluntary and community groups.

In Ireland, every year, around 7,500 people experience a stroke. About 90,000 people live with disability and the effects of stroke. Stroke is the third leading cause of death and the leading cause of acquired neurological disability. 1 in 4 of us will have a stroke.

The Irish National Audit of Stroke (INAS) found that in 2014, 73% of stroke patients reached hospital in the recommended timeframe.

Currently, fewer than 50% of stroke patients arrive to hospital within three hours of symptoms starting — a critical window for lifesaving and disability-reducing treatments.

This new 3-year evidence-based awareness campaign builds on previous shorter awareness campaigns to ensure more people understand the critical importance of getting early treatment.

Professor Rónán Collins, HSE National Clinical Lead for Stroke, said; “Every second counts when it comes to stroke. We know that public awareness of the symptoms has improved thanks to previous FAST campaigns, but many people still hesitate before calling an ambulance. This new campaign is designed to close that gap — to make sure the second you suspect a stroke is the second you dial 999 or 112. Doing so saves lives and reduces disability.”

The campaign also continues to emphasise the established F.A.S.T. acronym: • Face – Has the face drooped or become weak on one side?

• Arm – Has an arm become suddenly weak or clumsy on one side?

• Speech – Has speech suddenly become slurred or confused in nature?

• Time – Time to act FAST: phone 999 or 112 for an ambulance immediately.

Siobhán McGrath, was a fit and healthy 34-year-old Dublin senior ladies' football team player when she had a stroke three years ago.

She says; “I didn’t realise at first

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that I was having a stroke, and I waited before seeking help. I now know that not acting FAST delayed my recovery. This campaign is vital in helping people act immediately when they spot the signs.”

Improving public awareness is one key recommendation of our National Stroke Strategy.

Another area where we are making real progress is in early stroke rehabilitation. The HSE will shortly publish a new report, Early Supported Discharge (ESD) for Stroke 2022 to 2023. ESD means stroke survivors have therapy, social work and nursing support at home so they can leave hospital earlier. They are more independent, spend less time in hospital and are more likely to avoid long-term residential care. Early supported discharge (ESD) also improves bed capacity in stroke units. More than 800 people benefited from the initiative in 2023. This is an increase from 370 patients in 2019 with the expansion of ESD teams to 11 sites, where a median of 22% patients are now discharged via ESD. Speaking on ESD, Professor Rónán Collins explained that this model of care enables stroke survivors to begin their recovery at home sooner, providing multidisciplinary treatment and support to help manage this vulnerable time of transition between hospital and home.

Minister for Health, Jennifer Carroll MacNeill, said; “Stroke is a medical emergency which can result in damage to the brain and long-term disability. However, we have very effective treatment options when these are provided quickly. If you or a loved one notice any one of the FAST signs and symptoms, it is essential to call emergency services immediately on 112 or 999. Every second counts.

“This campaign is a major milestone on our journey to future-proofing our stroke services. We know the incidence of stroke is expected to rise significantly in coming decades.

That is why, through the National Stroke Strategy, we are investing in Ireland’s longest sustained public awareness campaign. This investment is part of over ¤13 million invested in the National Stroke Strategy since 2022.

“Our network of Early Supported Discharge Teams are expanding across the country, with 11 teams now enabling stroke survivors to access rehabilitation at home. This is expected to rise to 15 teams by the end of 2025, meaning we are on track to delivering 21 teams nationally as envisaged within the National Stroke Strategy.

81 “Early Supported Discharge provides an essential support, ensuring that more people are not just living longer, but living to their full potential after a stroke. By delivering more care in people’s homes, we are also freeing up space in our hospital stroke units.”

Look out for the campaign on TV, radio and online, and the key message: ‘The second you suspect a stroke is the second you dial 999 or 112’. For more information, visit www.hse.ie/stroke DR DAVID MURPHY APPOINTED DIRECTOR OF VETERINARY SCIENCES AT THE HPRA The Health Products Regulatory Authority (HPRA) announces that Dr David Muphy has been appointed Director of Veterinary Sciences. Dr Murphy has over 25 years of experience working in the regulation of veterinary medicines, his most recent role being HPRA Veterinary Assessment Manager, with overall responsibility for safety and efficacy assessment of veterinary medicinal products.

From 2016 to 2022, Dr Murphy was Chair of the European Medicines Agency’s (EMA) Committee for Veterinary Medicinal Products (CVMP). As CVMP Chair, he was responsible for guiding the work of the committee and ensuring that its opinions and recommendations were evidence-based, scientifically robust and consistent.

Since 2023, Dr Murphy has acted as Co-Chair of the Veterinary Strategic Focus Group (VSFG).

The VSFG is responsible for providing strategic support to the European Heads of Medicines Agencies (HMA) on matters relating to veterinary medicines, with a focus on medicines availability, optimisation of regulatory processes and efficient resource management.

Dr Lorraine Nolan, Chief Executive of the HPRA, welcomed Dr Murphy’s appointment; “Dr Murphy brings a wealth of knowledge and expertise in the evaluation and monitoring of veterinary medicines combined with an in-depth understanding of national and EU regulatory frameworks.”

Dr Murphy holds a PhD from University of Glasgow and a Bachelor of Veterinary Medicine from University College Dublin.

HSE APPROVES MIRIKIZUMAB FOR THE TREATMENT OF ELIGIBLE ADULTS WITH MODERATELY TO SEVERELY ACTIVE ULCERATIVE COLITIS[I] Eli Lilly and Company has announced that the HSE has approved mirikizumab for the treatment of adult patients who have had moderately to severely active Ulcerative Colitis (UC) who had inadequate response with, lost response to, or were intolerant to either conventional therapy or a biologic treatment.

Reimbursement is restricted to use as a subsequent line of therapy following treatment with a lowercost biologic therapy.

“This decision means mirikizumab will now be made available in Ireland for the treatment of adults with moderate to severe Ulcerative Colitis. Ulcerative Colitis is a chronic, relapsing inflammatory disorder affecting the large intestine. It is characterised by symptoms of diarrhoea, bleeding and urgency, and often has negative effects on patients’ personal, psychological, professional and social well-being,” said Professor Glen Doherty, Consultant Gastroenterologist at The Centre for Colorectal Disease at St Vincent’s Hospital, Dublin. “I am delighted that an additional treatment option will now be available through Ireland’s healthcare system for eligible patients diagnosed with Ulcerative Colitis”.

Victoria Spillane, Chief Operating Officer of Crohn’s & Colitis Ireland, welcomes the news: “Over 40,000 people in Ireland are living with Crohn’s Disease and Ulcerative Colitis. They are lifelong conditions for which there is no known cure, and the symptoms are painful and debilitating. Existing medications may not work for some people or indeed stop working for others.

Expanding the treatment options for eligible people living with Colitis is a promising step forward and we welcome the HSE’s decision to recommend mirikizumab.”

Dr David Murphy

This approval for reimbursement was based on results from the LUCENT program, which included two randomised, double-blind, placebo-controlled Phase 3 clinical

trials, consisting of one 12-week induction study (LUCENT-1) and one 40-week maintenance study (LUCENT-2) for 52 weeks of continuous treatment.

About Ulcerative Colitis Ulcerative Colitis (UC) is a chronic immune-mediated inflammatory condition of the large intestine.

It is frequently associated with inflammation of the rectum but often extends proximally to involve additional areas of the colon.

Patients with new-onset UC often present with characteristic symptoms of an inflamed rectum, namely, bleeding, urgency, and tenesmus. The management of UC must involve a prompt and accurate diagnosis, assessment of the patient’s risk of poor outcomes, and initiation of effective, safe, and tolerable medical therapies.

About mirikizumab Mirikizumab is an interleukin23p19 antagonist indicated for the treatment of moderately to severely active Ulcerative Colitis in adults.

Mirikizumab selectively targets the p19 subunit of IL-23 and inhibits the IL-23 pathway. Inflammation due to over-activation of the IL-23 pathway plays a critical role in the pathogenesis of UC. Treatment with mirikizumab starts with 300mg IV infusions at weeks 0, 4 and 8. After completion of the induction dosing, the maintenance dose of mirikizumab is 200mg by subcutaneous injection every four weeks in two 100mg pre-filled pens. [i] Lilly data on file. Available in due course at: https://www.hse.ie/eng/staff/ pcrs/items

IRISH PEOPLE STRUGGLING MORE THAN EVER WITH MENTAL HEALTH Irish people are struggling with mental health more than ever despite an increase in information available, according to findings published today as part of the Irish Life Health of the Nation Report 2025. The research looks at Ireland’s overall health and wellbeing standards across a range of metrics, pinpointing the current health challenges Irish adults face, and highlighting the opportunities to make positive changes for our overall wellbeing.

When it comes to our mental wellbeing, the research shows that stress levels are rising, with 29% feeling anxious or stressed more than half the time while 19% report feeling sad or depressed just as often.

Younger adults continue to be the most stressed group, with more than 2 in 3 (67%) feeling stressed on a weekly basis, while stress levels are also rising among

35–54-year-olds, increasing from 54% in 2024 to 57% this year.

The research highlights how stress is impacting each generation differently, revealing the pressures and challenges across age groups.

Adults under 35 are primarily stressed by work-related factors, while those aged 35-54 report stress from household tasks, parenting and a demanding workload in their professional life.

More than half of adults (55%) say they are actively trying to reduce their stress levels. However, 63% of respondents admit that while they know what steps to take to improve their mental health, they struggle to put them into practice.

Social media and AI The research also found that adults are increasingly turning to social media and AI for health information. Half of those under 35 report receiving a significant amount of health-related content through social media, while nearly one third (32%) have used AI to get a better understanding of their health.

Despite this growing reliance, more people wish to spend less time on social media and online in general. For the first time, alcohol consumption is no longer the most cited habit people want to reduce their dependence on, with over half (52%) indicating they want to cut back on their social media use.

Stacey Machesney, Head of Health and Wellbeing at Irish Life: “What really stood out in this year’s findings is the number of people actively seeking to reduce their dependence on social media. At Irish Life, we’re seeing a sharp rise in demand from corporate organisations for our programmes that build healthier digital habits and support employees in managing their relationship with technology. Encouragingly, more employers are now interested in expanding these supports to families, recognising the impact on children and teenagers too. That shift marks a real turning point and awareness is no longer enough; the challenge now is to turn intent into action by promoting more mindful and purposeful use of technology in everyday life.”

Work life balance Some return to office policies are also contributing to increased stress, with 34% of employees saying they are feeling at least some pressure to work in the office more than they would like. Women are more likely than men to say working in the office has negatively impacted their flexibility to manage responsibilities outside of work (30% of women vs. 24% of men).

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Clinical Profiles

Parents are more likely to feel stressed, with 76% reporting at least one stress factor related to work or family responsibilities, compared to the national average of 59%. Furthermore, parents are the most likely to be adversely affected by a reduction in remote working, with one in three feeling negatively impacted.

TALLAGHT UNIVERSITY HOSPITAL & SDCC LIBRARIES LAUNCH NEW LIBCABINET SERVICE South Dublin County Council (SDCC) Libraries, in partnership with Library & Information Services at Tallaght University Hospital (TUH), are delighted to announce the installation of a LibCabinet in the Hospital foyer, offering patients, staff, and visitors a convenient way to borrow books from the public library. The installation of the new service is the first of its kind in a hospital in the country.

The LibCabinet aka “The Little Library” is a self-service library Little Libraries caption: Pictured from left to right at the launch of the Little Library in the main atrium of TUH were Barbara Keogh Dunne, CEU of TUH; Sharon Larkin, Director of HR TUH; Mayor of South Dublin Cllr Pamela Kearns; Lorna Maxwell, Director of Community; Jean McMahon, Head of Library & Information Services TUH; Síle Coleman; County Librarian

kiosk that enables users to borrow, return, and browse a curated selection of books at their convenience. Located in the main hospital foyer, the LibCabinet aims to bring the joy of reading directly into the daily lives of patients, staff, and visitors, supporting wellbeing and lifelong learning.

“This collaboration demonstrates the positive impact libraries can have beyond our own walls,” said Sile Coleman, Acting County Librarian, SDCC. “By bringing books from the public library service directly to the Hospital community, we are helping to support comfort, distraction and relaxation in a busy healthcare setting.”

Tallaght University Hospital has welcomed the initiative as part of its ongoing commitment to promoting holistic care. “We are delighted to partner with SDCC Libraries on this project,” said Sharon Larkin, Director of HR at TUH. “The LibCabinet provides patients and staff with easy access to reading material that can make a real difference during hospital visits. At TUH, we are proud to have a hospital library that that provides access to world-class healthcare resources and supports staff in their research, continuing development and in direct patient care. The availability of this new resource, a collaboration between both of our Library services, is an incredible additional benefit to staff, who often work very long

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hours with long commutes and find it is difficult to get the time to access the public library services.”

“This fantastic new service is part of SDCC Libraries’ commitment to extending services into community spaces and making books more accessible to all,” said the Mayor of South Dublin, Cllr. Pamela Kearns. Library membership is free, and new members can register online or at any branch to enjoy a wide range of resources, including eBooks, audiobooks, online learning, and more.

The Little Library LibCabinet at TUH was officially launched today with both organisations looking forward to welcoming the Hospital community to explore the collection.

EUROPEAN COMMISSION AUTHORISES TWICE-YEARLY LENACAPAVIR FOR HIV PREVENTION Gilead Sciences, Inc. (Nasdaq: GILD) has announced that the European Commission (EC) has granted marketing authorisation for lenacapavir for PrEP (under the brand name Yeytuo®)—the company’s twice-yearly injectable HIV-1 capsid inhibitor—for use in combination with safer sex practices for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults and adolescents with increased HIV-1 acquisition risk, who weigh at least 35kg.

Initiation of lenacapavir requires

2 days of oral tablets at the time of the first injection. Lenacapavir for PrEP is licensed for use in the European Union’s 27 member states, as well as Norway, Iceland and Liechtenstein.

The marketing authorisation application (MAA) was reviewed under an accelerated timeline based on the assessment by the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) that twice-yearly lenacapavir for PrEP is a product of major interest for public health. In July, the CHMP adopted a positive opinion recommending lenacapavir for PrEP for EC authorisation.

The EC authorization follows authorisation by the U.S. Food and Drug Administration (FDA) in June, as well as the issuance of guidelines by the World Health Organisation (WHO) in July that recommended twice-yearly lenacapavir as an additional PrEP option for HIV prevention.

EC authorization of lenacapavir for PrEP is supported by efficacy and safety data from two Phase 3 trials The EC authorisation of lenacapavir for PrEP was supported by data from the Phase 3 PURPOSE 1 and PURPOSE 2 trials conducted

by Gilead. In the PURPOSE 1 trial (NCT04994509), data at the primary analysis showed that administration of twice-yearly subcutaneous lenacapavir led to zero HIV infections among 2,134 participants, 100% reduction in HIV infections and superiority of prevention of HIV infections when compared with once-daily oral emtricitabine 200mg and tenofovir disoproxil fumarate 300mg(F/TDF) in cisgender women in sub-Saharan Africa. In the PURPOSE 2 trial (NCT04925752), at the primary analysis there were two HIV infections among 2,179 participants in the twiceyearly subcutaneous lenacapavir group, demonstrating 99.9% of participants did not acquire HIV infection and superiority of prevention of HIV infections when compared with once-daily oral F/TDF among a broad and geographically diverse range of cisgender men and gender-diverse people. In both trials, lenacapavir demonstrated superiority of prevention of HIV infections when compared with background HIV incidence and was generally well-tolerated, with the most common adverse reactions in PURPOSE 1 and PURPOSE 2 being injection site reactions (71%

83 and 85% respectively), almost all of which were mild or moderate in intensity. Data from both trials were published in The New England Journal of Medicine.

demonstrates how innovative partnerships can strengthen healthcare delivery for all vulnerable populations.

Unveiled today by Secretary General of the Department of Health, Robert Watt, as part of the launch of Safetynet’s Strategic Plan 2025–2028, this innovative model introduces traumainformed mental health supports designed to overcome language and cultural barriers.

JOHNSON & JOHNSON INNOVATIVE MEDICINE PARTNER WITH MULTIPLE MYELOMA IRELAND Johnson & Johnson (J&J) staff have embarked on the first mile of the 2025 ‘Miles for Myeloma’ challenge with Multiple Myeloma Ireland (MMI), kicking off the annual month-long challenge at the state-of-the-art biopharmaceutical site in Ringaskiddy, Cork.

This September, during Blood Cancer Awareness Month, the J&J team from Cork and the commercial organisation in Dublin have joined forces to walk, run, cycle and swim to clock up Miles for Myeloma and raise funds for this important cause.

MMI is the only charitable organisation in Ireland working to empower people affected by multiple myeloma and related conditions to live full lives, offer crucial support, education and advocacy. The longstanding partnership between J&J and MMI underscores a shared mission to advance patient care and support critical research, truly making a difference in the lives of those affected by this challenging disease.

Go to www.multiplemyelomaireland.org to find out more and sign up for the Miles for Myeloma challenge.

As part of this approach, native Arabic-speaking psychotherapists from the Irish Red Cross work in close collaboration with Safetynet’s migrant mental health and clinical teams to provide targeted mental health support among forced migrants.

Lorraine Cooney about the hospital and the care they received, the PALS Coordinator will assist them in doing so, or refer them to the appropriate person who will be able to assist them further.

LAUNCH OF SAFETYNET STRATEGIC PLAN Safetynet Primary Care, in partnership with the Irish Red Cross, has pioneered a revolutionary community-led healthcare approach that has provided mental health support to 134 clients from 36 different countries since launching in May 2024. This Irish-developed model

Breaking Down Barriers Key achievements include: • 134 clients supported across 36 nationalities since May 2024 • In-person Arabic-speaking psychotherapists and online interpreters for all languages • Dramatic improvements in engagement among previously unreachable populations

health coordinator Liban Abanur.

"When someone from your own community, who understands your journey and speaks your language, is part of your care team, it changes everything."

Partnership Excellence "This partnership exemplifies our commitment to empowering communities to lead their own healthcare solutions. When we move beyond traditional service delivery to genuine community empowerment, we see transformative results," said Deirdre Garvey, Secretary General, Irish Red Cross.

Strategic Expansion Speaking at today's launch at Wynns Hotel Dublin, Secretary General of the Department of Health Robert Watt said: "Today's launch of Safetynet's Strategic Plan 2025-2028 reinforces our commitment to ensuring no one is left behind in Ireland's healthcare system. Their communityempowerment model proves that the right partnerships can achieve genuine health equity."

• Cultural group therapy programmes launching to promote integration "We're seeing patients who would never have accessed mainstream mental health services now engaging regularly with support," said mental

Nicola Perry, CEO, Safetynet Primary Care and Dr Angy Skuce, Medical Director, Safetynet Primary Care with Secretary General of the Department of Health Robert Watt

NEW PATIENT ADVICE AND LIAISON SERVICE COORDINATOR Sligo University Hospital (SUH) is delighted to announce the appointment of Lorraine Cooney to the role of Patient Advice and Liaison Service (PALS) Coordinator. Lorraine, a native of County Roscommon, has over 15 years clinical experience as a Radiation Therapist, and for the past two years, she worked as the PALS Coordinator at Mayo University Hospital, prior to her recent appointment.

The Patient Advice and Liaison Service Coordinator acts as the main contact between patients, their families, carers and the hospital. They ensure that the patient voice is heard either through the patient directly or through a nominated representative.

If a patient wants to provide feedback or make a comment

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