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September 2018 Volume 10  Issue 9

THE INDEPENDENT VOICE OF PHARMACY

Your throat is your strength.

In this issue:

www.septabene.ie

AL

TR

NEWS:

L-ROUND

Pharmacists slam government over Slaintecare Page 4

E AT M E N T

NEWS: Call for improved access to contraception Page 10

NEWS:

1/2018, Ireland, 67-2018, TBP/MB.

Biosimilars a ‘better use’ of HSE resources Page 14

NEW A new sore-throat medicine with a unique formula for all-round treatment: • Analgesic: quickly relieves pain • Anti-Inflammatory: reduces inflammation • Antiseptic: eliminates causes of infection • SUITABLE FOR DIABETICS • SUITABLE FOR COELIACS

Helping to manage chronic pain Page 20

FEATURE: Pharmacists breaking down taboos over men’s health Page 25

CPD: Children’s Health Page 35

Benzydamine hydrochloride/Cetylpyridinium chloride Septabene lozenges and spray: The spray solution and lozenges contain benzydamine hydrochloride and cetylpyridinium chloride. Septabene spray: Indicated for adults and children aged 6 years and over for anti-inflammatory, analgesic and antiseptic treatment of irritations in the throat, mouth and gums, in gingivitis, pharyngitis, laryngitis and before and after tooth extractions. Septabene lozenges: Indicated for anti-inflammatory, analgesic and antiseptic treatment of symptoms of sore throat associated with upper respiratory infections including pharyngitis, laryngitis and tonsilitis. Children from 6 to 12 years of age: The recommended dosage is 3 lozenges a day. The lozenge should be slowly dissolved in the mouth every 3-6 hours. For a single dose of the spray, press the spray head once. This may be repeated every 2 hours 3-5 times a day. Adults, elderly and children over 12 years of age: The recommended dosage is 3-4 lozenges a day. The lozenge should be slowly dissolved in the mouth every 3–6 hours. For a single dose of the spray, press the spray head once to twice. This may be repeated every 2 hours 3-5 times a day. Precautions: Septabene should not be used for more than 7 days. If there is no improvement after 3 days, the patient should consult a doctor. The use of topical preparations, especially over a long period of time, may lead to sensitization, in which case the treatment must be discontinued and doctor consulted to set up a suitable therapy. Septabene must not be used in combination with anionic compounds, such as those present in toothpastes, therefore it is not recommended to use the product immediately before or after cleaning teeth. Benzydamine use is not advisable in patients with hypersensitivity to salicylates (e.g. acetylsalicylic acid and salicylic acid) or other NSAIDs. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma. Caution should be exercised in these patients. Septabene should not be used in patients with open wounds or ulcerations in the mouth or throat. Septabene contains isomalt (E953). Patients with rare hereditary problems of fructose intolerance should not take this medicine. Direct contact of Septabene spray solution with eyes should be avoided. Septabene spray contains small amounts of ethanol. Contraindications: Septabene lozenges and spray: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of the SPC. Children aged under 6 years: The pharmaceutical form is not appropriate for this age group. Fertility, pregnancy and lactation: There are no or limited amount of data from the use of benzydamine hydrochloride and cetylpyridinium chloride in pregnant women. Septabene is not recommended during pregnancy. It is unknown whether benzydamine hydrochloride (metabolites) are excreted in human milk. A risk to the newborns and infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue (abstain from) Septabene therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman. Adverse reactions: Septabene lozenges and spray: Rare: Hypersensitivity reaction, bronchospasm, urticaria, photosensitivity. Very rare: Oral mucosal irritation, burning oral sensation. Not known: Burning mucosa, anaesthesia of oral mucosa. Shelf life: 2 years. Legal category: Medicinal product not subject to medical prescription. Marketing authorisation number: Septabene spray PA1347/049/001, Septabene lozenges PA1347/063/001. Marketing authorisation holder: Krka, d. d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia. SPC: http://www.hpra.ie/homepage/medicines/medicines-information/ find-a-medicine/results?query=septabene&field= Date of preparation: June 2017. Additional information is available on request from Krka Pharma Dublin Ltd. Unit 4A, Leopardstown Business Centre, Ballyogan Road, Leopardstown, Dublin 18. D18 KX88. Reference number: 01-02-2018.

67-2018_SEPTABENE_Ad-A4_IE.indd 1

FEATURE:

17.1.2018 12:31:32

REPORT: Time for the immediate unwinding of FEMPI Page 40 1


Contents Page 5: Expanding role for pharmacists in suicide prevention

4

Page 16: PSI reviews pharmacists’ code of conduct Page 18: Tracelink to support pharmacists in serialisation pilot study Page 40: IPU calls for immediate end to FEMPI

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Page 48: Pharmacists braced for the impact of a no-deal Brexit

JOURNALIST Áine Carroll editorial@irishpharmacynews.ie Beau Donelly Editorial@ipn.ie CONTRIBUTORS Dr Paul Carson | Robert McOwan Dr Heli Goode

Regulars sept-IPN.pdf

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23/08/2018

Pharmacy owner Ann-Marie Horan gives voice in this edition to the fears many will be feeling. “It’s a hard situation because we don’t actually know yet if we are dealing with a hard Brexit and that makes it even more difficult to plan. If there was a hard Brexit, companies would have to re-test their products in an EU or Customs Union country.” This month’s IPN also reports on the IPU’s pre-Budget submission which calls for the immediate unwinding of FEMPI. It is now nine years since the Financial Emergency Measures in the Public Interest Act was used to cut payment rates to pharmacists. Since then, the State through FEMPI and other measures has extracted over ¤3.1 billion from the community pharmacy sector in reduced medicine reimbursements and cuts to pharmacy fees and margins. The submission also includes a number of specific proposals which would increase the role of pharmacists in the healthcare sector. These include a Minor Ailment Scheme which could save nearly 950,000 GP consultations every year and keep the focus on primary healthcare in the community and a New Medicine Service which could be delivered within the community pharmacy setting.

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

EDITOR Jonny McCambridge editorial@ipnirishpharmacynews.ie

These are uncertain times for pharmacists and this edition of IPN attempts to get to grips with some of the bigger issues looming over the horizon. Brexit, and particularly the prospect of no agreed departure deal is in all of our minds. Taoiseach Leo Varadkar has warned that the government has “a concern around medicines”, saying that the state will stockpile supplies, including blood, over the coming months.

Page 6: Pharmacists not crying wolf over Brexit

MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

Foreword

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

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Meanwhile pharmacists are keeping the pressure on the Government on a number of other issues. The release of last month’s Slaintecare Implementation Strategy has been criticised for ignoring the potential services pharmacists can offer. Similarly calls are growing for the Government to engage with pharmacists on creating access to contraception without prescription. September’s IPN is also packed with the usual array and features and clinical articles, this month on subjects as varied as children’s health, men’s health, head lice, cough, cold and flu and Crohn’s Disease. Do you have a news tip? Is there a community pharmacy topic you would like to see featured in Irish Pharmacy News? Do you know someone in your business going the extra mile to promote best practice in Irish community pharmacy? Email editorial@irishpharmacynews.ie

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News news brief DELAYS IN DRUG APPROVALS MEAN IRISH HEART AND CANCER PATIENTS LOSE OUT ON NEW TREATMENT

IPU slams government over Sláintecare Strategy The pharmacists’ union has accused the government of missing key opportunities to draw on the expertise of the profession, following the release of its 10-year plan to reform Ireland’s healthcare system. “Sláintecare provides many useful proposals, particularly on treating patients locally,” IPU president Daragh Connolly said. “However, this strategy makes only one passing reference to pharmacies and it does not provide any blueprint for future primary care services in Ireland. This is a missed opportunity.”

A new report from the Irish Pharmaceutical Healthcare Association (IPHA) says that Irish patients are among the last in Europe to get access to new medicines, meaning they could be missing out on new heart and cancer drugs. IPHA is the representative body for the pharmaceutical industry and it says that the approval process for new medicines in Ireland is "frustratingly slow". IPHA claims that some new drugs - including seven cancer drugs, two cardiovascular drugs and one musculoskeletal treatment - are still pending approval here despite the fact that the very same drugs are available for use in 12 European countries. Director of Communications, Bernard Mallee, says the lack of certainty over funding is the biggest problem. "There's isn't a predictability around the funding envelope that's available for innovative medicines. And while the industry is delivering huge savings, we are not seeing those savings invested back into the availability of medicines for Irish patients. This is causing some uncertainty in terms of when we can get access to those medicines and what the outcomes for patients might be,” added Mallee. “That medicines for cancer and heart disease, Ireland's two biggest killer diseases, feature so prominently in the list is very concerning," he added. A spokesperson for the Department of Health said it was "not in a position to comment on claims and assertions made by the representative body for the pharmaceutical industry" without having seen their data. However, it said the Health (Pricing and Supply of Medical Goods) Act 2013 governing approval of new drugs had "put in place a fair, transparent and rigorous process for the assessment of all drugs with clear decision-making processes.”

4

IPU President Daragh Connolly The Irish Pharmacy Union said the government had ignored the potential services pharmacies could offer, despite public support for expanding pharmacists’ roles and the profession being “ready and willing” to help address health service capacity problems. In response to last month’s release of the Sláintecare Implementation Strategy, the union said the government had failed to act.

Pharmacies present an additional 1800 locations across Ireland through which services could be provided, the union said, adding that 50% of the population live within one kilometre of their local pharmacy. “Community pharmacists are in a unique position to expand their role as healthcare providers for the benefit of both patients and the State,” Mr Connolly said. “Ireland is currently lagging far behind countries, such as Canada and the UK, where community pharmacies are providing an increased range of services. These services include pharmacy-based Minor Ailment Schemes, New Medicine Services, management of

chronic diseases, improved access to contraception and a wide range of vaccination services without the need for a doctor’s prescription. “The experience in these countries has shown that involving pharmacies in this kind of healthcare has delivered significant benefits to both patients and the State, taking pressure off other parts of the healthcare system, including GPs and hospitals, and leading to better health outcomes.” Recent research has shown more than 90% of people would like pharmacists to be able to prescribe some medications for minor ailments, and most people have reported relying on a pharmacist’s advice instead of visiting their doctor. “The time is right to optimise our delivery of primary care by providing appropriate convenient, accessible and cost-effective healthcare through pharmacies in communities throughout the country,” Mr Connolly said. “Patients cannot afford to wait.”

Court hears about concerns from creditors in Bradley's Pharmacy examinership application An examiner has been appointed to the Bradley Pharmacy Group by the High Court. It comes after the group sought protection from creditors due to factors that included a historical debt owed to Bank of Ireland. Bradley's employ 139 people and has debts of approximately €24 million. There were no objections to the news that PWC’s Ken Tyrell would take up the role of examiner and Tyrell now has 100 days to secure the group’s future. The court heard that the companies in the group are insolvent and cannot pay their debts. It also heard there have been several expressions of interest in the group by potential investors. Tyrell was appointed as interim examiner in early August. When granting the order, Justice Denis McDonald criticised some aspects of Bradley’s examinership application, and in particular drew attention to the failure to disclose all relevant matters to the court. The judge also referred to a lack of candour in respect of payments made to Mr. Brian Pagni who is the director of the companies within the group. The judge found the group failed to disclose the full amount of money paid out of the

group to Pagni as repayments on a business loan he had advanced to the company. Group management accounts were furnished to Bank Of Ireland in July and showed there had been ¤2.9 million outstanding on the director’s loan. As part of the examinership application process, a report by an independent expert furnished to the court showed that the outstanding sum on the director’s loans was ¤2 million. The judge said he was not satisfied that managing director Pagni had fulfilled his duty to fully disclose all relevant matters when the group sought the examinership order, and that these monies had been paid to Pagni at a time when the businesses within the group were experiencing difficulties. Bank of Ireland, which is the group’s largest creditor, along with

the group’s former supplier United Drug, and a landlord of one of the pharmacy premises expressed through their legal teams “serious concerns” they had about how the group had been run in the period before the group applied for protection from creditors. An independent expert report recommended that certain steps be taken to secure the group’s survival. These include restructuring the groups banking debts, securing fresh investment and the examiner securing approval for a scheme of arrangement with the group’s creditors. Bradley’s Pharmacy Group were unavailable for comment when approached by IPN. It has been reported that Lloyd's is expected to buy the Bradley's chain.


News Offaly Pharmacist warns people not to use HIV self-test kit too soon after exposure Rose Finlay, pharmacist in totalhealth Pharmacy in Tullamore, has urged people who think they may have been exposed to HIV to consult their doctor. A new HIV self-test kit from Mylan has recently been made available to Irish consumers. Using a skin prick test similar to how Diabetic patients test their insulin levels, concerned individuals can now check at home if they have become infected with the virus. Though the test is highly accurate when used as per the manufacturer's instructions, Finlay is keen to warn consumers about false negatives that could arise if people test very soon after exposure. “You must [leave] a three month period since you think you were exposed to HIV before you do the test and you should consult your doctor as soon as possible. [They] will then perform another test to confirm.” The number of people diagnosed with HIV in Ireland in 2016 reached a record high of 518 cases. Rates have been rising steadily since 2011, and the number of new infections has rapidly increased in the past three years. It is hoped that the self-test kits can help people to get speedy access to treatment, as strong evidence suggests higher success dealing with HIV the earlier it is diagnosed.

Viral suppression of the disease in Europe is around 65 per cent, and in the Netherlands it is even higher. According to a United Nations programme introduced in 2013, if viral suppression surpasses 90 per cent, the disease could be better controlled. Mylan’s head of infectious diseases, Anil Soni, said this requires the disease being diagnosed at early stage to avoid it spreading. Global pharmaceutical company Mylan has launched the kit in Ireland. Country manager Owen McKeon said: “Ireland becomes our fourth market to launch in, following already successful launches in France, Italy and Spain. “Over the coming months, we will be working with HIV patient organisations to increase awareness of the importance of early testing, and how tools like our self-testing kit, as well as taking a proactive approach to your health, can help in the fight against the spread of HIV.” Users are advised to wait three months from the point of potential exposure to HIV and testing. This

Rose Finlay, pharmacist at totalhealth pharmacy in Tullamore window period is the time it takes for the body to produce antibodies that signal the presence of HIV. Those people living with HIV, but who are not aware of their status, could be unknowingly transmitting it to others. To use the kit, the user takes a pinprick sample of their blood with the device. It then looks for the presence of HIV antibodies in the blood and results are provided within 15 minutes.

The Scottish government has announced plans to make suicide prevention training mandatory for healthcare professionals, including pharmacists. Irish Pharmacy News spoke with local pharmacists to see if this is something that could work in an Irish context.

Treacy tells IPN that mandatory suicide prevention training for healthcare professionals is a good idea, but that the pharmacists are just “one cog in the wheel.” In order to bring the figures down, the HSE would need to be better resourced. “Every area of healthcare is under strain at the moment so capacity is

an issue for everyone. Psychiatric services are under pressure and professionals working in that sector are already under-resourced. Cognitive behavioral therapy can be a very valuable tool in suicide prevention and patients seem to find it effective so there are opportunities that we can build on. Of course pharmacists want to help people who are in distress and if someone comes in looking for help no one will be turned away, so yes the training would be helpful.” Lorcan Gormley is a pharmacist in Dublin who describes himself as a survivor of suicide. He spoke to IPN. “Every death in a community is a tragedy but suicides are felt even more keenly. Pharmacists are pillars of the community and every pharmacy in Ireland will have lost a patient to suicide. To be able to prevent a needless death is something that can only be welcomed.”

IRISH HEALTH PRACTITIONERS TRANSITIONING TOWARDS NEW DYSPHAGIA DIETARY GUIDELINES The Irish Association of Speech and Language Therapists (IASLT) has told IPN that it is collaborating with the HSE on a transition towards new dietary standards and guidelines for people with dysphagia.

Pharmacists’ expanding role in suicide prevention Mayo pharmacist Des Treacy said: “Suicide prevention is really important - the figures these days are just through the roof. The government put a lot of resources into bringing down the number of road deaths over the past few years and the numbers reduced, from over 400 deaths on the roads per year to around 180. That figure is still too high, but it is a vast improvement. Mandatory training for pharmacists on suicide prevention would go some way towards addressing the problem, but it would only be the tip of the iceberg.”

news brief

The CSO publishes its Vital Statistics Yearly Summary every year and 392 deaths by suicide were recorded in 2017, down slightly from the 399 recorded in 2016. The highest suicide rate was in Co. Monaghan, with 19.2 deaths by suicide per year per 100,000 population, followed by Cork city (18.0), and Leitrim (15.4). A spokesman for the Scottish government said, “Community pharmacists have a key role in raising awareness about suicide and helping break down the stigma often associated with suicide. They also can help by signposting people who are at risk of suicide to appropriate resources and support services.” The government has also committed to funding the creation of “a core general module on mental health and suicide awareness” by May 2019, accompanied by a “suite of additional ‘bolt on’ modules appropriate for particular professional groups.”

It comes after the NHS watchdog, NHS Improvements, announced that it is calling for health services and care providers to replace the term ‘soft diet’ with the framework drawn up by the International Dysphagia Diet Standardisation Initiative (IDDSI). This follows the publication of data showing that a number of people in the UK with swallow difficulties were hurt in the past number of years due to being fed inappropriately textured food. Two people choked to death on food that should have been liquidised. Speech and language therapists work in multidisciplinary teams alongside dietary specialists in the management of dysphagia, which the medical term for a disorder that affects feeding, eating, drinking and swallowing (FEDS). Experts are calling for an end to imprecise terminology as the term ‘soft diet’ is causing confusion and the IDDSI framework provides clarity by using colour and a numerical index to describe texture modification for food and drink. People affected by dysphagia must makes changes to the consistency of what they consume in order to avoid the risk of harm from choking. This can involve liquidising food or using a special thickening agent to thicken drinks. Other signs of dysphagia include coughing or choking when eating or drinking, or bringing food back up, sometimes through the nose.

5


News news brief PHARMACISTS HAVE THEIR SAY ON HIGH TECH MEDICINES SYSTEM Pharmacists are split on the benefits of the new electronic ordering system for high tech medicines, according to an industry poll. The survey, run by PharmaBuddy, asked pharmacists if they believed the High Tech Ordering and Management System would streamline the ordering and supply of high tech medicines. More than 120 pharmacists responded to the survey, with just under 46% answering “no”, while 38% answered “yes.” The remaining 16% of participants were unsure. The High Tech Ordering and Management System went live in March. The HSE has said the system will “streamline administration” of the scheme and provide “enhanced visibility of stock management and spending.”

PHARMACIST SANCTIONED AFTER ILLEGALLY ACCESSING HEALTH RECORDS A community pharmacist in rural Canada has been suspended for six months and fined CAD$5000 after she was caught spying on the health records of dozens of people.

Pharmacists not ‘crying wolf’ over Brexit fears, IPU A medicines shortage following adverse weather earlier this year is proof that pharmacists are not crying wolf over the threat of Brexit, the profession’s representative body has warned. Daragh Connolly, president of the Irish Pharmacy Union, said the Government needs to communicate with the industry as to what plans will be in place to offset any negative impact Britain’s exit from the EU will have on the medicines supply chain. Mr Connolly said the costs in the supply chain have been driven down to the point that pharmacies and wholesalers cannot afford to hold onto stock, and the latter lacks the capacity to stock weeks’ worth of supplies. The supply chain is now such a fine thread that if any stress is applied, it breaks. Mr Connolly said any delay in that chain has a knock-on effect, adding that “80% of the drugs on my shelf came through the UK, be it through packaging, transport, or manufacturing”. “Things are hanging by a very, very fine thread when it comes to supply, so a truck that would have previously taken one day to come from Dover now takes three due to Brexit [and this] will hit supply.

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Mr Connolly said something needs to be done at Government level to establish who will pay for extra stock and where will it be stored. “We need pharmacists to get the message out to politicians, regulators, and the Department of Health. This is coming in six months,” he said. The industry’s other concern is that any regulatory divergence between Ireland and a post-Brexit Britain may see manufacturers pull out of the Irish market if it deems the cost of doing business here too prohibitive. “Ireland has had access to the pharma market by piggybacking on the UK. Having some 60m people next door who speak the same language has been beneficial,” said Mr Connolly. “If manufacturers have to produce different batches, or packaging, or marketing material for Ireland and that drives up costs, they might

decide not to bother if they think it won’t pay them to do it.” Mr Connolly said such scenarios could see pharmacists refer patients back to their doctors for a new prescription, or could mean customers would be forced to import medicines from another country at a greater expense. A spokesperson for the HSE said that it is working on contingency plans, which sources say include stockpiling or attempting other measures to “disentangle” the Irish medicines market from the UK. “The HSE is working on contingency plans in a number of areas in relation to Brexit, including measures required to maintain patient services and continuity of supplies. This includes liaison with the Pharmaceutical Industry and distributors in relation to medicines, in order to identify risk areas regarding supply and to ensure that contingency arrangements are in place in the event of disruption arising due to Brexit.” Brexit report: Page 52

Uniphar continues expansion strategy with Sisk Healthcare acquisition It is understood that Dublin-based Uniphar Group plc has agreed to pay €65 million for Sisk Healthcare. The deal, which has been cleared by the Competition and Consumer Protection Commission subject to certain conditions, will be the fourth such acquisition by Uniphar in 12 months.

A report released by the Information and Privacy Commissioner for Nova Scotia revealed the pharmacy manager was investigated late last year over a series of electronic privacy breaches. Commissioner Catherine Tully ruled the pharmacist had inappropriately accessed highly sensitive personal health information of 46 people over a two year period. The pharmacist looked up the prescription history and medical conditions of her child’s girlfriend and parents, her child’s friends, teachers and former teachers, relatives, co-workers, a former high school classmate, and a person she had been involved in a car accident with. She also created false profiles to access the information and told her spouse about the health records, the report said.

You just need to look at the shortages we experienced after deliveries were delayed due to the snow earlier in the year to know we are not crying wolf.”

European provider of wholesale and outsourced specialist services in the broad pharma and medical sectors. Uniphar is already a leading provider of outsourced services to the pharmaco-medical sector in Ireland and the UK, and has a diverse customer base. It operates from Ireland, the UK and the Benelux region and has annual turnover of about ¤1.3 billion.

Ger Rabbette, Uniphar Chief Executive The terms of the deal have not been disclosed but it is understood that Uniphar has agreed to pay the agreed sum in cash (with some of it deferred for two years), plus equity for the healthcare distribution business of Sisk Group. The move cements Uniphar’s ambitions to become a pan-

Uniphar chief executive, Ger Rabbette, spoke about what the Sisk deal will do for company’s expansion strategy. “Our current acquisition strategy seeks businesses with strong management teams and good potential for growth which Uniphar can help to accelerate and realise. We see the acquisition of Sisk Healthcare, along with our other recent transactions, as creating a strong platform for growth in the provision of outsourced and specialist services to pharmacomedical manufacturers and

being key to the development of a successful pan-European business.” The Competition and Consumer Protection Commission (CCPC) has imposed certain conditions on the deal after it became concerned that Uniphar could use its access to third parties' commerciallysensitive information to influence the trading decisions of Sisk Healthcare. During the course of the investigation, the CCPC found that confidentiality commitments relating specifically to orthopaedic products, diagnostic imaging products and custom procedure packs were necessary. It imposed a so-called firewall as a solution to dealing with the exchange of sensitive information between Uniphar's pre-wholesale/logistics division and Sisk Healthcare's wholesale business units after the deal is done. Uniphar said it welcomed the decision and accepted the commitments.


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Skerries pharmacist sees bright future for independents Mark O'Flaherty is the pharmacist and proprietor at the Strand Street Pharmacy in Skerries. With seven pharmacies in the town, O'Flaherty knows how to make his business perform. "Price is king - it always has been. There are four pharmacies on this street alone - it is very competitive out here.� O'Flaherty bought the store in 2017 and he maintained some of the features of the business that worked for the previous owner. "This has always been a competitively-priced shop. The owner who I bought the premises from was always known for having low prices. I liked his business model and I run it on the same basis, if you have good prices on prescriptions and on over the counter products people will come back. If you don't stay competitive you would want to be a very good sales person." O'Flaherty takes a common sense approach to running a business in an increasingly crowded market. "Competition drives prices down. We saw it across the retail sector: as soon as the German multiples entered the market the established supermarkets had to start dropping their prices, and the same is happening in the pharmacy sector." Fit to compete O'Flaherty doesn't buy into the idea that independent pharmacies are a thing of the past. "To a certain extent there is an opinion out there that the independent [pharmacy] is on its way out but I don't believe that for a second. There are a lot of groups buying up independents but there are always newly qualified pharmacists being produced in the colleges, both here in Ireland and also coming across from the UK. I think there will be more store openings and more competition in the sector, and I predict that more and more pharmacists will open up on their own, and this will create greater competition for the bigger players. The independent pharmacy is under serious jeopardy in the UK but I can't see that happening in this market. Over there, it's a two or three-horse race at the moment.

8

Mark O'Flaherty at his pharmacy in Skerries

There are independents but they are vastly outnumbered by the groups now. Independents aren't able to compete when it comes to bulk-buying. It's very difficult at the moment for independent pharmacists in the UK." O'Flaherty is confident that the Irish market is in a different space. "There are still plenty of opportunities for growth here. We haven't reached saturation point yet and there is still plenty of room left for competition. I think we will see more and more independent stores opening. As long as you are fit to compete then you have nothing to worry about." Independent Strand Street Pharmacy is fully independent and is not

aligned to a franchise. "I'm fully independent. It's just me, myself and I. While I am not part of a franchise I do subscribe to a buying group which I am reasonably happy with. We have encountered some problems though, through nobody's fault and in the twelve months I've been here there have been supply problems with eltroxin and some stomach medicines. There have also been supply problems with certain antibiotics that have gone out of stock." O'Flaherty gives his take on why medicine shortages are becoming more common. "As we start to become cheaper than the average country in Europe for the price of medicines then demand will grow for medicines that are produced here to be

exported. It's a double-edged sword, as we get cheaper then we will most likely experience supply shortages, which is presently what is happening in the UK. It's definitely something that needs to be looked at in the future. Working together under the umbrella of the PSI, the IPU, the HSE and the government, hopefully we can come up with ways to help minimise disruption to the supply of medicines because as pharmacists that is our number one focus: making sure our customers always have access to the vital medicines that they need." Sociable O'Flaherty tells Irish Pharmacy News that he first discovered his passion for pharmacy when on summer work experience with an uncle in the 90s. "It just sat well with me. I knew from an early age that I wanted to be a pharmacist, it is a sociable profession to be in. Everyone is different but I like the interaction. I just wouldn't be happy to be cooped up in an office behind a computer all day. It's also a case that I genuinely like helping people out so this works for me." Originally from Naas, O'Flaherty talks about the difference between working for a larger group and working as an independent. "Groups and franchises have their advantages and disadvantages. I was part of

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Adverse events should be reported to the Health Products Regulatory Authority at www.hpra.ie or via email to medsafety@hpra.ie Adverse events should also be reported to UCB Pharma Ireland Ltd via email UCBCares.IE@ucb.com

July 2018 UK/18ZI0030


Profile a group before and I was limited in the amount of decisions I could make and there were a lot of decisions that were made for me that I just wasn't in a position to reverse. I wasn't given the space to say if I didn't agree with something and my views just weren't taken into account. A lot of groups will have a one-size-fits-all approach to their pharmacies but this can have drastic effects on individual businesses within the group. While I wouldn't rule out maybe joining a group in future, at the moment this is just a perfect fit for me. I make

Mark O'Flaherty, pharmacist with counter assistant Mary Murray

all my own decisions and I do all my own branding as well. I advertise locally in the paper and everything comes down to me. As much as I put into the business it is generally reflected in outcomes." Mark O'Flaherty knows that it was a brave decision to go out on his own, but twelve months into his proprietorship, he has no regrets. "There was a lot of sweating, a lot of restless, sleepless nights and at times I did question whether I had done the right thing but looking back it was a good decision and I am glad I did it."

News It’s time Ireland caught up with the rest of the world over contraceptives - IPU Pharmacists have said the government must engage with them if it is serious about reducing the number of unplanned pregnancies. Mr O’Loughlin said: “The prevention of unplanned pregnancies will form a key part of the Government’s strategy, with plans for a free contraception service for all women already announced. “Some years ago, the Health Service Executive carried out the Irish Contraception and Crisis Pregnancy Study 2010, which found that nearly half of the women surveyed (47 per cent) would prefer to get their contraception from a pharmacy and that 15 per cent of women and 9 per cent of men experienced difficulty in accessing contraception. Barriers to access included locality, cost and embarrassment. Darragh O'Loughlin, Secretary General of the Irish Pharmacy Union General Secretary of the Irish Pharmacy Union (IPU) Darragh O’Loughlin said this year’s vote to allow the Oireachtas to legislate for termination of pregnancy would have ongoing implications for pharmacists. The IPU has already made a submission to Health Minister Simon Harris stating that there is no clinical reason why women should need a prescription before they can obtain the contraceptive pill or patch. This has been backed by Fianna Fail.

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“According to the study, difficulty in accessing contraception remains an important issue and the authors suggested that ‘more readily available access to affordable contraception would increase the use of contraception’. The study recommended that “strategies that facilitate choice in accessing contraception should be implemented” and that ‘the role of community pharmacists in the provision of sexual health advice and services needs to be further developed’.” Mr O’Loughlin continued: “The supply of hormonal contraception under protocol without prescription by a specially trained pharmacist is becoming increasingly accepted

worldwide. In Ireland, we have a de facto version of this service when a woman uses an online doctor to renew her prescription, as the online doctor is essentially an algorithm, with the blood pressure and BMI checks being carried out by the pharmacy. “Last year, the New Zealand ministry of health medicine classifications committee recommended reclassification of certain oral contraceptives from “prescription” to “restricted” medicines, saying that they were satisfied that “pharmacists can supply oral contraceptives to women who meet the specified criteria with the same levels of safety as other healthcare professionals”. “In several states of the USA, women can now access contraception directly from a pharmacist without a prescription. Women seeking contraception answer a health questionnaire at the pharmacy and get their blood pressure checked. If there are no problems identified, then they can get a contraceptive prescription. Questions asked include inquiries into chronic diseases, smoking habits, current and past use of different types of contraceptives, and blood clot history.” He added: “In a study conducted by researchers from the University of Washington, which measured the effectiveness of pharmacists’

counselling and interview processes, 70 per cent of women reported continuing use of their prescribed birth control. Both women and pharmacists reported satisfaction with the experience, and nearly all study respondents said they’d be willing to continue seeing pharmacist prescribers for contraception and other services. “It isn’t only pharmacists and women’s rights activists who advocate for better access; expert medical organisations do too. The American Academy of Family Physicians supports access to contraception without prescription. It says oral contraceptives are safe and effective and that women correctly self-identify contraindications. Also, the American College of Obstetricians and Gynecologists has said that oral contraceptives should be available without prescription, that women can self-screen for contraindications, and that cervical cancer/STI screening are not medically required to safely provide contraception. “If the Government is serious about reducing unplanned pregnancies by improving access to contraception, then the Minister must engage with us on our proposal. Things have moved on since a condom required a prescription. Now it’s time we made more progress on contraception and caught up with the rest of the world.”


SOLUBLE TABLETS Paracetamol, Caffeine

FAST ACTING PAIN RELIEF

Solpa-Extra 500mg/65mg Soluble Tablets (P) contain paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and children over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Children 12-15 years: 1 tablet dissolved in water every 4-6 hours. Max 4 tablets a day. Not suitable for children under 12 years. Contraindications: Hypersensitivity to the ingredients. Caution: Particular caution needed under certain circumstances, such as renal or hepatic impairment, chronic alcoholism and malnutrition or dehydration. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Interactions: Warfarin and other coumarins, cholestyramine, probenecid, chloramphenicol, metoclopramide, domperidone, sedatives, tranquilizers and decongestants. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions, TEN, SJS, drug-induced dermatitis, sterile pyuria. Unknown: neutropenia, leucopenia, nervousness, dizziness. PA 1186/017/001. MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. Date of preparation: 05/04/2017.


News Daily aspirin did not lower risk of first heart attack, study reveals Daily aspirin did not reduce the occurrence of major cardiovascular events in a study of more than 12,500 participants considered to be at risk, according to the results of the ARRIVE trial, presented at the European Society of Cardiology (ESC) Meeting in Munich, Germany. Michael Gaziano, MD a preventive cardiologist at Brigham and Women’s Hospital, presented findings from the Aspirin to Reduce Risk of Initial Vascular Events (ARRIVE) study, which was sponsored by Bayer. The study was a randomized, controlled clinical trial of the use of daily aspirin to prevent a first cardiovascular event among more than 12,500 participants considered to be at moderate cardiovascular risk. The benefits of taking aspirin to prevent a second or subsequent cardiovascular event have been well established in previous studies but the effectiveness of taking aspirin to prevent a first cardiovascular event has been unclear, despite 30 years of randomized clinical trials. They sought to assess both the potential benefits as well as the risks to people at moderate risk of cardiovascular disease who may already be receiving some protection from modern preventative and therapeutic strategies. Participants were randomly assigned to receive either

daily aspirin tablets (100 mg) or a placebo. A total of 12,546 participants were enrolled from primary care settings in the UK, Poland, Germany, Italy, Ireland, Spain, and the U.S. The primary endpoint was time to first occurrence of a composite of cardiovascular death, heart attack, unstable angina, stroke, and transient ischemic attack. The rate of such cardiovascular events did not statistically differ between the aspirin group and the placebo group. During the study, 269 patients (4.29%) in the aspirin group and 281 patients (4.48%) in the placebo group experienced such cardiovascular events. Overall, these rates were lower than expected. The authors conclude that this may be reflective of contemporary riskmanagement strategies, such as the use of statins. Given that aspirin is known to increase patients’ risk of gastrointestinal bleeding, ARRIVE excluded patients at high risk of bleeding. It also excluded patients with diabetes. Gastrointestinal bleeding events (mostly mild) occurred in 61 patients in the

Michael Gaziano, MD, a preventive cardiologist at Brigham and Women’s Hospital aspirin group versus 29 in the placebo group. The overall incidence rate of adverse events was similar in both treatment groups. “The decision on whether to use aspirin for protection against cardiovascular disease should be made in consultation with a doctor,

considering all the potential risks and benefits,” Gaziano said in a prepared statement about the results. The authors’ declaration of interests and the roles of the Executive Committee and of the sponsor can be found in The Lancet.

New deal for Lloyds Pharmacy staff on pay and conditions LloydsPharmacy has agreed a new deal with staff which delivers pay increases for their 960 staff, a range of additional benefits, implementation of banded working hours and a voluntary severance package to be introduced. The deal followed robust negotiations with the staff Colleague Representative Committee (CRC), which is comprised of representatives nominated by colleagues independent of management. Several improvements to pay and conditions resulted: 1. Pay increases for all staff ranging from 1.5% to 11%. This means that average annual salaries across the company are now benchmarking favourably within the sector and are typically an average of ¤11.63 for full-time store staff, ¤17.16 for store managers and ¤32 for

pharmacists. These salaries exclude monthly care bonus available to all staff and the bonus scheme for managers and assistant managers. All increases were backdated to 1st April 2018. 2. New measures to recognise longer serving staff including additional paid annual leave and the introduction of banded pay scales which will deliver further pay increases. 3. No staff member is now on less than ¤10.60 per hour. 4. Improved paid sick leave of not less than 4 days per colleague annually.

5. A system of banded hours for all colleagues, giving them even greater certainty of hours. 6. Full funding of all professional fees for pharmacist colleagues. 7. Improved support systems including the introduction of additional Regional Business Managers. 8. A Voluntary Severance package, details of which will be announced shortly. Commenting on the latest colleague support for enhanced terms and conditions, Pat Watt, LloydsPharmacy Director of Sales and Marketing stated:

“As a new management team we want to build further strong links with our staff, particularly through the Colleague Representative Committee. “Our staff are pleased to have agreed the improved pay, conditions and support measures through successive companywide ballots. It provides a positive roadmap for all staff to enjoy improved remuneration and security of benefits in a viable framework. We will invest strongly in our business and staff at what is a particularly challenging time for our sector.”

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News Prescribing biosimilars a ‘better use’ of HSE resources The clinical director of the National Centre for Pharmaeconomics (NCP), Professor Michael Barry, has called on the HSE to increase the uptake on biosimilar medicines. a very good reason, someone starting on biologics should start on a biosimilar. Then you have got to put in the structures to enable this to happen at hospital level. We have spent the last five years concentrating on community expenditure because that is where most of it takes place, but we need to get to grips with hospital prescribing.” Owen McKeon, Chair of Medicines for Ireland and Country Manager for Mylan

Professor Michael Barry, clinical director of the National Centre for Pharmaeconomics

It comes after Medicines for Ireland, the representative organisation for generic and biosimilar manufacturers, recently called for the immediate publication of a national biosimilar strategy, which was first promised by the Government in February 2017. MFI says that replacing expensive branded biologics with biosimilars could deliver potential savings of ¤25m. Professor Barry told RTE’s Morning Ireland recently that “we have seen a low uptake with generic medicines in the past, and we are seeing it again now with biosimilars. We are almost wedded to branded products.”

tackled. The HSE needs to take this one seriously and to have a good quality team producing a policy and also implementing it and, in addition, empowering excellent pharmacy units in our hospitals. There is also an appreciation among our own colleagues that safety and efficacy is very important but they cannot ignore the cost issue and I think prescribers for a long time have done just that.”

Professor Barry said while biosimilars are more complex than generic medicines, the HSE needs to stop ignoring the cost issue. “There is no doubt about that. It’s an issue that should be

Professor Barry said increased prescribing of biosimilar medicines would constitute a better use of the HSE’s resources and urged the executive to start a process whereby biosimilars become the norm, as opposed to the exception. “The first thing is to have a biologics policy to make it clear, for example, that unless there is

Prof Barry gave examples of two particularly expensive medicines which cost the health service millions of euro each year: Adalimumab, sold under the trade name Humira and used to treat a variety of conditions including Crohn’s disease; and etanercept, an injectable drug used for treating rheumatoid arthritis. “Between the two you are talking around ¤200m a year. That’s a lot of money. We need to be putting resources where they are needed, looking after our elderly, etc, so why waste them on medicines when you don’t need to?” said Prof Barry. Describing the use of biosimilars as a no-brainer, Prof Barry said resources are needed to put the strategy in place. “You need to get together a goodquality, experienced team to drive this initiative on and implement it but also to empower our hospital pharmacies to ensure it’s delivered,” he said.

Meanwhile Generic drugmaker Mylan has also called on the Government to boost its efforts in approving biosimilar drugs for use here in a move that could save the State around ¤140 million a year. The US/Dutch company with a number of operations in Ireland said some Irish hospitals had already opted to purchase biosimilar medicines, but that the “legislature are lagging behind their own HSE”. A biosimilar is a biologic medical product almost identical to the original and manufactured by a different company. The products are manufactured once the original comes off patent. Mylan’s country manager Owen McKeon said Ireland was lagging significantly behind Europe in the take-up of biosimilars where an estimated ¤1.5 billion in savings have been achieved since 2006, equating to the employment of approximately 40,000 nurses. “Biosimilar medicines have proved their value to patient care right across Europe for over a decade now. They are playing a key role in providing increased access to and more affordable medicines to patients and national health services. Yet in Ireland we have failed to embrace this change, and are now falling far behind our European colleagues.”

Hesitancy over biosimilars traced to ‘inadequate prescriber knowledge’ The 2018 annual conference of the United Kingdom and Ireland’s Prescribing and Research in Medicines Management has heard the results of a number of studies relating to the prescribing of biosimilars, and found that improved education around pharmacovigilance systems and adverse drug reaction (ADR) reporting for biologic medicines among healthcare providers could improve the uptake on biosimilars. A research group from Ireland presented their findings and outlined the results of questionnaire responses obtained from 88 physicians, 197 general practitioners, 104 nurses, 169 community pharmacists, 87 hospital pharmacists, and 53 pharmacists who worked in other capacities. The researchers found that some of the hesitancy around the prescribing of biosimilars

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can be traced to inadequate prescriber knowledge. Reporting on the findings, the Centre for Biosimilars said that “overall, only 60% of providers said they had adequate knowledge of how to report an ADR, and while 81.5% were familiar with the term ‘biological medicine’, only 64.8% were familiar with biosimilars. Furthermore, while 87.7% of providers reported that biologics were recorded by brand name in their practices, 48% said that they

did not routinely record the batch numbers of biologics given to their patients.” Researchers say the findings should “aid in the design of educational programs for providers in Ireland and in the design of measures to improve the batch traceability of biologics.” During the event, researchers from the UK also outlined their findings regarding training provided to GPs by pharmacists on reducing

costs through prescribing the biosimilar insulin glargine. 77% of participants said they were “extremely likely or likely” to change their prescribing patterns after the training. The Centre for Biosimilars reported that, “after the campaign, the biosimilar comprised 10% of total insulin glargine prescribing, versus 0.1% prior to the initiative,” leading researchers to announce that the campaign was “broadly successful.”


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


News Dozens of complaints made to pharmacy regulator Forty-six complaints were lodged with the pharmacy regulator last year, with most relating to dispensing errors and practice issues. While the number of complaints raised with the Pharmaceutical Society of Ireland was relatively low, only four more complaints were received last year compared to 2016, chief officer Niall Byrne said there was no room for complacency when it came to the quality of pharmacy services. “Pharmacists, particularly those with governance responsibilities, and pharmacy owners, have a clear duty of care to their patients and to the wider public,” he said. “By working together, the regulator and the profession can continue to build a stronger culture of patient safety and thereby ensure that future patient needs are met through the availability of competent and capable pharmacists working within well-governed and safe pharmacy services.” The PSI, which published its 2017 annual report last month, shows most complaints were made by members of the public. Twelve complaints related to dispensing errors, including nine

that alleged incorrect doses of the correct medicine had been supplied to patients, and three alledging the wrong medicine had been dispensed. Nine complaints related to pharmacy practice issues, which included matters relating to the management of medicines, record keeping, storage and disposal of medication and counselling of patients. Key figures from the report show: • 346 pharmacists and 25 pharmacies were added to the register

PSI Annual Report 2017 Key Facts and Figures

310

Over

2 million

visits to pharmacies every month

346 new pharmacists added to the PSI Register

6,096 pharmacists registered at the end of 2017

3 out of 4 78%

of pharmacists ≤ 25 years are female

75%

pharmacists aged ≤ 45 years

46

complaints about pharmacists

1,853 community pharmacies and

78 hospital pharmacies on the PSI Register

adults generally or always attend the same pharmacist

PSI Annual Report 2017 is available at http://bit.ly/PSI17

pharmacy inspections carried out

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fitness to practise inquiries

advisory visits to pharmacies to support use of the Pharmacy Assessment System

1,826

• 310 pharmacies were inspected • 1300 pharmacists had an extract of their continuing professional development ePortfolio reviewed • 455 queries related to pharmacy practice were answered by PSI staff

• 46 formal complaints about pharmacists and pharmacies were processed

• 4 public consultations were carried out to inform the PSI’s work

With more than two million visits to pharmacies every month, Mr Byrne said pharmacists play an important role in public health and patient care.

• 13 formal fitness-to-practice inquiries were held

“In addition to their widespread availability across the country, the

profession is highly trusted,” he said. “The PSI’s core objective is to play our part in maintaining that trust through a robust and effective regulatory system.” The PSI regulates the professional practice of more than 6000 pharmacists, 362 pharmaceutical assistants, and 1930 pharmacies.

PSI reviews phamacists’ code of conduct The Pharmaceutical Society of Ireland (PSI) is currently undertaking a review of the code of conduct for pharmacists. Revealed in the PSI annual report, the review, which includes a series of consultations, will reflect current practice environments, the evolving pharmacist role and our changing health service. The annual report stated: “During 2017 we commenced a review of the Code of Conduct for Pharmacists. Section 7(2)(a)(iii) of the Pharmacy Act 2007 confers a duty on the PSI to draw up a Code of Conduct for pharmacists. “The Code applies to all registered pharmacists whatever their scope of practice and is intended to provide support and guidance in the practice of their profession. Breaches of the Code may be considered professional misconduct under Part 6 of the Pharmacy Act. The review of the Code, which will continue in 2018, will help us to consider if the Code is fulfilling its required

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function for patients, the public and pharmacists, as well as from a regulatory perspective.” The report continued: “During May and June, we invited a wide range of feedback on the current Code of Conduct to help us consider any changes that might be needed in a revised Code. An online consultation was held with key stakeholders and pharmacists, where views were sought on the current Code of Conduct, areas for improvement, and what important characteristics pharmacists should demonstrate. “We received responses from 465 pharmacists and 105 stakeholders. With the intention of gathering public opinion on trust in the pharmacy profession and to establish the character traits which the public think are most important in pharmacists, an independent survey was conducted, which

involved face to face interviews with 1,000 members of the public. Workshops were also facilitated with members of the PSI Council and PSI staff during 2017. This review will continue in 2018.” The PSI annual report also details the publication of the ‘Future Pharmacy Practice - Meeting Patients’ Needs’ report to examine how pharmacy practice in Ireland can meet patients’ needs in the future. The report stated: “The aim of the work is to provide insight into the envisaged role pharmacists should be playing in the context of national strategy, examining how pharmacy practice can progress, improve and most valuably contribute to the health and wellbeing of patients in an evolving healthcare sector. “In 2017, we focussed on engaging

with stakeholders to share the recommendations and findings and to inform policy development and healthcare reform. We presented the findings and recommendations of the report to key policy makers in the Department of Health in June, to pharmacy stakeholders at the Irish Pharmacy Union conference in May and the Hospital Pharmacists Association of Ireland conference in April.” It added: “The findings of the report also contributed to external initiatives and policies on pharmacy and medicines issues, including the PSI’s submissions to the national antimicrobial resistance action plan and the HSE’s framework for chronic disease management. We also presented the findings of the report to undergraduate and postgraduate pharmacy students.”


Flexible dosing to suit a wide range of patients.1–3

Constipation relief for everyday people. MOVICOL®, MOVICOL® Liquid Orange Flavour and MOVICOL® Paediatric Plain. Prescribing Information REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC) BEFORE PRESCRIBING Presentation: Movicol Sachet of white powder which dissolves in about 125ml of water to make a lemon/lime flavoured drink. Each sachet contains: 13.1250g macrogol 3350, 0.1785g sodium hydrogen carbonate, 0.3507g sodium chloride and 0.0466g potassium chloride. Movicol Liquid A clear concentrated liquid, which is diluted in water to make an orange flavoured drink. Each 25ml of Movicol Liquid is diluted in 100ml of water before use and contains the following active ingredients: 13.1250g macrogol 3350, 0.1785g sodium hydrogen carbonate, 0.3507g sodium chloride and 0.0466g potassium chloride. Movicol Paediatric Plain Sachet of white powder, which dissolves in about 62.5ml of water. Each sachet contains: 6.5630g macrogol 3350, 0.0893g sodium hydrogen carbonate, 0.1754g sodium chloride and 0.0251g potassium chloride. Does not contain flavourings or sweeteners. Uses: Movicol: Treatment of chronic constipation and faecal impaction in adults, adolescents (aged 12 years or older) and older people. Movicol Liquid: Treatment of chronic constipation in adults, adolescents (aged 12 years or older) and older people. Movicol Paediatric Plain: Treatment of chronic constipation in children aged 2-11 years. For the treatment of faecal impaction in children from the age of 5 years. Dosage and administration: Movicol Chronic Constipation: Adults, adolescents (aged 12 years or older) and older people: 1-3 sachets daily in divided doses, according to individual response. For extended use: adjust dose down to 1 or 2 sachets. Children (below 12 years): not recommended. Alternative Movicol products are available for children. As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of Movicol treatment does not normally exceed 2 weeks, but can be repeated if required. Faecal Impaction: Adults, adolescents (aged 12 years or older) and older people: 8 sachets per day. A course of treatment for faecal impaction does not normally exceed 3 days. The 8 sachets should be taken over 6 hours (2 sachets per hour maximum in cardiovascular impairment). The 8 sachets may be dissolved in 1 litre of water. Children (below 12 years): Not recommended. Alternative Movicol products are available for children. Movicol Liquid Chronic Constipation: Adults, adolescents

(aged 12 years or older) and older people: 25ml diluted in 100ml of water 1-3 times daily in divided doses, according to individual response. For extended use, the dose can be adjusted down to 1 or 2 doses per day, each consisting of 25ml diluted in 100ml of water. As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of Movicol Liquid treatment does not normally exceed 2 weeks, but can be repeated if required. Movicol Liquid is not recommended for faecal impaction Movicol Paediatric Plain Chronic Constipation: The usual starting dose is 1 sachet daily for children aged 2-6 years, and 2 sachets daily for children aged 7-11 years. The dose should be adjusted up or down as required to produce regular soft stools. If the dose needs increasing this is best done every second day. The maximum dose needed does not normally exceed 4 sachets a day. Treatment of children with chronic constipation needs to be for a prolonged period (at least 6-12 months). Faecal Impaction: Escalating dose regimen starting with 4 sachets a day up to 12 sachets a day (at day 7) for children aged 5-11 years. Refer to Summary of Product Characteristics (SmPC) for full dosing recommendations. Not recommended in children with cardiovascular impairment or renal insufficiency. Doses for prevention of re-impaction should be as for patients with chronic constipation. For patients of 12 years and older it is recommended that Movicol is used. Contraindications: Intestinal perforation or obstruction due to structural or functional disorders of the gut wall, ileus and severe inflammatory conditions of the intestinal tract, such as Crohn’s disease, ulcerative colitis and toxic megacolon. Hypersensitivity to macrogol, or any of the excipients. Warnings and precautions for use: The fluid content of the re-constituted solution does not replace regular fluid intake and adequate fluid intake must be maintained. Diagnosis of impaction should be confirmed. If patients develop any symptoms indicating shifts of fluids/electrolytes the product should be stopped immediately. When using paediatric forms of Movicol to treat faecal impaction, use with caution in patients with impaired gag reflex, reflux oesophagitis or diminished levels of consciousness. Movicol Liquid contains benzyl alcohol. Do not exceed the maximum recommended daily dose.

macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride Interactions: There is a possibility that the absorption of concomitantly administered medication could be transiently reduced. Pregnancy and lactation: Can be used during pregnancy and lactation. Undesirable effects: Reactions related to the gastrointestinal tract are the most common and include: abdominal pain, abdominal distension, nausea, vomiting, dyspepsia, diarrhoea, flatulence, borborygmi and anal discomfort. Allergic reactions, including anaphylactic reactions, dyspnoea and skin reactions (e.g. angioedema, urticarial, pruritus, rash and erythema) can occur. Other effects can include electrolyte disturbances, headache and peripheral oedema. Licensing and legal category: Movicol Legal category: Subject to prescription; MA number: PA 0102/023/002. Movicol Liquid Legal Category: Subject to prescription; MA number: PA 1336/2/4. Movicol Paediatric Plain Legal Category: Subject to prescription; MA number: Number PA 102/23/4. For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, UK UB9 6NS +44 1895 826606 E-mail: medinfo@norgine.com Date of preparation: Jan 2018 Version number: UK/MOV/0118/0183

Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on +44 1895 826606. References 1. Attar A et al. Gut 1999;44:226–30. 2. Gruss HJ, Ulm G. Eur J Ger 2004;6(3):143–50. 3. Thomson MA et al. Arch Dis Child 2007;92:996–1000. Date of preparation: March 2018. Code: UK/MOV/0118/0186. MOVICOL, NORGINE and the sail logo are registered trademarks of the Norgine group of companies.


News Tracelink to support 16 pharmacies in news brief serialisation pilot study CANCER CONFERENCE TO DRAW PATIENTS FROM ACROSS IRELAND

TraceLink Inc, the world's largest track and trace network for connecting the life sciences supply chain has announced that it has joined the Irish Medicines Verification Organization (IMVO) serialisation pilot study and will support a number of hospitals, pharmacies and clinics connect to the Irish Medicines Verification System (IMVS). "The IMVO is a new organisation set up to protect patients in Ireland from the dangerous threat of falsified medicines being supplied through legitimate channels. It is beneficial for us to be connected to the TraceLink network in order to have the ability to easily scan the new 2D codes on medicine packaging and ultimately ensure patient safety in our hospital," said Catherine Kelly, Chief Pharmacist, UPMC Whitfield, US.

Hundreds of people are expected to attend the Irish Cancer Society’s annual conference for cancer survivors and their families. The Living Well with Cancer conference offers information sessions and workshops covering topics including advances in cancer therapies, fatigue, sexuality and intimacy, exercise and diet, self confidence, and returning to work. Irish Cancer Society chief executive Averil Power said: “More than 150,000 people are now living with or beyond cancer in Ireland and there is a growing need to understand and recognise the life changing implications that a cancer diagnosis can have for both the patient and their loved ones.” Up to 800 cancer patients, survivors and their supporters are expected to travel to the events from across Ireland. The conferences will take place at the Clayton Hotel, Ballybrit, Galway on September 15 and the Clayton Hotel, Silver Springs, Cork on September 22. For more information or to register to attend the conference visit: www.cancer.ie/living-well

JOIN THE CONVERSATION ABOUT LYMPHOMA World Lymphoma Awareness Day will take place on September 15, bringing together patients, caregivers, and healthcare professionals from around the globe. This year’s theme, Small Things Build Confidence, is aimed at encouraging and supporting people who are living with cancers of the lymphatic system. From September 9 to 15, patients and their families are invited to join the worldwide Facebook conversation on the Lymphoma Coalition page and share the small things that have helped boost their confidence.

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Shabbir Dahod, president and CEO of Tracelink TraceLink has passed IMVO's selfcertification tests which confirm that its pharmacy system connects correctly to the IMVS. TraceLink will support 16 pharmacies and clinics across Ireland during the pilot, which aims to gather critical data and end user insights into the day-to-day operation of a serialisation service for compliance with the EU Falsified Medicines Directive (FMD). As part of the pilot, the 15 pharmacies and one private clinic will use TraceLink's Android or iOS-based pharmacy applications and a Bluetooth scanner to scan medicine barcodes and verify them against the IMVS.

Purpose-built for flexible integration into any pharmacy workflow, TraceLink's pharmacy application can be accessed through a smartphone, tablet, or a set of APIs. These APIs can integrate with all capable pharmacy management systems, enabling any pharmacy, clinic or hospital in Ireland to easily comply with verification and decommissioning requirements under the FMD. All equipment is provided by TraceLink for the duration of the pilot. TraceLink is fully connected with SolidSoft, the blueprint provider for the IMVO. "Serialisation pilots at the medicine decommissioning level will help us and our pharmacy partners to understand user adoption and where further training is needed, while also determining best practices for compliance in real-world scenarios. We are extremely pleased to be involved in initiatives like this as we strive for a better connected and safer pharmaceutical supply chain," said Shabbir Dahod, president and CEO, TraceLink. "The FMD is a significant turning point for the

European healthcare industry to create a safer supply chain for the benefits of patients everywhere." In order to comply with the EU FMD, which aims to reduce counterfeiting in the pharmaceutical supply chain, pharmacies and clinics in Europe must introduce new processes. Under the regulation, pharmacists and healthcare providers must adopt the end-to-end verification system, which means they must scan and verify the authenticity of drug products against National Medicines Verification Systems (NMVS) before the medicine can be dispensed to patients. Ireland is one of the first countries to have an operational serialisation service in place ahead of the FMD deadline in February 2019. As part of EU FMD, all NMVS systems are required to connect into the EU Hub. Pharmaceutical manufacturers with EU FMD requirements are required to upload serialisation data to the EU Hub, which is then distributed to the appropriate NMVS for medicine verification. TraceLink has developed a streamlined program for its more than 190 manufacturing customers with EU FMD requirements to rapidly complete conformance testing and successfully receive European Medicines Verification Organization (EMVO) approval to submit data to the EU Hub. With TraceLink's conformance test kit, 42 companies have been able to complete their conformance testing, with 21 having already received EMVO approval.

Issues with finding pharmacy locums continue Irish Pharmacy News has learnt that the continuing lack of affordable locum cover is having a real impact on some pharmacies. One manager told how the rates are so prohibitively expensive that some stores are resorting to using known colleagues and qualified friends and family as an alternative to obtaining cover through locum provider agencies. IPN is aware of one instance where a pharmacist, who runs a late night store, worked 90 hours in one week (9am-10pm over seven days) as they were unable to find cover. The trend, identified by Irish Pharmacy News in last month’s

edition, does not appear to be improving. Sources told IPN that the shortage of locums is multifaceted. Many are leaving retail pharmacy and the shortage of qualified personnel is being reflected in the rates. Pharmacy locums on attractive rates are tending to not work the full 40 hour week and this is contributing further to the shortage. Business owners and managers can mitigate the problem with creative rostering and better

planning around annual leave and are being encouraged by people inside the business to resist paying over the top rates. Last month sources told IPN that filling locum shifts is becoming a stressful exercise and is putting a real strain on resources. Before shortages became a problem, locums would book work days in advance, but now the pattern appears to be that locums are waiting longer to book work, and the rate is higher when booked closer to the time.


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Osteoarthritis is the most common form of arthritis in Ireland, affecting more than 400,000 people. Osteoarthritis is caused by wear and tear of cartilage in the joints. Inflammation of the joints can occur, which can cause cartilage to erode, leaving the joint with pain, swelling and stiffness. ZinCuFlex® is a new health food supplement with proven benefits for joint health. Combining the power of ginger, curcumin and vitamin C, ZinCuFlex® may help to protect joints and help maintain joint mobility. In 2015, Nordic Phytotech conducted a study of 200 ZinCuFlex users in Denmark. The results were outstanding with 90% participants reporting a significant improvement in joint mobility, with many feeling the difference within 14 days.

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Coronary heart disease is one of the leading causes of death in Ireland for both men and women. High cholesterol is one of the major risk factors associated with coronary heart disease. According to Dr Angie Brown, Medical Director of the Irish Heart Foundation, only 18% of adults over 45 years have a healthy cholesterol level in Ireland. Zerochol is a natural food supplement that contains plant sterols, scientifically proven to lower LDL cholesterol. As plant sterols are structurally similar to human cholesterol, they work by blocking the absorption of cholesterol in the gut, which contributes to a significant decrease in the blood LDL ‘bad’ cholesterol level. New research confirms that 1.6 g (two tablets) of Zerochol® plant sterols can lower cholesterol by 17% in three months, without any side-effects. Zerochol also reduced triglycerides by 17%, further improving the overall lipid profile and reducing risk of heart disease.

Reduce your risk of heart attack with omega-3 There is more scientific evidence behind the cardiovascular health benefits of fish oil than any other nutritional supplement. The most beneficial omega-3 fats EPA and DHA are primarily found in fresh, oily fish such as mackerel, salmon, anchovies and sardines. Your body can’t naturally produce omega-3 and 89% of Irish people are not consuming sufficient oily fish in their diet, so often there is a need to supplement. Omega3s have been found to improve numerous heart disease risk factors. They help to reduce blood pressure, reduce triglycerides, improve blood circulation and reduce cholesterol levels.

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Helping patients to manage chronic pain Pain management is really important for the individual patient as there is evidence of high co-morbidity rates between depression and chronic pain. Some people are never pain-free and so it needs to be carefully managed. The European Pain Federation says that “chronic pain, besides causing untold suffering for millions of patients worldwide, tears at the very economic and social fabric of our culture.” The cost of chronic pain among patients attending a pain management clinic in Ireland was estimated by Raftery et al in 2012 to be around €5.34 billion or 2.86% of GDP per year. Chronic lower back pain costs were estimated at €28 million. Deirdre Ryan, chairperson for Chronic Pain Ireland, spoke to IPN about the important role pharmacists can play in pain management. “Patients can often be prescribed pain medication from, for example, both their GP and a pain consultant. Ideally, clinicians should know what the other is prescribing but this is not always the case. Pharmacists can act as that safety net before a medication is dispensed to the patient where there may be interactions between medications, or perhaps a higher risk of serotonin shock. Pharmacists can also make use of opportunities to dispel the idea that drug sideeffects should be tolerated just because the patient’s overall level of pain has reduced. Opioid Induced Constipation (OIC) can have serious implications but can be easily managed by pharmacist intervention, reducing the need for patients to return to GP for prescription items.” Pain, both acute and chronic, is a significant public health issue and inadequate pain relief can bring emotional and financial costs. Many professional pain practitioners believe chronic pain should be recognised as a disease in its own right.

Joanne O'Brien, President of the Irish Pain Society

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hospital and they will help you. It’s really important that you don’t suffer in silence, that you seek out advice and support, and that really you participate in the management of your own pain. When you have a good day, don’t walk for miles and then not be able to do anything for the next five days. Pace yourself: do a little bit, every day. It’s much better for your pain. There’s also non-pharmacological treatments that you could have: relaxation, physiotherapy, massage. Always keep a note of these and inform your doctor or healthcare professional what you have found useful.”

Dr Paul Muphy is pain consultant at St Vincent's Hospital

Dr. Paul Murphy is a pain consultant at St. Vincent’s Hospital. He spoke to Chronic Pain Ireland recently. “There are a number of challenges with respect to chronic pain and these include challenges to the medical profession, to patients and to society as a whole. Primarily amongst these is recognition that this is a specific disease which affects a large proportion of the Irish population. We as the medical professional need to be able to recognise and identify this problem, to diagnose it accurately and to offer appropriate treatments. Sufferers of chronic pain, like sufferers of other disorders such as diabetes, asthma and epilepsy, have a right to access a range of multidisciplinary services to help treat their pain and improve their quality of life.” The International Association for the Study of Pain defines it as an “unpleasant sensory and emotional disorder due to actual or potential tissue damage, or expressed in terms of such damage.” This definition is important because it allows clinicians to treat patients for pain even in the presence of investigations, such as a scan or an MRI, that show ‘normal’ results.

Dr Murphy continues. “We have changed our clinical approach to pain in recent years with the declaration of Montreal. We now consider chronic pain to be a disease entity in it own right and as a result of this we need to treat it as a specific disease like any other disease, much like any other disease process. This has led us to target not only the specific neurological problems with pharmacological and other approaches, but also to identify the impact that this has on a psychosocial level for the patient. This has helped us to embrace the input of clinical psychology, occupational therapy, and other services.” Joanne O’Brien is an advanced pain nurse practitioner and the president of the Irish Pain Society. Speaking to Chronic Pain Ireland, O’Brien wants people to have a stake in their own pain management. “I think it’s very important that you know your own pain: you know what makes it better, and what makes it worse. When you have chronic persistent pain it’s very important to take responsibility. If you are suffering, remember you are not alone. There are supports out there. Engage with your GP or with your local

Patients experiencing chronic pain often go through several evaluations and treatments prior before figuring out what works best for them. Pharmacists can assist their patients to use a ‘step-up’ method when treating pain and the very first option to consider is paracetamol. This is really for mild pain and is used to ‘take the edge off’. Once you get past paracetamol, side effects need to be considered and while Ibuprofen is a very good painkiller and anti-inflammatory, it can cause nausea and stomach upset. It also interacts with medicines such as Warfarin and other anti-clotting agents and so may not be suitable for some patients. Topical treatments, or ‘rubs’, are becoming increasingly popular, have fewer side effects and are very effective at relieving pain. They are also targeted to the site of pain, and so are not metabolised inside the body. Stronger topical rubs of 2% are now available and are proving to be popular with patients. Codeine-containing products are also effective but can have side effects that some patients find unpleasant. Health care providers can advise patients to keep a pain diary to see how different activities and medications affect them. Pharmacists can advise patients to visit www.mypainfeelslike.ie for more resources on identifying and dealing with pain.


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References: 1. Merry A, et al. AFT-MX-1, a prospective parallel group, double-blind comparison of the analgesic effect of a combination inhibiting drug, an anti-inflammatory drug and thiazide diuretic at the same time increases the risk of renal impairment. Blood of paracetamol and ibuprofen, paracetamol alone, or ibuprofen alone in patients with post-operative pain. Department of Anaesthesiology, dyscrasias have been rarely reported. Patients on long-term therapy with ibuprofen should have regular haematological monitoring. University of Auckland, New Zealand 2008. *compared with the same daily dose of standard paracetamol or ibuprofen alone. Like other NSAIDs, ibuprofen can inhibit platelet aggregation. GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at anytime during treatment. Combination therapy with protective agents (e.g. misoprostol or proton pump Easolief Duo 500 mg/150 mg film-coated tablets Each tablet contains paracetamol 500 mg and ibuprofen 150 mg. inhibitors) should be considered. Use with concomitant NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided. Presentation: A White, capsule shaped tablet with breakline on one side and plain on the other side. Indications: Short-term NSAIDs may lead to onset of new hypertension or worsening of pre-existing hypertension and patients taking antihypertensive symptomatic treatment of mild to moderate pain. Dosage: Adults/elderly: The usual dosage is one to two tablets taken every medicines with NSAIDs may have an impaired anti-hypertensive response. Fluid retention and oedema have been observed in six hours up to a maximum of six tablets in 24 hours. Children: Easolief Duo is contraindicated in children under 18 years. some patients taking NSAIDs. NSAIDs may very rarely cause serious cutaneous adverse events such as exfoliative dermatitis, toxic Contraindications: Severe heart failure, known hypersensitivity to paracetamol, ibuprofen, other NSAIDs or to any of the epidermal necrolysis and Stevens-Johnson syndrome. Products containing ibuprofen should not be administered to patients with excipients, active alcoholism, asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid or other NSAIDs, history acetylsalicylic acid sensitive asthma and should be used with caution in patients with pre-existing asthma. Adverse ophthalmological of gastrointestinal bleeding or perforation related to previous NSAID therapy, active or history of recurrent peptic ulceration/ effects have been observed with NSAIDs. For products containing ibuprofen aseptic meningitis has been reported only rarely. NSAIDs haemorrhage, severe hepatic failure or severe renal failure, cerebrovascular or other active bleeding, blood-formation disturbances, may mask symptoms of infection and fever. Interactions: Warfarin, medicines to treat epilepsy, chloramphenicol, probenecid, during the third trimester of pregnancy. Warnings and precautions: This medicine is for short term use and is not recommended zidovudine, medicines used to treat tuberculosis such as isoniazid, acetylsalicylic acid, other NSAIDs, medicines to treat high blood for use beyond 3 days. Clinical studies suggest that use of ibuprofen, particularly at a high dose may be associated with a small pressure or other heart conditions, diuretics, lithium, methotrexate, corticosteroids. Refer to summary of product charachteristics increased risk of arterial thrombotic events. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic for other interactions. Fertility, pregnancy and lactation: Easolief Duo is contraindicated during the third trimester of pregnancy. heart disease, peripheral arterial disease and/or cerebrovascular disease should only be treated with ibuprofen after careful Driving and operation of machinery: Dizziness, drowsiness, fatigue and visual disturbances are possible after taking NSAIDs. consideration and high doses should be avoided. Careful consideration should be exercised before initiating long-term treatment If affected patients should not drive or operate machinery. Undesirable effects: Dizziness, headache, nervousness, tinnitus, of patients with risk factors for cardiovascular events. The use of paracetamol at higher than recommended doses can lead to oedema, fluid retention, abdominal pain, diarrhoea, dyspepsia, nausea, stomach discomfort, vomiting, flatulence, constipation, slight hepatotoxicity, hepatic failure and death. Patients with impaired liver function or a history of liver disease or who are on long term gastrointestinal blood loss, rash, pruritus, alanine aminotransferase increased, gamma-glutamyltransferase increased, abnormal liver ibuprofen or paracetamol therapy should have hepatic function monitored at regular intervals. Severe hepatic reactions, including function tests, blood creatinine increased and blood urea increased. Refer to Summary of Product Characteristics for other adverse jaundice and cases of fatal hepatitis, though rare, have been reported with ibuprofen. Paracetamol can be used in patients with effects. Pack size: 24 tablets. Marketing authorisation holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Marketing chronic renal disease without dosage adjustment. There is minimal risk of paracetamol toxicity in patients with moderate to severe authorisation number: PA0126/294/1. Medicinal product not subject to medical prescription. For retail sale through pharmacy only. renal failure. Caution should be used when initiating treatment with ibuprofen in patients with dehydration. The use of an ACE A copy of the summary of product charachteristics is available upon request. Date prepared: March 2018. 2018/ADV/EAS/008H.


News Rise in number of adverse reactions news brief to medicines IRISH HEALTH PROFESSIONALS COULD DO MORE TO HELP OBESE KIDS Healthcare professionals in Ireland are missing opportunities to educate parents about how to recognise a healthy weight in preschool-aged children, new research has found. The study, carried out by researchers at NUI Galway, shows a need for better information to be provided by healthcare professionals to mothers about infant feeding, healthy weight, and obesity. The research, which used data from about 20,000 families collected in the longitudinal ‘Growing Up in Ireland’ study, found more than one fifth of Irish mothers were unable to identify if their child was overweight or obese at the age of three. This decreased to 18 per cent when the child was aged five. Failure to identify a child’s overweight or obesity status was more likely to occur if the child was a girl, had a higher birth weight, and if the mother was obese or working. Other factors that affected a mother’s misperception of their child’s weight included gestation age, income and urban living.

The number of adverse reactions to medicines increased by more than a third last year, according to the Health Products Regulatory Authority. In 2017, the HPRA received 4,402 new adverse reaction reports associated with the use of human medicines. While this figure represents a 35% increase in reporting rates compared with 2016, the HPRA said the rise was a result of changes to reporting requirements across the European Union for marketing authorisation holders. The new reporting guidelines, which came into effect in November 2017, require marketing authorisation holders to notify all non-serious adverse reactions reports to the HPRA, in addition to serious adverse reaction reports. More than three quarters of all adverse reaction reports last year were notified by MAHs.

The remaining reports came from patients and healthcare professionals including pharmacists, doctors and nurses. More than 1800 adverse reaction reports related to anti-neoplastic drugs.

safety in normal clinical practice, by increasing knowledge about known adverse reactions and also by acting as an early warning system for the identification of previously unrecognised adverse reactions," it said.

Medicines that are subject to additional monitoring - identifiable by a black inverted triangle included on the package leaflet accounted for 26% of the reports submitted last year.

"Such information is one of the tools used by the HPRA in its ongoing safety evaluation of marketed medicines and contributes to the identification of medicines where a change in their authorisation status is required such as the addition of warnings and precautions for use, restriction in usage or rarely withdrawal from the marketplace."

The HPRA has reminded healthcare professionals to report all adverse reactions associated with the use of these medicines. "Information collected through spontaneous adverse reaction reporting systems is an important method of monitoring medicines

To report a suspected adverse reaction to the HPRA, go to hpra.ie or call 01 676 4971.

Cake is just what the doctor ordered Haven Pharmacy Brennan’s in Ballyboden held a bake sale in-store last month to raise money for children’s cancer charity, Aoibeann’s Pink Tie.

Key findings from the study show: • there are missed opportunities for healthcare professionals to improve knowledge exchange and early interventions to assist parents in recognising a healthy weight for their children • improvements are required so healthcare professionals can ensure mothers have information and an accurate understanding of infant feeding, and healthy weight and obesity in their preschool aged children • educational interventions to inform mothers of healthy weight range during the child’s early years could lead to more accurate weight perceptions as the child gets older.

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Sonya and Louise re-fueling during training ahead of their bike ride later this month.

Louise, Ann, Sonya, Anne-Marie, Amy and Annie showing off all their cakes in-store

The event, led by Haven’s trainee technician Sonya Beatty and support pharmacist Louise Walsh, was a massive success, with more than ¤1100 raised for the charity.

work they do and raise some awareness for them.”

“Sonya’s cousin was diagnosed with cancer in the past year so she’s had personal dealings with the charity,” said Walsh. “We know they do great work and we just wanted to support the important

The event saw all Haven’s staff and some customers donate home baked cakes, slices and other goodies which were sold in-store. “We do a couple of bake sales every year and pick different charities, but this has been the most successful to date,” said Walsh.

“We smashed our goal of ¤500 so that was just great.” Beatty and Walsh have already raised a further ¤300 in sponsorship for Aoibeann’s Pink Tie by pledging to take part in the Great Dublin Bike Ride later this month. The 105 km circuit will see the pair cycle from Dublin to Naul, on the northern edge of Fingal, and then back to the city.


The only COPD Triple Therapy delivered in a single daily inhalation.1 Improvement in lung function and quality of life vs. ICS/LABA. 2,3

NE W A combination of ICS/LAMA/LABA (FF/UMEC/VI)) m administered through a single daily inhalation from the Ellipta inhaler, which is easy to use1–5

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. TRELEGY Ellipta FF/UMEC/VI 92/55/22 mcg OD is indicated for maintenance treatment in adult patients with moderate-to-severe COPD who are not adequately treated by a combination of an ICS and a LABA.1 COPD, chronic obstructive pulmonary disease; FF, fluticasone furoate; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol. References: 1. Trelegy Ellipta 92/55/22 mcg SPC. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA, et al. N Engl J Med. May 3 2018;378(18):1671-1680 4. Svedsater H et al. BMC Pulm Med 2013; 13:72–86. 5. van der Palen J et al. NPJ Prim Care Respir Med 2016; 26:16079. Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) Prescribing information. Please consult the full Summary of Product Characteristics (SmPC) before prescribing. Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg), umeclidinium bromide (UMEC) 62.5 micrograms and vilanterol as trifenatate (VI) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting β2-agonist (LABA). Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or life-threatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central

A full list of adverse reactions can be found in the Summary of Product Characteristics. In common with other corticosteroid-containing medicines, there is an increased risk of pneumonia in patients with COPD treated with TRELEGY Ellipta.1 Trelegy Ellipta should be used with caution in patients with unstable life-threatening cardiovascular disease.1

Please see www.trelegy.ie to find out more

serous chorioretinopathy (CSCR); consider referral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of β-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or long acting β2-adrenergic agonists is not recommended. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, pharyngitis, rhinitis, influenza, nasopharyngitis, headache, cough, arthralgia, back pain. Uncommon (≥1/1,000 to <1/100): candidiasis of mouth and throat, viral respiratory tract infection, supraventricular tachyarrhythmia, tachycardia, atrial fibrillation, oropharyngeal pain, fractures; Not known (cannot be estimated from the available data): vision blurred. Marketing Authorisation (MA) Holder: GlaxoSmithKline Trading Services Limited, Curabinny, Co. Cork, Ireland. MA No. [EU/1/17/1236/002]. Legal category: POM B. Last date of revision: June 2018. Job Ref: IE/TLY/0006/17(1). Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling: (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255. TRELEGY Ellipta was developed in collaboration with TRELEGY and Ellipta are registered trademarks of the GlaxoSmithKline Group of Companies. © 2018 GlaxoSmithKline Group of Companies. All rights reserved. Zinc code: I E /TLY/0004/17(2) Date of preparation: July 2018


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How pharmacists can help break down the taboos over men’s health issues Day-to-day, pharmacists see a wide range of issues affecting their male patients, ranging from blood pressure and cholesterol management, to erectile dysfunction and back pain, to type 2 diabetes, cancer, and heart disease. Pharmacists interviewed by Irish Pharmacy News all reported similar themes in treating male patients: men are more reluctant to seek help and less aware of the health risks of their lifestyle choices. Obesity, for example, was a key theme raised. One pharmacist said men appear to be less aware of the health risks of carrying extra weight, and that it was more socially acceptable for men to have a beer belly or put on weight as they age. “This is something that could be tackled at a community pharmacy level,” he said. Encouraging men to adopt a healthier lifestyle by stopping smoking, cutting down alcohol consumption, or increasing exercise can have a very beneficial effect on men’s health and is a key health promotion role that community pharmacists can play. On a broader level, the pharmacists believe, it is important to take part in initiatives such as Men’s Health Week by running in-store events and having conversations with their male customers. Information sessions hosted by pharmacists on male-specific topics would also be beneficial, they said, as would promoting men’s point-of-care testing for blood pressure, cholesterol and HbA1C. “These don’t need to be conducted in-store, but instead could be run in conjunction with local sporting clubs,” said a pharmacist. Cardiovascular Disease Cardiovascular disease, the umbrella term used to describe a range of serious heart conditions, is the most common cause of death and disability in Ireland, and one of the leading health risks facing men. About 10,000 people die every year from cardiovascular disease (including coronary heart disease, stroke and other circulatory diseases). The most

recent figures from the Central Statistics Office show the number of men who die from the disease is higher than the number of women. Community pharmacists can help lower the risk factors for developing heart disease by advising patients about the importance of decreasing saturated fat and alcohol consumption, quitting smoking, managing stress, and lowering high cholesterol and hypertension. Routine checkups should be recommended to help men monitor their heart health. Boots pharmacist Susan O’Dywer believes the biggest health risk facing men is chronic disease. She says men frequently delay seeking support to address poor lifestyle choices (such as smoking and excessive drinking) or investigate symptoms when compared to women. “This can have consequences as diseases are then harder to treat,” she said. “As a result Irish males have a lower life expectancy than females.” Cancer Cancer is a leading cause of death for people in Ireland. The Irish Cancer Society projects that by 2020, one in two people in Ireland will be diagnosed with cancer in their lifetime. According to the National Cancer Registry of Ireland, the most common cancers for men are skin, prostate, bowel, and lung. Together, they make up about 13,000 new cancer diagnoses each year. Skin Cancer Skin cancer is the most common type of cancer in Ireland. Figures show an estimated 6,113 men are diagnosed with non-melanoma skin cancer and 530 men are diagnosed with melanoma skin cancer every year. In Ireland, the majority of people have the type of light-

Eugene Renehan Superintendent Pharmacist at Meaghers Pharmacy Group

coloured skin that does not tan and burns easily, making them more susceptible to developing skin cancer. Men aged over 50 are among the highest risk group for developing skin cancer, which is likely attributable to more frequent sun exposure and fewer visits to the doctor. Prostate cancer Almost 3500 Irish men are diagnosed with prostate cancer every year. The outlook for prostate cancer is often good because the disease progresses very slowly, however, in cases where it is not caught early, or where it spreads to other parts of the body, the prognosis is poor.

Bowel Cancer More than 1600 Irish men are diagnosed with bowel cancer every year, with the disease usually striking people over the age of 60. As the second most common cause of cancer death in Ireland, health experts recommend men maintain a healthy diet and weight, keep physically active and eat at least five portions of fruit and vegetables daily. The risk of developing bowel cancer is higher in people who are overweight, eat a diet high in fats and low in fruit, vegetables and fibre, and have had an immediate family member who has had bowel cancer.

25


Feature Diabetes

More than 1,600 men are diagnosed with bowel cancer every year in Ireland

Lung Cancer There are about 1400 new cases of lung cancer in men annually. In recent years, the number of cases of lung cancer have been declining among men, but more Irish people still die from this disease than any other type of cancer. Most people who get lung cancer are over the age of 50, and nine out of every 10 cases are due to smoking. Respiratory diseases Diseases of the respiratory system claimed the lives of more than 1850 men in Ireland in 2015, the most recent data from the Central Statistics Office shows. More than 40% of deaths were caused by chronic lower respiratory diseases while one third of deaths were due to influenza and pneumonia. Most people with COPD smoked at some point in their life. Alcohol Eugene Renehan, superintendent pharmacist at Meaghers Pharmacy Group, says the

26

biggest health risks facing Irish men are alcohol misuse and not caring for their mental health. “You only have to look at our rate of suicide in young and adult men to see we have a problem,” he says. “The rate of alcohol misuse in Ireland is significantly higher than other countries and part of this is where men turn to alcohol to deal with issues that may require counselling or additional support.” Alcohol abuse among men is a major public health concern in Ireland, contributing to hospitalisations, disease and death. Irish men drink alcohol at extremely high levels and almost two-thirds binge drink, putting their health at serious risk, according to the World Health Organisation. The Health Research Board’s national alcohol survey found men across all age groups drink more frequently than women, and most men started drinking alcohol before the age of 18. Alarmingly, almost one-third said they had experienced harm as a result of their own alcohol use,

with men 1.5 times more likely than women to report harm. Alcohol has been attributed to thousands of male cancer deaths in Ireland, at a rate higher than the European average, including cirrhosis and alcoholic liver disease. Low testosterone A normal part of aging in men, testosterone levels usually begin to decline slowly after the age of about 30. It is likely that the condition is underdiagnosed: one survey found half of Irish men did not know that testosterone deficiency was a medical condition, despite affecting almost one in 10 over the age of 50. It is important to determine whether a patient’s low testosterone is part of the natural aging process or if it is due to hypogonadism, a condition whereby the body does not produce normal amounts of testosterone. Some causes of low-T can include chronic medical conditions such as diabetes, infections, obesity, or hormonal conditions.

There are an estimated 220,000 people in Ireland who have diabetes and the number is growing rapidly, according to Diabetes Ireland. Diabetes is more common in men than women, and presents a unique set of complications for men. They can experience sexual impotence and lower testosterone levels, leading to depression and anxiety. People at higher risk of getting type 2 diabetes include those aged over 40, people who have a family member with the condition, those who are overweight, do not exercise, have high blood pressure and cholesterol. With approximately 30,000 undiagnosed cases of diabetes, anyone experiencing symptoms (lack or energy, excessive thirst, frequent passing or urine, weight loss, blurred vision, recurring infection) should be referred to their doctor for a blood test. Community pharmacists play an important role in diabetes management, helping patients schedule their medication and advising them about potential drug interactions. Pharmacists can also help patients reduce their risk of developing type 2 diabetes by educating them about the importance of eating a healthy diet and keeping active. Boots pharmacist Susan O’Dywer says one of the biggest challenges in treating men’s health in the pharmacy setting is their reluctance to seek help. “This presents a challenge in terms of identifying people who would benefit from services offered by the pharmacy,” she said. “When looking at the numbers of patients availing of flu vaccinations each winter, males are just as likely as females to present in the pharmacy for vaccination. This suggests that males are willing to attend services that will be of benefit when they are aware of them, and they are offered in a convenient accessible location such as community pharmacy.” Male-pattern hair loss Male-pattern baldness is the most common type of hair loss, defined by a receding hairline and/or hair thinning on the crown and temples. According to the HSE, the condition will affect about half of all men at some point. Male-pattern baldness is caused by over sensitive hair follicles and is linked to the hormone dihydrotestosterone


Start with Combodart® (dutasteride/tamsulosin) First line treatment for BPH management for patients with moderate symptoms onwards.1-2 RAPID

SUPERIOR

symptom improvement2

symptom improvement vs tamsulosin from month 91,2

Starts as rapidly as with tamsulosin monotherapy

SUSTAINED symptom improvement over 4 years1,2

3 X LESS AUR AND BPH-RELATED SURGERY* vs tamsulosin at 4 years1,2

Adverse events associated with Combodart include impotence, decreased libido, ejaculation disorders, breast tenderness and enlargement, and dizziness. Men taking Combodart should be regularly evaluated for prostate cancer risk including PSA testing. Any confirmed increase from lowest PSA level while on Combodart may signal the presence of prostate cancer or noncompliance to therapy with Combodart and should be carefully evaluated. For additional/complete safety information, please refer to the prescribing information for Combodart. COMBODART ABRIDGED PRESCRIBING INFORMATION (API). (Please refer to the potentially cause symptomatic hypotension. Intraoperative Floppy Iris Syndrome (IFIS, a variant of small pupil syndrome) has been observed during cataract surgery in some full Summary of Product Characteristics (SmPC) before prescribing)

PRESENTATIONS: Each hard capsule contains 0.5 mg dutasteride and 0.4 mg tamsulosin hydrochloride. INDICATION: Treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction in the risk of acute urinary retention and surgery in patients with moderate to severe symptoms of BPH. POSOLOGY & ADMINISTRATION: Adults (including elderly): The recommended dose is one capsule (0.5 mg/0.4 mg) taken orally approximately 30 minutes after the same meal each day. Capsules should be swallowed whole and not chewed or opened. Contact with the contents of the dutasteride capsule contained within the hard-shell capsule may result in irritation of the oropharyngeal mucosa. Where appropriate, Combodart may be used to substitute concomitant dutasteride and tamsulosin. Direct change from dutasteride or tamsulosin monotherapy to Combodart may be considered. Renal impairment: No adjustment in dosage is anticipated for patients with renal impairment. Hepatic impairment: Caution should be used in patients with mild to moderate hepatic impairment. CONTRAINDICATIONS: Combodart is contraindicated in women, children and adolescents; patients with hypersensitivity to dutasteride, other 5-alpha reductase inhibitors, tamsulosin (including tamsulosin-induced angioedema), soya, peanut or any of the other excipients; patients with a history of orthostatic hypotension or severe hepatic impairment. SPECIAL WARNINGS & PRECAUTIONS: Combodart should be prescribed after careful benefit risk assessment and after consideration of alternative treatment options including monotherapies. In two 4-year clinical studies, the incidence of cardiac failure was higher among subjects taking the combination of dutasteride and an alpha1-adrenoreceptor antagonist, primarily tamsulosin, than it was among subjects not taking the combination. Digital rectal examination, as well as other evaluations for prostate cancer or other conditions which can cause the same symptoms as BPH, must be performed on patients prior to initiating therapy with Combodart and periodically thereafter. Combodart causes a decrease in mean serum PSA levels by approximately 50%, after 6 months of treatment. Patients should have a new baseline established after 6 months of treatment with Combodart and PSA should be monitored regularly thereafter. Any confirmed increase from the lowest PSA levels while on Combodart may signal the presence of prostate cancer (particularly high grade cancer) or noncompliance to therapy with Combodart and should be carefully evaluated, even if those values are still within the normal range for men not taking a 5α-reductase inhibitor (see SPC section 5.1). Results of one clinical study (the REDUCE study) in men at increased risk of prostate cancer revealed a higher incidence of Gleason 8 – 10 prostate cancers in dutasteride treated men compared to placebo. The relationship between dutasteride and high grade prostate cancer is not clear. Men taking Combodart should be regularly evaluated for prostate cancer risk including PSA testing (see SPC section 5.1). The treatment of patients with creatinine clearance of less than 10 ml/min should be approached with caution. As with other alpha1-adrenoreceptor antagonists, a reduction in blood pressure can occur during treatment with tamsulosin, as a result of which, rarely, syncope can occur. Alpha1-adrenoreceptor antagonists and PDE5 inhibitors are both vasodilators that can lower blood pressure. Concomitant use of these two drug classes can

patients on or previously treated with tamsulosin and may lead to increased procedural complications during and after the operation. The initiation of Combodart therapy in patients for whom cataract surgery is scheduled is not recommended. Dutasteride is absorbed through the skin therefore skin contact with leaking capsules should be avoided. Tamsulosin is not recommended in patients taking a strong CYP3A4 inhibitor and should be used with caution in patients taking a strong or moderate CYP2D6 inhibitor, a combination of both CYP3A4 and CYP2D6 inhibitor, or in patients known to be poor metabolisers of CYP2D6. Tamsulosin should be used with caution in patients taking a moderate CYP3A4 inhibitor (e.g. erythromycin) in combination with either strong (e.g. paroxetine) or moderate (e.g. terbinafine) CYP2D6 inhibitors, or in patients known to be poor metabolisers of CYP2D6. Caution should be used in the administration of Combodart to patients with mild to moderate hepatic impairment. Combodart contains the colouring agent Sunset Yellow (E110), which may cause allergic reactions. Breast cancer has been reported in men taking dutasteride. Patients should be instructed to promptly report any changes in their breast tissue. INTERACTIONS: The following reflect information available on the individual components of Combodart. Dutasteride: Long-term combination of dutasteride with drugs that are potent inhibitors of the enzyme CYP3A4 (e.g. ritonavir, indinavir, nefazodone, itraconazole, ketoconazole administered orally) may increase serum concentrations of dutasteride. Tamsulosin: Concomitant administration of tamsulosin with drugs which can reduce blood pressure could lead to enhanced hypotensive effects. Combodart should not be used in combination with other alpha1-adrenoreceptor antagonists. Increased exposure to tamsulosin is expected in CYP2D6 poor metabolisers as compared to extensive metabolisers when co-administered with a strong CYP3A4 inhibitor. When tamsulosin is co-administered with both CYP3A4 and CYP2D6 inhibitors there is potential for significant increase in tamsulosin exposure. Caution should be used when Combodart is used concomitantly with cimetidine or warfarin. Diclofenac may increase the elimination rate of tamsulosin. FERTILITY, PREGNANCY & LACTATION: Fertility: Dutasteride has been reported to affect semen characteristics in healthy men. The possibility of reduced male fertility cannot be excluded. Effects of tamsulosin on sperm counts or sperm function have not been evaluated. Pregnancy: Combodart is contraindicated for use by women. As with all 5 alpha reductase inhibitors, when the patient’s partner is or may potentially be pregnant it is recommended that the patient avoids exposure of his partner to semen by use of a condom. Lactation: Combodart is contraindicated for use by women. It is not known whether dutasteride or tamsulosin are excreted in human milk. ABILITY TO DRIVE & USE MACHINES: No studies on the effects of Combodart on the ability to drive and use machines have been performed. Patients should be informed about the possible occurrence of symptoms related to orthostatic hypotension such as dizziness. UNDESIRABLE EFFECTS: DUTASTERIDE AND TAMSULOSIN CO-ADMINISTRATION: The following adverse events have been reported with an incidence of ≥1% during the four years of treatment in a comparison study of dutasteride 0.5 mg

and tamsulosin 0.4 mg once daily for four years as co-administration or as monotherapy): Impotence, decreased libido, ejaculation disorders (including reduced semen volume), breast disorders, dizziness. Adverse Events identified through post-marketing experience (therefore the true incidence is unknown) with dutasteride monotherapy include allergic reactions, including rash, pruritus, urticaria, localised oedema, and angioedema; depression; alopecia; hypertrichosis; testicular pain and testicular swelling. The following adverse events related to tamsulosin monotherapy have been reported from post marketing data: Intraoperative floppy iris syndrome (IFIS); atrial fibrillation; arrhythmia; tachycardia; dyspnoea, epistaxis, vision blurred, visual impairment, erythema multiforme, dermatitis exfoliative, ejaculation disorders dry mouth. Marketing Authorisation (MA) Holder GlaxoSmithKline (Ireland) Limited,12 Riverwalk, Citywest Business Campus, Dublin 24. MA Nr: PA1077/118/001. Legal category: POM A. Date of preparation of API: January 2018. Code: IE/DUTT/0040/15(2). Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255. *Actual Risk Reduction 7.7% (4.2% VS 11.9%) (p<0.001) References: 1. Combodart Summary of Product Characteristics, www.medicines.ie accessed January 2018. 2. Roehrborn CG et al. Eur Urol 2010; 57: 123-131. Date of Preparation: January 2018

IE/DUTT/0006/16(1)


Feature Pharmacy Group is active in sexual health education, and regularly dispenses PreP in its city centre pharmacies. “This is an amazing development in the fight against the rising rates of HIV we are seeing in males in Ireland,” superintendent pharmacist Eugene Renehan says. “It encourages males to get regularly tested and know their HIV status, significantly reducing the risk of infection particularly in the MSM group.” Pharmacists are a good source of information about the dangers of some herbal remedies and alternative therapies promoted to people with HIV, which are not safe and can interact with proven treatment. Male infertility

(DHT), which is made from testosterone. Other medical conditions and treatments can cause hair loss, such as anaemia, autoimmune conditions, stress, fungal infections, some medications, and cancer therapies. The only medicine in Ireland licensed to treat male-pattern baldness is Minoxidil, a lotion containing either 2% or 5% minoxidil, which should applied to the scalp every day. The drug tends to slow down hair loss, rather than stop or reverse it, and usually needs to be used for at least four months before any effect is seen. The balding process will often resume if treatment stops. Community pharmacies are perfectly placed to treat hair loss, offering an expansive range of OTC products ranging from oral supplements, formulas and vitamins, to shampoos, topical lotions, creams and sprays. Suicide More men in Ireland die by suicide than women. According to the HSE, there are approximately 500 suicides recorded each year in Ireland, with the male suicide rate three times greater than that for females. Suicide is more common in men aged between 15 and 44, particularly men in the 15 to 24 year age bracket. Research shows men are less likely to acknowledge depression and seek medical help for a mental health condition.

Eugene Renehan, superintendent pharmacist at Meaghers Pharmacy Group, says he has seen an increase in the use of anxiety /depression medication in male patients, but has found that men aren’t as willing to talk about mental health issues as women, and therefore, suffer in silence. Pharmacists can encourage patients to take various steps to improve their mental health, reducing the risk of developing conditions such as depression. Steps to boost physical activity, improve diet, reduce alcohol and drug intake, and avoid isolation can be recommended to patients struggling with mental health problems. Erectile dysfunction Erectile dysfunction, which is also known as impotence, is characterized by the inability to develop or maintain an erection during sexual activity. Occasional ED is common, with many men experiencing the condition during stressful times. However, frequent impotence could be a sign of an underlying health condition, emotional problem, or relationship difficulties. Patients suffering from prolonged ED should be referred to their doctor as the condition can sometimes be caused by cardiovascular disease, diabetes, hypertension or hyperlipidemia. Erectile dysfunction can have psychological consequences, such as anxiety and depression, and have a negative impact on a

man’s self-image. Treatment for ED depends on the underlying cause. PDE-5 inhibitors are type of medication used to treat impotence by increasing blood flow to the penis. HIV/AIDS According to the most recent figures from the Health Protection Surveillance Centre, 508 people were diagnosed with HIV in Ireland in 2016. More than three quarters of people newly diagnosed were men, with 30 to 39 years olds making up the highest number of cases. Sex between men was the predominant route of HIV infection, accounting for 51% of new diagnoses, while heterosexual contact accounted for 28% of transmissions. Just 4% of new diagnoses were reported among people who inject drugs. Pharmacists can play an active role in HIV prevention by educating patients about safe sex methods and safer injecting practices, and recommending patients attend HIV and STI testing clinics regularly. Pharmacists are well-placed to counsel patients with HIV about the importance of adhering to their treatment schedule. They can also help to dispel common myths about HIV, including that the disease can be transmitted by kissing or sharing a toilet seat, that people who have HIV also have AIDS, and that a person with HIV can only have sex with other people who have HIV. Meaghers

Male infertility is on the rise, with tens of thousands of Irish men experiencing problems conceiving with their partners. According to Irish reproductive centre the Waterstone Clinic, the causes of male infertility can be broadly divided into three categories: congenital, acquired, or unknown. Usually, problems with male fertility result from producing lower-than-normal levels of sperm, or no sperm at all. Other causes can be a blockage in the reproductive tract, abnormalities in sperm structure, or in sperm motility. There are many strategies pharmacists can encourage men to adopt in a bid to help them avoid fertility problems, including quitting smoking, consuming less alcohol, maintaining a healthy diet, and avoiding excessive heat to the testes. Benign prostatic hyperplasia Many men's prostate glands will increase in size as they get older because of a condition known as prostate enlargement, or benign prostate hyperplasia. The condition, which is common in middle aged and elderly men, is non-cancerous but can cause uncomfortable symptoms. As the prostate gets bigger it pinches on the urethra, and can affect urine flow (difficult to begin urinating, a weak stream, and dribbling when finished). Over time, as the muscles weaken, some men struggle to empty their bladder. This can lead to frequent urination, the constant feeling of needing to pee, incontinence, and disrupted sleeping patterns. Treatment for BPH varies according to the patient.

29


Feature

The first ever drug free treatment for nasal and sinus allergy

By Dr Paul Carson

“I tell my allergic rhinitis patients they’ve got asthma of the nose and will be on medication for the rest of their lives.” So said a consultant ENT at Guys & St Thomas Hospitals (London) at an ENT Masterclass I attended. Rhinolight® is now in use in approximately 300 centres worldwide. Treatment can be administered by a nurse or nurse assistant after a short training program. It is very much a low key ‘word-of-mouth’ success story with the parent company relying on allergists and ENT specialists discussing its use at meetings and one recommending it to another. Interestingly, in Hungary where it is manufactured and was first used, the company cannot sell any more units as every ENT/allergist has one in use in their practice. Dr Paul Carson

Current ‘best practice’ guideline options for allergic rhinitis including hay fever are: (a) long term antihistamines only, then (b) long term antihistamines + steroid nasal sprays and then (c) variations of Montelukast + antihistamine + steroid nasal spray. Studies of patient satisfaction after ENT surgery in rhinitis treatments revealed ‘poor’ and ‘worse than poor’ outcomes. No surprises there, surgical intervention in an allergic nose defies logic, it’s a medical, not a surgical condition. Allergic rhinitis with associated sinusitis (after all, the nose and sinuses are one long complex and interlinking zone of respiratory mucosa) is growing at an alarming rate: 24% of the population have allergic rhinitis, especially hay fever and it’s reckoned in the next decade that figure will rise to 50%. Let me remind you of that ENT consultant’s comment that allergic rhinitis patients “will be on medication for the rest of their lives”. If that’s offered to the parents of a five year old it’ll be rejected, and the nearest homeopath sought out.

30

Business opportunity

Now a new, exciting and drug-free treatment for nasal/sinus allergy is here. And it could end that heart-sink ‘asthma of the nose with lifelong medication’ forewarning. Rhinolight® is a medical device that uses U/V phototherapy to reverse the allergically damaged nasal lining. For decades U/V phototherapy has been used successfully in atopic (allergic) eczema. The inflammatory effect that occurs in the skin in eczema is very similar to the changes seen in an allergy damaged nose. In 2001 the developers of Rhinolight® worked on the concept of using U/V phototherapy (UV-B 5%, UV-A 25% and visible light 70%) to treat that allergic damage. During the initial research both standard anti-allergy medications and phototherapy were combined. As patient symptoms significantly improved it was decided to use Rhinolight® only. There was as much patient satisfaction with Rhinolight® alone as with the combination of Rhinolight® and anti-allergy medications. Rhinolight® does not damage healthy nasal tissue and thus can be safely used as a long term

treatment in allergic conditions affecting the nose and sinuses. And, at last, it’s a safe treatment for nasal/sinus allergy in pregnant/breast feeding women and elite athletes worried about what they can or cannot take during an allergy attack. What is Rhinolight® regulatory status? Rhinolight® has CE approval (the product and treatment meet European Medical Device Directive requirements) and is classified as a Medical Device Class IIa. Is Rhinolight® safe? There have been no serious adverse incident reports in 18 years of continuous treatments in many centres around the world. Compare that with the fears of long term effects of antihistamines and intra-nasal steroids. Or, even worse, naso-sinus surgery. Are there any side effects? Dryness and crusting of the nasal lining can occur, but can be treated with Vitamin E oil.

Pharmacies provide approved healthcare products and advice to their customers. Pharmacies are also businesses and cost/ profit balance must be positive or the premises will close. An Allergy Healthcare section could be created in any medium sized pharmacy. Pharmacy staff could be trained and upskilled in allergy management. A carefully chosen range of OTC anti-allergy stock would be displayed with emphasis on proven and trusted products. This would surely be a commercial winner – provided it’s done correctly and with an ethical approach. Offer a cost effective, informed and proven specialised healthcare facility and the money will follow. Dr Paul Carson has been involved in allergy healthcare for 30+ years. He has written seven popular self-help books on allergy and published numerous articles on allergy in medical journals. He is the medical advisor and co-founder of Hay Fever Relief, the world’s first 3D interactive app for pollen allergy sufferers. A specialist commentator to NICE, the UK Government body tasked with the duty of determining the best forms of medical treatment, he is a member of BSACI, IAACI, EAACI and on the board of the Irish Lung Foundation.


Rhinolight

ÂŽ

The first ever drug-free treatment for nasal & sinus allergy Now available Slievemore Clinic, Dublin www.allergy-ireland.ie

Telephone: 01-2000500 allergyireland@slievemore-clinic.com


Awards The Irish Pharmacy

2018

Winners’ Profiles

Clonmel Business Development (Multiple) of the Year Award 2018

Focus on families and new parents leads to awards success for pharmacy group Winner: CarePlus Pharmacy Group CarePlus Pharmacy Group has launched a series of initiatives providing support to new parents. It is this innovation which saw the group triumph in the coveted Clonmel Business Development (Multiple) of the Year category at the Irish Pharmacy Awards. CarePlus Pharmacy Group is acutely aware of the importance of offering support to new parents in their own communities, and it managed to pull off a masterstroke by employing the services of leading sleep specialist, Lucy Wolfe, as a brand ambassador for its baby category, “Nature Nurture”, over the past 12 months. This business development initiative is one key pillar categories for CarePlus Pharmacy and one it believes separates the brand with a real point of difference from the competition by offering parents outstanding products, expertise and service. Known as the “baby whisperer”, Wolfe, alongside midwife Dorothy Buck, has taken part in a series of exclusive events for CarePlus Pharmacy customers this year. The mother of four, who is a trained and certified sleep consultant, has been offering invaluable tips and support to get babies to sleep through the night. This is just one of a series of successful initiatives launched by CarePlus Pharmacy to offer support to new parents in their own communities, which also helped the brand secure the

32

much-coveted Clonmel Business Development (Multiple) of the Year award at the recent Irish Pharmacy Awards 2018. The Nature Nurture programme is designed to provide the CarePlus nominated “Pillar Champions” (its mum and baby advisors) with the tools and product information to deliver expert advice and customer care to expecting and new mums. As Breege McTigue, Head of Customer Engagement at CarePlus Pharmacy, tells Irish Pharmacy News, the group knows that parents need lots of advice and support during the first few months of parenthood, and that its dedicated in-store Baby Advisors are available in each of its community-focused stores across Ireland. “It is great to win the Business Development award, which is very much to do with our baby category,” says McTigue. “A key cornerstone of our business is to become a destination in the community for mum and baby, as well as be known for having CarePlus staff who are knowledgeable and look after our customer's wellbeing. CarePlus has a great mum and baby training programme, which is spread over three modules. We work in partnership with Lucy Wolfe, our resident sleep expert, Dorothy Buck, our resident midwife, and Irish Red Cross, who deliver invaluable paediatric first aid training.”

Lee-Ann McCarthy, head of marketing and Breege McTigue, head of customer engagement at CarePlus Pharmacy with Barry Fitzpatrick, Director of Sales, Clonmel Healthcare


so a lot of work goes on in the background, it's not down to one person. Having everybody working together and in collaboration is vitally important. It's challenging at times but we all know it's for the benefit of the business owner at the other end, so we're always looking to build efficiencies into systems, and we have very slick technology to help us with that.” STAFFING CarePlus has in excess of 300 employees working nationally across its network of pharmacies and support team, and it’s a number that is rising month on month. “We are recognised in the industry for our expertise, both in terms of the retail space and in the dispensary,” says McTigue. “Rather than us being out there in the market looking for people, it's really the other way round, where people are approaching us wanting to work with us.”

Breege McTigue, head of customer engagement at CarePlus Pharmacy

McTigue believes that one of the key factors in the the CarePlus success story is its focus on the training of the over 300 staff across the network. “We focus a lot on training, because it really underpins everything we do. We have 50 trained mother and baby experts in our pharmacy network, so being able to promote that is something we are always striving towards. Training and upskilling our staff on the frontline, as first point of contact for a parent, is key for us.” The objective of the training programme is to help the CarePlus pharmacy teams to provide more appropriate information and advice to customers. As part of activating this programme, CarePlus recruited “baby champions” across its network of 48 pharmacies. “Our target is to add an additional 5,000 mums to our customer base, and use our 50 mum and baby advisors to help new parents as best we can,” reveals McTigue, who adds that CarePlus is about 50% of the way towards that target.

“Training is so important to us,” reiterates McTigue, "because unless people are trained properly, customers just don't trust them. Our mum and baby advisors go out into the community where they work with parent support groups. We're always looking at topics that are relevant, such as a safe environment for parents to bring their children into being one of them. For example, we use our consultation rooms for things like breastfeeding, because we know mums can often feel a bit uncomfortable about it. Every time we look at training we look at what is relevant. We are always listening to feedback from our mum and baby advisors because they are on the ground working in the community.” McTigue also believes that collaboration between the various different teams that make up the CarePlus family is pivotal so that the network can run smoothly. “Collaboration is also very important to us,” she says, "because when everyone is involved in the process they understand how it actually works,

Lee-Anne McCarthy, Head of Marketing at CarePlus, adds: “If you look at our [recruitment] process, it's very slick. We will go in and show a pharmacist the transformation that will take place, about how their pharmacy could look, and it's a very attractive option. We show them the support they will get from us, that we are there for them, always offering support, creating marketing plans, training their team, making it really simple for them. So you can imagine being a pharmacist, they can see we offer world class systems and a super attractive pharmacy. We have world class systems in relation to ordering and in relation to managing stock. We are offering them efficiencies, so their staff can spend more time with customers, which is obviously pretty key. We are helping them build sales while also giving them access to really amazing intelligence tools, so they can know exactly where they are in relation to stock levels etc. I guess we are a pretty attractive option and people can see that. The Irish pharmacy industry is pretty small, so people are talking all the time.” Martina Vengrinova, a buyer for the OTC category at CarePlus,

believes the Nature Nurture initiative has proved a big success and it is something the group will continue to push moving forward. “I guess you can see straight away the increase in sales. We were trying to give the customer extra benefits, especially new mothers. There are a lot of products on the market, so we can help them decide about certain products. The feedback we get from local mothers is very good. So they can say themselves, 'okay, I known I can go to a CarePlus pharmacy and I can get the right advice.” CarePlus has signed a second year contract with Lucy Wolfe and will continue its collaboration with her as the brand's Baby Sleep Expert. The CarePlus Loves Baby event activated in-store this March saw an increase of 50% on key lines on promotion for that month. Footfall across the pharmacy network has increased because of the mum and baby advisors are driving the category and services to compliment it. CarePlus has also been busy this year rolling out module 1 & 2 of the Nature Nurture category training and supporting its advisors to develop relationships with customers in their pharmacies. In conjunction with its training programme, in-store events focus on different products every month. By running these events it motivates the CarePlus staff and also allows the brand to show the customer new offers or new products on the market. McTigue says CarePlus goes that extra mile for its customers by having additional services which make the life of the busy parent easier, from baby weighing, nutrition advice, baby massage classes, first aid training, working with local maternity hospitals, and mum and baby support groups. “This means that we are committed to delivering the best in class service to our customers. If we do not have an item in stock we will get it from another store and let the customer know by the end of the working day that we have sourced what they want.”

33


The new baby bottle for a more familiar feeling. Breastfeeding is and remains the best way to feed a baby. For over 60 years, NUK has been helping to support this with highquality products. However, depending on the situation, every now and then, mothers cannot breastfeed. This is when a good baby bottle is needed with which both breast milk and other foodstuffs can be fed and which lets bottle and breastfeeding be an optimal combination too. So, for this, the stronger a sense of nature such a bottle has, the more familiar the feeling for babies and the better they feel too.

he development of the NUK Nature Sense is based primarily on the scientific finding that the number of openings in a lactating breast are unique to each mother. So, according to the recent study from Münster University,

More needs, more flexibility. NUK Nature Sense Teats come with a varying number of tiny openings – for breast milk and other thicker liquids too. And as the baby grows, the teat can be Several tiny milk ducts

99%

would recommend the new NUK Nature Sense to others.

98%

confirm a more natural drinking experience.

92%

of babies accept the new teat.

Recommended by paediatricians and midwives:

96%

confirm a liquid flow similar to a breast.

98%

confirm the softness and a feeling almost like at a mother’s breast.

SUPER-SOFT ZONE

EX E FL

T XI RA BL E

A CO N T I LI C

The features of the NUK Nature Sense at a glance.

breastfeeding mothers have, on average, 7.6 active milk ducts with cases of even up to 16 active milk ducts and the number of active milk ducts increases with every additional birth. These

Tested by mothers:

SEVERAL TINY OPENINGS

EX E FL

findings provide the basis for the qualities of our new NUK Nature Sense, with its several tiny openings. These are modelled on the milk ducts in a mother’s breast and make it the baby bottle that lets babies enjoy a familiar feeling when drinking and, above all, a natural flow.

T XI RA BL E

T

The several tiny openings are modelled on the milk ducts in a mother‘s breast and ensure a smooth and natural flow. The extra-soft tip of the teat is particularly flexible and adapts itself to the mouth in a way similar to a nipple.

*

The wide, flexible lip rest gives a familiar feeling as if at a mother’s breast.

changed to a size for babies from 0–6 and 6–18 months. The flexible silicone teats are particularly heat and age-resistant, with a neutral smell and taste. The high-quality, polypropylene (PP) bottle is BPA-free and particularly hardwearing. Naturally, convincing – naturally, recommended too. The new NUK Nature Sense was developed in close collaboration with midwives and paediatricians and, before the market launch, was tested by mothers and babies. Asked for their opinion of the new bottle, the experts confirmed, in particular, that the NUK

The innovative NUK Anti-Colic Vent allows the liquid to flow constantly and helps prevent air being swallowed and causing discomfort.

Nature Sense has the most important properties of a good baby bottle and that they would recommend the bottle to mothers who do not want or cannot breastfeed, as well as to mothers who want to both bottle and breastfeed. See for yourself and test the new baby bottle. For more information, go to www.nuk.com

* Independent Research in Germany, 2016

Available to order from your local Intrapharma Sales representative: For Munster contact Maura Cronin 086 - 813 6540 | For Leinster Orla Smith 087 - 052 4507 For Connaught Mervyn Connaughton 086 - 819 8271 | For Northern Ireland Norma Beggs +44 77 205 77747


OBESITY –

A

modern,

mismanaged

&

misunderstood malady – By Dr. Heli Goode, MD, Naturopath

CPD 94: CHILDREN’S HEALTH; GLYPHOSATE GENERATION As published in Positive Health Online – Issue 232, August 2016 Obesity is a growing and serious health concern that has, by

Biography - Dr. Heli Goode, ARH, SOH, TCM, specialised in Ear, Nose & now, reached epidemic proportions, mostly in the Westernised Throat surgery in her native Estonia before starting her complementary practice world. Increased consumption of unhealthy food coupled with in England nearly 20 years ago. She integrates naturopathy, homoeopathy, decreased physical activity, in part, has led to rising obesity acupuncture, hypnotherapy rates and over traditional Chinese Medicine. She is available the past three decades. The WHO (World Health for consultations from her clinics in Leicester Street, London. Organisation) reportsand that Harley since 1980, worldwide obesity rates Dr. Goode is a lecturer for holistic medicinal practices and is a member the 2.3 have increased by almost 200%. By the end of 2015of nearly Natural Health Academy. billion adults were reportedly overweight and 700 million of

these obese. Obesity has been linked to certain cancers, cardiovascular diseases, diabetes and may shorten the human lifespan by eight to ten years.1 A grim prediction by the government suggests that obesity will continue to rise - up to 50% of women and 60% of men will be overweight by 2050 and up to 25% of children will have weight issues by that indicated timeframe.2

Reflection - Is this area relevant to my practice? What is your existing knowledge of the subject area? Can you identify any knowledge gaps in the topic area? Planning - Will this article satisfy those knowledge gaps or will more reading be required? What resources are available? Action - After reading the article complete the summary questions at www.pharmacynewsireland. com/cpdtraining and record your learning for future use and assessment in your personal log. Evaluation - How will you put your learning into practice? Have I identified further learning needs?

60 second summary What is there that is not poison? All things are poison and nothing is without poison. Solely the dose determines that a thing is not a poison. Famous words from the well-known Swiss doctor and philosopher Paracelsus (1493-1541). Nearly sixty years ago, Dr Rachel Carson, author of the frequently referenced toxicology book ‘The Silent Spring’ said “It is ironic to think that man might determine his own future by something as trivial as an insect spray”. With regulations of health and safety seemingly ruling our every step and action today, how relevant is this statement? Are we on the verge of creating another DDT-like disaster, some sixty years later? Recent years have shown a significant rise in certain childhood diseases. Growing numbers of children with severe allergies, asthma, autistic spectrum disorders, eczema and other chronic illnesses cause many parents, medics and scientists to ask a simple straight forward question; why? What has gone wrong within the environment, where and when?

Who is classed as overweight or obese?

Children’s Health; Glyphosate Generation

In the 17th Century, a Belgian mathematician and astronomer, Lambert-Adolphe-Jacques Quetelet, became fascinated in possible numerical links between different human body parts. After some calculations he concluded that by taking a person‟s weight in kilograms (kg) and dividing it by the height in meters (m2), it would give a specific numerical figure which is unique to every individual. He termed it the Body Mass Index (BMI) which, according to some experts, expresses the correlation between the body weight, coronary insufficiencies, cholesterol level and expected lifespan. Even though the BMI does not take into account the the effects of simultaneous exposure differences in people‟s ethnic background, ethnic characteristics and the wayto some TRENDS & CONSEQUENCES individuals store fat, in clinical practice it ischemicals, still a widely used method for assessing several including a mixture Why are so many young children issues. suffering weight/health-related A greater BMI leads and to a herbicides greater risk of developing of pesticides which may cofrom an epidemic of chronic, morbidities such difficult as type 2 diabetes. Anyone‟s BMI figure ill-effects, of more thanaffecting 25 indicates “the cause synergistic to diagnose andlevel treat healththere issues? at which is a significant increase in mortality” and is classified overweight children in polluted areas andaseven in .3 In Why are so many overweight, our kids healthcare system it is a key factor in deciding who qualifies for quality surgical weight the countryside, where the air 4,5 have learning difficulties, behavioural reduction procedures. is generally better but the usage of

problems, childhood diabetes or even agricultural chemicals is inevitably high. clinicians prefer their the Waist Circumference Measure to BMI - a simpler cancer? These Many medical issues raise anthropometrical which is “also a criterion for the metabolic syndrome”.due A waist Children are susceptible to illnesses ugly heads all over the world, measure especially measurement of more than 35isinchesto(88cm) for women and 40 inches (102cm) for men their immature immunity and stillwhere a Western lifestyle and economy indicates a significant health risk.3 Still, however we weighand or measure it, obesity and its developing organ systems. They are reigning. In its wake, this lifestyle leaves related conditions are costing the healthcare system nearly £6 billion annually. It is estimated therefore particularly vulnerable to air future generations with numerous health 6 that by 2050 the cost will have risen topollution, £50 billion per single year. hazardous chemicals, climate complications and most probably, highly change, poor or inadequate quality 1 toxic too. of water, food, general sanitation and Everyone agrees that the prosperity of hygiene. The World Health Organisation the Western society depends largely (WHO) have previously outlined the on the health and strengths of future damaging impact a toxic environment generations. In today’s well-developed can have on health and well-being.2 Western society, the major causes of “More than 1 in 4 child deaths could children’s health issues are no longer be prevented by cleaning up the old-fashioned infectious diseases. In environment” declares the document, industrially-developed countries, the noting that nearly 1.7 million children principal causes of growing children’s under the age of 5 die every year due health problems, disability and death to poor indoor and outdoor conditions, are non-communicable illnesses which including unsafe water and air quality.2 include developmental and chronic mental Babies and young children are specifically problems, allergies, asthma, autoimmune sensitive to polluted air. The average diseases, diabetes, obesity and childhood toddler inhales up to 25 litres of air per cancers, to name but a few. hour and due to their still-developing lungs The evolution and rapid growth of the are especially vulnerable and prone to chemical industry, with the discovery and any respiratory conditions by breathing use of new chemicals and materials such in aerosolized toxic mixtures of several as plastics, has undoubtedly resulted chemical pollutants in overcrowded, in huge technological advances. This unhygienic, highly industrialised or progress has had merit on wellbeing agricultural areas. and lifestyle factors with improvement in Worldwide, up to 14% of children present numerous areas of human activities. with asthma symptoms every year which But how safe are these new products are directly related to poor air quality, and innovations? mould and dampness in living conditions. According to Dr Philip J. Landrigan, 20% Annually, 570,000 kids under the age of of chemicals have been tested for safety five die from respiratory illnesses related to on human beings.1 Little is known about polluted air.2

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CPD 94: CHILDREN’S HEALTH; GLYPHOSATE GENERATION development due to prenatal exposure. Even though DDT was banned decades ago, its residues can still be found in wildlife and the food chain. This chemical, crossing the placental barrier, causes potential prenatal exposure in a specific set of expectant mothers and is linked to autism in offspring. While it is still unclear whether these mothers are genetically or biologically more susceptible to insecticides, it does warrant additional research. It also highlights that DDT, banned fifty years ago, is still affecting future generations.5

Current drastic changes in our climate, generally higher temperatures, recurrent heat waves, higher levels of atmospheric carbon dioxide, pose a severe threat to children with weakened immune and respiratory systems. Annually, diarrhoea can kill 361,000 children due to polluted water supplies and inadequate hygiene and sanitation.2 Acute poisonings from pesticides, herbicides, common household products such as solvents, exposure to lead and accidental ingestion of medicines are responsible for an estimated 23,000 yearly deaths in children under 5.2 Childhood cancer rates are rising with alarming speed. Research suggests 10-20% of paediatric cancers are found to be hereditary with the rest thought to be related to toxicological concerns. Emerging evidence shows a direct link between maternal and early exposure to environmental pollutants and childhood cancers.2 Another worrying trend is the growing rate of Autistic Spectrum Disorder (ASD), mainly among boys, with overall worldwide figures showing that 1 in 160 children are affected by autistic traits. Figures show highly industrialised and technologically-advanced Japan ranks as one of the leaders.2 According to the National Autistic Society UK, autism is more common than previously thought. In the UK for example, there are about 700,000 people affected by ASD, showing that 1 in every 100 children at present show signs of autistic spectrum.3 Scientists believe that such wide-seen health concerns result from chronic toxic exposure, be that through chemicals in

our soil, air, water or food. This synergistic co-existence is causing over-exposure. Hazardous substances are found in kitchens, bathrooms, sheds, playgrounds, parks, playrooms, gyms, schools and nurseries; everywhere children spend their time. ENDOCRINE DISRUPTORS Prof. Theodora Colborn, an environmental health analyst, coined the term endocrine disruptors in 1991. Endocrine disruptors are chemicals which may, in specific circumstances, disrupt the body’s endocrine functions thus causing adverse reproductive, developmental, immune and neurological effects. Her extensive studies showed the adverse effects of certain chemicals caused to offspring during developmental and growth stages. This disruption causes a poor foundation for wellness. During the last number of decades, man-made chemicals have further impacted the environment, revealing serious concerns for human health, wildlife and threats to the health of future generations. Prof. Andrea Gore, University of Texas, added further weight to the significant findings, stating that exposure to chemicals during pregnancy affects the brain even two generations later.4 Another recent study, led by Dr Alan Brown, published in the American Journal of Psychiatry, found “the first bio-marker evidence that maternal exposure to insecticides is associated with autism among offspring.” This study shows the health impact of insecticides, including DDT and its possible pathway to autism

Endocrine disruptors mimic naturally-occurring body hormones such as estrogens, androgens and thyroid hormones, causing potential overproduction and consequent disorder within the body. They are capable of interfering or blocking the way of natural hormonal pathways, disrupting signals and altering the function of the whole endocrine system. Any organ or system in the body directed by hormones can be derailed by endocrine disruptors and we are coming into contact with these chemicals every day. A wide range of chemicals and substances including dioxin and dioxin-like compounds, bisphenol A, flame retardants, pharmaceuticals, plasticisers, DDT and other synthetic pesticides are thought to be responsible for adverse endocrinal interference. These substances are found in most household products – plastic bottles, food containers and wrappings, children’s toys, detergents, pesticides, herbicides, insecticides, cosmetics, toiletries and certain foods. Medical studies confirm a strong link between endocrine disruptors and the risk of developmental issues in foetuses and babies.4 Birth defects are also being considered a leading cause of infant death.1 With growing evidence directly relating health concerns to environmental toxic exposure, despite having progressed from the days of the DDT disaster, we are still being afflicted by modern poisons. GLYPHOSATE In 1950, Dr Henri Martin, a Swiss chemist, discovered glyphosate N-phosphomethyl glycine. In 1970, Dr John Franz discovered the herbicidal potential of glyphosate, which lead to production of a product called Roundup by Monsanto in 1976. Roundup is widely used throughout the world - on fields, private and communal gardens, sport grounds and public parks. Its purpose; to kill weeds in the production of genetically modified grains and crops. Studies have found that high doses of glyphosate in animal testing can

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CPD 94: CHILDREN’S HEALTH; GLYPHOSATE GENERATION cause cancer but carcinogenic evidence in people has so far been exposed as “weak”.7,11 In 2015, the International Agency for Research on Cancer (IARC) classified glyphosate as a Group 2A Carcinogen considering it a ‘probable carcinogen’. It is surmised that the active component of glyphosate on its own is less toxic than in a mixture of commercial formulations. Glyphosate is the world’s most widely used herbicide. It is used in over 140 countries and its production is expected to rise. Agricultural glyphosate use in the US alone has risen 300-times from 1974. Over the last decade, 6.1 billion kgs of glyphosate has been used worldwide.7 Numerous studies performed on laboratory animals show the link between high doses of glyphosate and nephrotoxicity, liver enlargement and gastric disorders. Research also relates it to non-Hodgkin’s lymphoma, childhood leukaemia, multiple myeloma and neurodegenerative diseases such as Parkinson’s. It is also highly toxic to aquatic life.7 As previously noted, the increase in autism is alarming. In the 1990s, 1 child in 5000 was identified with an Autistic Spectrum Disorder (ASD). Today, according to the Centre for Disease Control’s Autism & Developmental Disabilities Monitoring (ADDM), it is approximately 1 in 59. It is predicted to rise further, reaching 1 in 3 by 2025.7 The exact cause of this condition is still unclear but according to some scientists, in many cases pesticides may be responsible. “Knowing the effect that glyphosate can have in the human body, particularly in the gastrointestinal tract, and comparing it with autism bio-markers such as alteration of intestinal bacteria, intestinal inflammation, lack of serotonin and melatonin, disorders to the mitochondria, iron and zinc deficiencies; the correlation between the two factors is evident. The risk of having autistic children increases in mothers who have been exposed to it during pregnancy”, says Vincenzo Torretta.7 Pesticide formulations contain adjuvants, also called inerts by the manufacturers. “Often kept confidential…Adjuvants in formulations are generally declared as inerts and therefore are not tested in long-term regulatory experiments. It is thus very surprising that they amplify up to 1000 times the toxicity of their active principles in 100% of the cases tested. The role of adjuvants is to increase active principle (AP) solubility and to protect it from degradation, helping cell penetration, and thus enhancing its activity and consequently side effects.”7,8

In addition to secret contents, the formulations contain active principles which are tested alone, and not in combinations with inerts. After testing the toxicity of the active principles of three major herbicides, three insecticides and three fungicides on human embryonic cells well below agricultural dilutions, the conclusion was that all formulations were cytotoxic and “despite a relatively benign reputation, Roundup was among the most toxic herbicides and insecticides tested…It is commonly believed that Roundup is among the safest pesticides, but was found in this experiment to be 125 times more toxic than glyphosate”. The idea of safe Roundup is distributed by manufacturers but contradicts the scientific findings of combined toxicity of AP and the so called “inert”, posing “endocrine disruptive effects below toxicity threshold”.8 Another group of researchers who tested the potential toxic effect and endocrine disruption of Roundup on human embryonic and placental cells, concluded that the cytotoxic and endocrine disruptive effect is amplified with time and exposure to this formulation. ”It may affect human reproduction and foetal development in case of contamination”. It was found that “glyphosate acts directly as a partial inactivator on microsomal aromatase in a dose-dependent manner and Roundup is more efficient than its active principle, glyphosate, suggesting a synergistic effect provoked by the adjuvants in Roundup.”9 Similar to DDT traces, residues of Roundup are found in a wide range of

everyday food and drink including wheat, oats, beans, legumes, wine, orange juice, potatoes and even ice cream. In 2016, a Boston University study found the presence of herbicides in 62% of honey. Glyphosate has been found in human urine samples, breast milk, drinking water, beer and feminine hygiene products. The fact that glyphosate is found in breast milk is alarming, confirming it can be passed to babies. Infants and young children have a limited capacity to detoxify chemicals, making them vulnerable recipients to this dangerous chemical. But despite growing evidence showing hazardous effects on the environment, soil microbial community, monarch butterflies, honeybees, aquatic life, mammals and humans, it is argued that low doses are safe. However, widespread exploitation of chemical herbicides has created another issue; herbicide-resistant weeds. Pesticides don’t distinguish between helpful and harmful wildlife and so while the crops are being sprayed, useful bugs including bees are also being terminated. As we fight against intrusive enemies with growing amount of pesticides and herbicides, we also expose our children to a toxic mix of substances which have harmful effects on health. It is important to understand that several factors can influence risk for environmentally related illnesses, such as chemical exposure prior to conception, prenatal care, mother’s age, lifestyle, nutrition and overall health condition. Children as they grow and develop, differ from adults considerably. The

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CPD 94: CHILDREN’S HEALTH; GLYPHOSATE GENERATION

Sustainable World: The Atlas on Children’s Health and the Environment 3. National Autistic Society UK 4. Andrea Gore, PhD, Exposure to Endocrine Disruptors during Pregnancy affects the Brain Two Generations Later, Endocrinology Society press release 2015 5. Alan S Brown, M.D. et al, Association of Maternal Insecticide Levels With Autism in Offspring From a National Birth Cohort, The American Journal of Psychiatry, 16 Aug 2018 6. Benbrook C. Trends in the use of glyphosate herbicide in the U.S. and globally. Environ Sci Eur.2016;28(1): 3. https://doi.org/10.1186/s12302-0160070-0. 7. Vincenzo Torretta et al, Critical Review of the Effects of Glyphosate Exposure to the Environment and Humans through the Food Supply Chain, Sustainability 2018, 10,950; MDPI 8. Robin Mesnage et al, Major Pesticides Are More Toxic to Human Cells than Declared Active Principles, Biomed Res Int. 2014; 179691 9. Benachour N et al, Time-and dosedependent effects of Roundup on human embryonic and placental cells, Arch Environ Contam Toxicol. 2007 Jul;53(1): 126-33 Epub 2007 May 4

toxicodynamic processes absorption route of the chemicals, metabolism, excretion, tissue and organ vulnerability are all agerelated, making children vulnerable to foreign or synthetic substances.10, 11, 12 Recently, a lawsuit against Monsanto, the manufacturer of Roundup highlighted the potential dangers of excessive and continued use of certain chemicals. Health regulators will actively continue to consider the impact of a toxic environment. That is good news. Doctors acknowledge cases of children whose growth, development and unusually high levels of chronic illnesses are not resembling those of past generations. Regardless of chemical and pharmaceutical advances, children are weaker and sicker than their parents and if we don’t act now, their life span will be shorter as well. A comprehensive and relevant health strategy is required to stabilise the good health of today’s children, and safeguard future adults. WHO have acknowledged that integrative concepts – nutrition, acupuncture, homoeopathy and homotoxicology have pragmatic and appropriate potential. The question now is, how do we actively harness that to fulfil the needs of today’s health landscape.

REFERENCES 1. Landrigan, Philip J., Landrigan Mary M; Children and Environmental toxins: What Everyone Needs to Know, Oxford University Press, 2018 2. World Health Organisation, Inheriting a

10. Philip J. Landrigan and Fiorella Belpoggi, The Need for Independent Research on the Health Effects of Glyphosate-based Herbicides, Environmental Health, 29 May 2018 11. Michelle Perro, MD; Vincanne Adams, PhD, What’s Making Our Children Sick?, 2017 12. C F Bearer, How are Children Different from Adults?, Environmental Health Perspectives; 1995 Sep;103(Suppl 6):7-12

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Report Pharmacists have played their part in the economic recovery – Time for the immediate unwinding of FEMPI The Irish Pharmacy Union (IPU) has called for the immediate unwinding of FEMPI. According to a pre-Budget submission issued by the IPU, since 2009 the State has extracted over €3.1 billion from the community pharmacy sector with almost €1.4 billion through FEMPI measures alone. alone come to ¤1.386 billion. This comprises ¤527 million in cuts to dispensing fees and mark-ups (see Table 1) and ¤859.5 million (Table 2) in cuts to the wholesale margin/ingredient cost.

IPU president Daragh Connolly

It is now nine years since the Financial Emergency Measures in the Public Interest (FEMPI) Act was used to cut payment rates to pharmacists. Since then, the State through FEMPI and other measures has extracted over ¤3.1 billion from the community pharmacy sector in reduced medicine reimbursements and cuts to pharmacy fees and margins. The cuts through FEMPI measures

The submission states: “Independent research and analysis has found that the current fee arrangement does not adequately reimburse pharmacists for their cost of labour, overhead contribution and profit margin. It is an uneconomic level of fee for the service that is provided by qualified professionals with regulatory obligations and reporting requirements. Pharmacies have delivered substantial productivity and efficiency gains, under a growing regulatory and administrative burden and in the face of increased demand and greatly reduced fees. We have played our part in the economic recovery of this country.” Commenting on the submission, Daragh Connolly, IPU President said: “There are currently over 1,800 community pharmacies treating patients throughout the country. The majority (89%) of these remain family owned businesses, each of whom has been badly impacted by FEMPI cuts. The average pharmacy relies on State schemes for two-thirds of its revenues, but a decade of decline has seen the average

turnover per pharmacy from State schemes decrease by a third. “This is leading to huge pressures, particularly for pharmacies in rural and disadvantaged areas, and risks leading to closures if not immediately reversed. It is now long overdue that action is taken on FEMPI, that cuts are reversed and that the important role of community pharmacists is recognised to ensure equity, fairness and the sustainability of pharmacies in communities across the country.” According to Mr Connolly, Irish community pharmacists could also be empowered to improve the services they can provide to patients nationwide. “Our submission detailed a number of proposals to expand the role of community pharmacists, which would alleviate the significant pressures on the healthcare system. With nearly 78 million visits to community pharmacies every year, pharmacists are the most accessed healthcare professionals in Ireland and expanding their role will provide significant benefits to both the patient and the State.” The IPU submission states: “With an ever-increasing demand for healthcare as our growing population continues to age, and with the ongoing constraints on the resources available to deliver

Table 1: Reductions in Fees and Mark-ups paid to Pharmacists by the State Year Pharmacy No of items Mark-up & Reduction fees & mark ups dispensed fees per item per item under state since 2009 schemes 2017* 76,312,934 ¤5.29 ¤0.92 2016 ¤397,440,000 75,175,841 ¤5.29 ¤0.92 2015 ¤389,740,000 73,542,223 ¤5.30 ¤0.91 2014 ¤381,070,000 72,715,536 ¤5.24 ¤0.97 2013 ¤393,930,000 74,378,504 ¤5.30 ¤0.91 2012 ¤403,860,000 75,724,736 ¤5.33 ¤0.88 2011 ¤386,630,000 72,023,261 ¤5.37 ¤0.84 2010 ¤372,990,000 69,251,377 ¤5.39 ¤0.82 2009 ¤420,960,000 67,825,991 ¤6.21 Total (*estimate) Source: PCRS Data and Fitzgerald Power

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State Savings

¤70,182,372 ¤69,136,626 ¤66,697,624 ¤70,236,816 ¤67,697,977 ¤66,123,326 ¤60,380,232 ¤56,816,616 ¤527,271,589

healthcare, we simply do not have the option of doing nothing. There is an urgent need for a fundamental shift in health policy and the immediate implementation of change. The time is right to optimise the delivery of primary care by providing appropriate, convenient, accessible and cost-effective healthcare through pharmacies in communities throughout the country. “However, this cannot be done in isolation. In order to provide these key services, our community pharmacies need to be adequately resourced to ensure that they can provide the continuum of care which is urgently required in our communities and which patients are demanding. “Economic advisors EY-DKM analysed the Irish community pharmacy sector and concluded that there is an under-provision of certain services in pharmacies in rural and disadvantaged areas, where demand for these services is higher. This deficit arises because there is less opportunity in these areas for pharmacies to develop the retail business which is necessary to subsidise the income from State schemes, upon which rural pharmacies are utterly reliant. It is clear that the State urgently needs to invest in enhanced pharmacy-based services which, internationally and domestically, have demonstrated real benefits in terms of patient outcomes, reduced total care costs and, crucially, the additional capacity which can be released in more complex healthcare settings such as General Practice and Emergency Departments. Now is the time to deliver. Specific Proposals made by the IPU included: • Minor Ailment Scheme A Minor Ailment Scheme could save nearly 950,000 GP consultations every year and keep the focus on primary healthcare in the community. The IPU has already collaborated with the Department of Health and the HSE on a pilot Minor Ailment Scheme, which enabled medical card patients to receive treatment for common illnesses, free of charge,


Table 2: Reductions in Medicine Reimbursements paid to Pharmacists by the State

Year PCRS payments No. of items Cost Reduction FEMPI State Savings for medicines dispensed per per item reductions under State item since 2009 schemes 2017* 75,579,617* ¤84,500,000* 2016 ¤945,900,000 74,494,210 ¤12.70 ¤6.18 ¤84,492,157 ¤460,509,104 2015 ¤956,750,000 72,911,181 ¤13.12 ¤5.76 ¤85,461,329 ¤419,772,401 2014 ¤979,010,000 72,132,792 ¤13.57 ¤5.31 ¤87,449,695 ¤382,816,851 2013 ¤1,053,290,000 73,823,818 ¤14.27 ¤4.61 ¤94,084,728 ¤340,462,478 2012 ¤1,161,460,000 75,202,381 ¤15.44 ¤3.43 ¤103,746,972 ¤258,318,978 2011 ¤1,114,610,000 71,590,122 ¤15.57 ¤3.31 ¤99,562,113 ¤236,971,544 2010 ¤1,191,880,000 68,860,539 ¤17.31 ¤1.57 ¤106,464,227 ¤108,168,541 2009 ¤1,273,770,000 67,468,626 ¤18.88 ¤113,779,020 Total ¤859,540,240 ¤2,207,019,896 (*estimate) Source: PCRS Data and Fitzgerald Power

directly from their local community pharmacy in a timely manner and without the need for a visit to the GP. The IPU is calling for this scheme to be rolled out nationally.

• New Medicine Service The IPU has also called for a New Medicine Service to be rolled out, which could be delivered within the community pharmacy setting. This

service would improve adherence to medicines for people who have been newly prescribed medicines for certain long-term conditions or therapies, and would improve patients’ health outcomes by

ensuring more effective medicine taking. Economic analysis of a similar service which has operated in the UK since 2011, has found that it offers the NHS short-term savings of £75.4 million, and longterm savings of £517.6 million. • Phasing-out prescription levy The IPU would also like to see a phasing-out of the medical card prescription levy, especially for those patients who are vulnerable or cannot afford to pay the levy. This would help to prevent patients with more complex medical needs being forced into advanced care in an already overburdened health system. Mr Connolly concluded by stating, “Pharmacists are ready willing and waiting to enhance the levels of care they provide. The IPU has made several policy proposals to the Department of Health, which offered pharmacy-based solutions to primary healthcare deficits. We would like to see a greater role for pharmacists in supporting self-care in line with other countries such as the UK, Canada and New Zealand.”

CASE STUDIES CASE STUDY 1: TREATMENT OF MINOR AILMENTS

CASE STUDY 2: NEW MEDICINE SERVICE

Context / background: Many conditions treated in primary care are low complexity in nature and can most effectively be treated with non-prescription medicines.

Context / background: Currently, at-risk patients are given new medicines and counselled by their GP and pharmacist, but are not supported with a structured service through the crucial first weeks of their medicine, a time where uncertainty and confusion can cause many to take their medicines incorrectly.

Private patients access these medicines every day throughout Ireland supported by the knowledge and expertise of the pharmacist. GMS patients, however, are required to make an appointment and visit a GP to receive a prescription to access the same treatment. This represents an inequality of access to convenient, low complexity care and also exacerbates existing capacity strains in primary care by generating an estimated 947,806 unnecessary GP consultations per year. Proposed Service: The proposed service would allow identical access to medication for minor ailments as is currently enjoyed by private patients for forty different conditions such as headache, indigestion, constipation, diarrhoea and hay fever. The service is structured as follows: 1. A patient presents at a pharmacy with one of the low complexity conditions listed: Acne, Allergic Rhinitis, Athlete’s food, Atopic dermatitis, Chesty cough, Cold sore, Colic, Constipation, Cough, Cystitis, Dandruff, Diarrhoea, Dry cough, Dry eyes, Dry skin, Dysmenorrhoea, Dyspepsia, Ear wax, Ezcema, Haemorrhoids, Hay fever, Head lice, Headache, Insect bites, Migraine, Mouth ulcers, Nappy rash, Nasal congestion, Nausea/vomiting, Oral thrush, Pain, Ringworm, Scabies, Teething, Temperature, Threadworms, Travel Sickness, Vaginal thrush, Verucca, Warts 2. Following consultation with the pharmacist, the patient is either a) referred to a GP or to a higher complexity setting such as an Emergency Department or; b) is supplied with a non-prescription medicine by the pharmacist to treat the illness, and is advised on the appropriate regime to manage the condition. 3. The patient either pays privately for the medicines (as happens at present) or pays a ¤2.00 prescription levy if they are a public patient.

Pharmacists can be utilised for their knowledge and lead medicine adherence initiatives, leading to fewer adverse events and reduced requirement for complex and expensive treatment options. The New Medicine Service (NMS) was first introduced in England in 2011. The concept for the NMS is based on findings from research showing that problems with newly-prescribed medicines appeared rapidly and were widespread, and that a significant proportion of patients on a long-term medication quickly become non-adherent. A review of this service conducted in 2016 found that, from the scheme’s introduction in 2011 to the end of August 2016, community pharmacists carried out 3.6 million NMS consultations, resulting in a 10% improvement in adherence to medicine regimes. Proposed Service: When a patient is first prescribed a new medicine the patient is automatically referred to the ‘New Medicine Service’ by their GP or pharmacist. The New Medicine Service is a structured service with the following steps: 1. The patient has an initial consultation with the pharmacist, where the pharmacist outlines all the issues and common questions regarding the medicine. 2. The patient has a follow up consultation with the pharmacist 7-14 days later, either face to face or by telephone where the patient can discuss any issues they are having, potential side effects, and device technique among others. 3. At any point if the pharmacist observes adverse patient outcomes or persistent non-adherence, they may refer the patient back to the prescribing GP. This service is initially for conditions with a high rate of avoidable hospitalisation, such as asthma, COPD, Type 2 diabetes, hypertension, antiplatelet/anticoagulant therapy and statin therapy. The service can be further expanded to other conditions where non-adherence is an issue.

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News Helping pharmacists to make good decisions around workplace bullying When making a ruling on a 2017 workplace bullying case, known as Ruffley v Board of Management of St. Anne's School, the Supreme Court noted that "conduct is judged according to the standard of human beings, and not of angels." In other words, a certain amount of disagreement in the workplace is to be expected, and pharmacies are no exception.

Pharmacist coach Rachel Dungan

Rachel Dungan of 4Front Pharmacy Solutions, www.4front.ie, specialises in helping pharmacists and their teams to achieve their potential through professional training and coaching. Over 25 years, Dungan has identified some issues that are specific to pharmacy businesses in respect of workplace bullying. "Often in pharmacies, staff teams operate at different levels of expertise and influence, and this can lead to a 'misalignment of expectations.' For example, a young newly qualified pharmacist may feel undermined by the pharmacy owner and may feel that there are no supports available to them. Non-dispensing members of staff can often perceive that they are being undermined by other members of the team and a lot of these issues can be addressed with more effective communication. Training needs should also be considered, as staff are sometimes expected to pick things up by osmosis and when they don't perform to the expected standard, through lack of training, issues can arise."

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Due to the high level of professionalism that is expected among pharmacy workers, Dungan believes that sometimes behaviours are tolerated that normally wouldn't be and people are often afraid to name what they are experiencing, through fear. For example, a pharmacist may feel they have been spoken to in a disrespectful manner by a doctor or a consultant, or a locum may believe they have experienced "unbelievable undertones" of disrespect, often with no means of resolving their dissatisfaction. This causes people to be judgemental of subsequent behaviour and they may feel defensive when they come across that person again, leading to a cycle of poor interactions. Dungan says "the presenting issue is not always named as bullying." Serious Bullying is a serious allegation to make against another person so it is important to be clear on what bullying is, and what it is not, before any action is taken. A complaint should only be made when the complainant is satisfied that their situation meets the standard definition as set down by the Health and Safety Authority, whereby bullying is defined as "repeated inappropriate behaviour, direct or indirect, whether verbal, physical or otherwise, conducted by one or more persons against another or others, at the place of work and/or in the course of employment, which could reasonably be regarded as undermining the individual's right to dignity at work." Bullying does not include: expressing differences of opinion; offering constructive feedback, guidance, or advice about work related behaviour; reasonable action taken by an employer relating to a worker's performance, including

Often in pharmacies teams operate at different levels of expertise and this can lead to a misalignment of expectations disciplinary action and assigning work. Putting an employee on a performance improvement programme, once justified, does not constitute bullying. The list of what bullying does include is much longer, and on it appear things like spreading gossip; excluding, intimidating or undermining someone; removing responsibilities; constantly changing guidelines; impossible expectations; purposefully withholding or giving wrong information; making obviously offensive jokes; intruding on a person's privacy; assigning unreasonable duties; underwork; yelling; profanity; abusive or threatening behaviour; constant criticism; belittling opinions; undeserved punishment; blocking opportunities for training, leave or promotion; tampering with personal belongings or work equipment. In order to meet the definition, the behaviour must be repeated.

Advice Terry Gorry is a solicitor based in Meath and he has some simple, helpful advice on his website, www.employmentrightsireland. com, for employers who operate small businesses. The advice is straightforward: have a workplace policy in place and communicate it to all staff. There are three codes of practice, freely available on the internet, that all employers can print off and hand to employees: 1. The HSA's, 'Code of Practice for Employers and Employees on the Prevention and Resolution of Bullying at Work' 2. The Equality Authority's 'Code of Practice on Sexual Harassment and Harassment at Work' and 3. The 'Code of Practice Detailing Procedures for Addressing Bullying in the Workplace' (the Industrial Relations Act Code-statutory instrument 17/2012). These small action can help to ensure employees are clear on what is expected from them, and what is expected from the employer, in the event of a complaint. When things stray beyond disagreement into somebody feeling targeted, employers have a responsibility to act appropriately. Addressing the issues around what is often perceived to be bullying can in many instances help to bring resolutions. Particularly in a healthcare environment, when one member of staff does not feel safe, this leads to a drop in safety levels for patients, so when bullying does occur, employers should be ready to address it immediately, for everyone's sake.


For the treatment of rheumatoid arthritis in adults

Nordimet (metholtrexate) Solution for injection in Pre-Filled Pen Please refer to the Summary of Product Characteristics for full prescribing information. Further information is available on request Presentation: Nordimet: Pre-filled pen containing 7.5 mg (in 0.3 ml), 10 mg (in 0.4 ml), 12.5 mg (in 0.5 ml), 15 mg (in 0.6 ml), 17.5 mg (in 0.7 ml), 20 mg (in 0.8 ml), 22.5 mg (in 0.9 ml) and 25 mg (1.0 ml) methotrexate in solution for injection. Indications: Active rheumatoid arthritis in adult patients. Polyarthritic forms of severe, active juvenile idiopathic arthritis, when the response to nonsteroidal anti-inflammatory drugs (NSAIDs) has been inadequate. Severe recalcitrant disabling psoriasis, which is not adequately responsive to other forms of therapy such as phototherapy, PUVA, and retinoids, and severe psoriatic arthritis in adult patients. Dosage and administration: Nordimet should only be prescribed by physicians with experience in the various properties of the medicinal product and its mode of action. Nordimet is injected once weekly, administered subcutaneously. Rheumatoid arthritis: Recommended initial dose is 7.5 mg of methotrexate once weekly. Depending on the individual activity of the disease & patient tolerability, the initial dose may be increased. A weekly dose of 25 mg should in general not be exceeded. Once the desired therapeutic result has been achieved, the dose should be reduced gradually to the lowest possible effective maintenance dose. Polyarthritic forms of severe, active juvenile idiopathic arthritis: The recommended dose is 10-15 mg/m² BSA per week. In therapy-refractory cases the weekly dose may be increased up to 20mg/m² BSA per week. Use in children < 3 years of age is not recommended. Psoriasis vulgaris and psoriatic arthritis: A test dose of 5 - 10 mg subcutaneously administered one week prior to initiation of therapy is recommended. Recommended initial dose Date Of Preparation: April 2018 I/18/NOR002

7.5 mg methotrexate once weekly. Dose increased gradually but should not, in general, exceed a weekly dose of 25 mg of methotrexate. Once the desired therapeutic result has been achieved, dose should be reduced gradually to the lowest possible effective maintenance dose. The dose should be increased as necessary but should in general not exceed the maximum recommended weekly dose of 25 mg. Renal impairment, hepatic impairment or elderly patients: Please refer to SmPC. Note: When switching from oral to parenteral use, a reduction in the dose may be required, due to the variable bioavailability of methotrexate after oral administration. Contraindications: Hypersensitivity to methotrexate or to any of the excipients. Severe hepatic impairment, if serum bilirubin is > 5 mg/dl (85.5 µmol/l). Alcohol abuse. Severe renal impairment (creatinine clearance < 30 ml/min).Pre-existing blood dyscrasias (e.g. bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anaemia). Immunodeficiency. Serious, acute or chronic infections such as tuberculosis & HIV. Stomatitis. Ulcers of the oral cavity and known active gastrointestinal ulcer disease. Pregnancy. Breast-feeding. Concurrent vaccination with live vaccines. Special warnings and precautions: Patients must be clearly advised that the therapy is to be administered once a week, and not every day. Patients receiving therapy should be appropriately monitored. Doses exceeding 20 mg/week can be associated with significant increase in toxicity, especially bone marrow suppression. The possible risks of effects on reproduction should be discussed with male and female patients of childbearing potential. Interactions: Consult SPC for detailed information on interactions. Undesirable effects: See SmPCs for full list of undesirable effects. Nordimet: Very common: Stomatitis. Dyspepsia. Appetite loss. Abdominal pain. Nausea. Raised liver enzymes.

Common: Leukopenia. Anaemia. Thrombopenia. Headache. Tiredness. Drowsiness. Pneumonia. Interstitial alveolitis/pneumonitis. Oral ulcers. Diarrhoea. Exanthema. Erythema. Pruritus. Uncommon: Pharyngitis. Pancytopenia. Precipitation of diabetes mellitus. Depression. Enteritis. Pancreatitis. Gastrointestinal ulceration and bleeding. Cirrhosis, Fibrosis and fatty degeneration of liver. Inflammation and ulceration of bladder. Renal impairment. Rare: Infection. Conjunctivitis. Sepsis. Allergic reactions. Anaphylactic shock. Hypogammaglobulinaemia. Visual disturbances. Pericarditis. Pericardial effusion. Pericardial tamponade. Thromboembolic events. Pulmonary fibrosis. Pneumocystis carinii pneumonia. Shortness of breath and bronchial asthma. Pleural effusion. Acute hepatitis. Renal failure. Anuria. Very rare: Lymphoma. Agranulocytosis. Severe courses of bone marrow depression. Acute aseptic meningitis. Convulsions. Paralysis. Impaired vision. Retinopathy. Haematemesis. Toxic megacolon. Hepatic failure. Stevens-Johnson syndrome. Toxic epidermal necrolysis. Not known: Eosinophilia. Encephalopathy/Leukoencephalopathy. Legal classification: POM. MA numbers: Nordimet: EU/1/16/1124/001 – 008. Further information available from: Nordic Pharma Ltd, Unit 3, Commerce Park, Brunel Road, Theale, Reading, United Kingdom. Date of prescribing information: January 2017. Code for PI: NOR/17/001i


News Methylphenidate most effective ADHD treatment for children, study reveals The most effective short-term drug treatments for ADHD differ between adults and children, according to a new review. “Accounting for all included outcomes, our results support methylphenidate in children and adolescents, and amphetamines in adults, as the first pharmacological choice for ADHD,” the authors wrote. “In fact, in adults, amphetamines were not only the most efficacious compounds … but also as well tolerated as methylphenidate and the only compounds with better acceptability than placebo. “In children and adolescents, even though amphetamines were marginally superior to methylphenidate … methylphenidate was the only compound with better acceptability than placebo and, unlike amphetamines, was not worse than placebo in terms of tolerability.”

Dr Andrea Cipriani from Oxford University

The study, published in The Lancet Psychiatry, compared seven ADHD drugs (amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, modafinil) over 12 weeks of treatment. Researchers examined data from 133 randomised clinical trials to determine how effective the

drugs were at reducing ADHD symptoms, as well as their safety and side effects. In total, 14,346 children and 10,296 adults were included in the study. The authors concluded that the most effective treatment for children was methylphenidate, while for adults it was amphetamines.

With respect to ADHD core symptoms in children and adolescents, all drugs were superior to placebo, the researchers said. In adults, amphetamines, methylphenidate, bupropion, and atomoxetine were superior to placebo, but modafinil was not. The study did not include studies of antipsychotic drugs and antidepressants because, despite commonly being prescribed for patients with ADHD, they do not treat core ADHD symptoms. ADHD, which is characterised by age-inappropriate and impairing

levels of inattention, hyperactivity, or impulsivity, is estimated to affect about 5% of children and 2.5% of adults. The authors wrote that while prescriptions for ADHD drugs have increased significantly in recent decades, clinical guidelines vary, and the efficacy and safety of ADHD medications remains controversial. "Medication can be an important tool for people with ADHD, and our study illustrates that in the short term, these can be effective and safe treatment options for children, adolescents and adults," said Dr Andrea Cipriani, University of Oxford, UK "It's important to note that the data available only allow us to compare the effectiveness at 12 weeks, when we know that both children and adults can be on these medications for longer. More research is needed into the long-term effects of medication. Environmental modifications - such as changes made to minimise the impact of ADHD in day-to-day living - and non-pharmacological therapies should be considered first in ADHD treatment, but for people who require drug treatments, our study finds that methylphenidate should be the first drug offered for children and adolescents, and amphetamines should be the first drug offered for adults."

Study claims Omega-3 supplements offer little benefit A Cochrane review has ruled there is scarce evidence to support using over-the-counter omega-3 supplements to improve heart health. Increased consumption of omega-3 is widely promoted due to a common belief that it helps protect against heart disease and other medical conditions. But a new study, to date the most extensive review of the effects of omega 3 fats on cardiovascular health has found the dietary supplements offer little, if any, benefit to patients. The review, which drew on 79 randomised controlled trials around the world involving more than 112,000 people, found that increasing omega 3 polyunsaturated fatty acids

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had “little or no effect” on cardiovascular health. The trials included in the study ran for between 12 to 72 months and included adults at varying stages of cardiovascular risk, mainly in high income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA rich or enriched foods or dietary advice, compared to placebo or usual diet. The Cochrane researchers found that increasing long-chain omega-3 fats had “little or no effect on all cause deaths and cardiovascular events, and probably makes little

or no difference to cardiovascular death, coronary deaths or events, stroke, or heart irregularities.”

supplements does not benefit heart health or reduce our risk of stroke or death from any cause.”

Lead author Dr Lee Hooper, from the University of East Anglia, said the findings go against the popular belief that long-chain omega-3 supplements protect the heart.

Dr Hooper said there was “moderate evidence” that increased alpha-linolenic acid, which is found in plant oils and nuts, could slightly reduce the risk of cardiovascular events.

“This large systematic review included information from many thousands of people over long periods. Despite all this information, we don’t see protective effects,” he said. “The review provides good evidence that taking long-chain omega-3 (fish oil, EPA or DHA)

“However, the effect is very small,” he said, “143 people would need to increase their ALA intake to prevent one person developing arrhythmia.” Essential omega-3 fats are found in some plant foods and oily fish, such as salmon.


News New guideline launched to improve the quality and safety of treating Type 1 Diabetes The first ever National Clinical Guideline for Adults living with type 1 Diabetes has been launched in Ireland. The publication of the guideline will see an agreed framework that will ensure all adults with type 1 diabetes regardless of where they live in Ireland, have equitable access to high quality care. The guideline will also act as a driver to standardise type 1 diabetes care nationally. There are approximately 20,000 adults living with type 1 diabetes in Ireland. Long term good health depends, perhaps more than with any other long-term condition, on full engagement of the person with type 1 diabetes in life-long dayto-day self-management. The National Clinical Effectiveness Committee Guideline is the first to be developed in Ireland using the UK’s National Institute for Health and Care Excellence (NICE) contextualisation process; whereby a recent NICE guideline is adapted for use in another country. The recommendations are based on the best research evidence and on national and international clinical expertise.

Dr Anna Clarke, Health Promotion and Research Manager, Diabetes Ireland

This initiative was led by a group from the Health Service Executive’s (HSE) National Clinical Programme on Diabetes, supported by the Department’s Clinical Effectiveness Unit and a team from NICE. The guideline was quality assured by The first ever National Clinical

Guideline for Adults living with Type 1 Diabetes has been launched in Ireland. the National Clinical Effectiveness Committee (NCEC). Type 1 diabetes is an autoimmune condition that causes destruction of the insulin producing cells in the pancreas. This means that people with type 1 diabetes must selfinject insulin in order to manage their blood glucose and avoid a range of serious short and longterm complications. Dr Kevin Moore, Chair of the Guideline Development Group said, “Type 1 diabetes care requires a multidisciplinary approach to care that empowers patients to successfully manage this life-long condition. Current evidence shows variation in how care is delivered across Ireland and so this NCEC National Clinical Guideline will standardise the approach with a special focus on patient education and clinical review. Overtime, this will mean better outcomes for patients with type 1 diabetes.” Current evidence shows the care of people with diabetes varies across Ireland. Care may be limited, unstructured and ad-hoc in some locations with limited access to specialist expert diabetes opinion.

Current services are not supportive of the person with type 1 diabetes. In order to support the type 1 diabetes community, the health service needs to provide informed, expert support, education and training as well as a range of other services and interventions for the prevention and management of long term health problems. Dr Anna Clarke, Health Promotion and Research Manager, Diabetes Ireland, said: “There is an immediate need for additional Advanced Nurse Practitioner’s in type 1 diabetes who could avert hospital admissions and distress for people with diabetes by being available to resolve simple queries such as: • Determining a plan of action for having taken too much or too little insulin • Dealing with too high or too low glucose levels • How to cope with common ever day illness that affects diabetes • Helping the individual to determine what is an emergency “This is not an expensive option but a simple cost effective support mechanism that would bring cost savings almost immediately for the HSE through reduced hospital admissions.”

Sex and BMI to inform type 2 diabetes treatment A patient’s gender and body mass could be used to guide second-line treatment for type 2 diabetes, a study has found, potentially streamlining treatment for hundreds of thousands of people in Ireland with the disorder. New research from the University of Exeter in the UK shows these basic patient characteristics can affect the risks and benefits of mellitus therapy with commonly prescribed drugs sulfonylureas and thiazolidinediones. Researchers examined anonymous data from more than 22,000 patients starting sulfonylurea or thiazolidinedione therapy to identify features associated with increased one-year HbA1c fall with one therapy class and reduced with the second. They then used individual randomised trial data to assess whether the pre-specified patient subgroups showed different five-year glycemic responses and side effects.

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The study found that a patient’s sex and BMI could impact the glycaemic response and side effects of mellitus therapy, providing evidence that personalised approaches in diabetes could be based on individual characteristics available to doctors. The researchers wrote that, in the first cohort of patients, males and those with lower BMI were associated with greater glycemic response with sulfonylureas and a lesser response with thiazolidinediones. In the trial group, non-obese males had a greater overall HbA1c reduction with sulfonylureas

than with thiazolidinediones. In contrast, obese females had a greater HbA1c reduction with thiazolidinediones than with sulfonylureas. The authors concluded that patient subgroups defined by sex and BMI have different benefits and risks on thiazolidinedione and sulfonylurea therapy, and can therefore inform discussion about the choice of therapy after metformin, the first-line drug treatment for type 2 diabetes. The findings are important because they show that doctors have available to them basic information that could help personalise medication for patients with type

2 diabetes, achieving better health outcomes and avoiding harmful side effects. “Our findings will allow for much more informed discussions of the benefits and risks of these therapies than the present ‘one size fits all’ approach,” they said. The study, Sex And BMI Alter The Benefits And Risks Of Sulfonylureas And Thiazolidinediones In Type 2 Diabetes: A Framework For Evaluating Stratification Using Routine Clinical And Individual Trial Data, was published in Diabetes Care.


Brexit Pharmacists and students braced for impact of a no-deal Brexit Taoiseach Leo Varadkar has warned that the government has “a concern around medicines”, saying that the State will stockpile supplies, including blood, over the coming months. This is in response to increasing concerns that Britain and the EU will not reach a deal on Britain’s exit from the EU. believes that Irish pharmacists could suddenly find themselves in a situation whereby medicines they have been reaching for years are suddenly not authorised for use on the Irish market. Horan is concerned that medicine shortages will worsen in the event of a no-deal Brexit. “There are products that go short every month. I have three patients who are on chemotherapy at the moment so every month I have to ring up and ask if I can increase my allocation [of certain drugs]. Products are already tightly controlled and can be difficult to get. In the event of a hard Brexit we could find ourselves in a very scary place and the HPRA will have a lot of important decisions to make.” Uncertainty

Pharmacy owner Ann-Marie Horan

Medicines currently pass relatively freely across European borders thanks to the mutual recognition agreement, a system whereby member states accept medical products, through an abridged process, that have been authorised in another EU state. Currently six out of every ten medicines used here either originates, is packaged, or passes through the UK before reaching Ireland. Despite the fact that Ireland will remain in the EU after Britain exits the bloc, if no deal is reached, there are fears medicine supplies could dwindle rapidly.

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Concerned Irish pharmacists are growing increasingly concerned about the supply of drugs in the context of Brexit, given that medicine shortages are already a challenge, with some important drugs being supplied on an allocation basis as it is. Ann-Marie Horan, pharmacist and pharmacy owner, met with Irish Pharmacy News at her premises, the Fortfield Pharmacy, in Dublin’s Terenure. Unless a comprehensive agreement is reached, Horan

Horan uses the very bad snow we experienced earlier this year to demonstrate how quickly the effects of a no-deal Brexit will be felt by Irish pharmacists and their patients. “It will happen very quickly - we get two deliveries of drugs every day here. Wholesalers only keep a few days of drugs in stock. During the snow, we waited weeks for some medicines to get back to good supply levels. They were held up at ports but it was manageable because small amounts were getting through. To help us manage the stock ourselves we dispensed a weekly instead of a monthly supply in some cases. If a hard Brexit were to happen, you would notice [shortages] very quickly.” Horan believes that the uncertainty around what is going to happen is not helping matters. “It’s a hard situation because we don’t actually know yet if we are dealing with a hard Brexit and that makes it even more difficult to plan. If there was a hard

Brexit, companies would have to re-test their products in an EU or Customs Union country. In reality that means they would have to comply with two different sets of regulations. “If these regulations could be aligned and an agreement was reached that these products that we have been using for years don’t have to be retested then that would solve everything, but the problem is the uncertainty. Moving your testing operations abroad is an expensive process and for companies who just don’t know yet what will happen in terms of Brexit, they aren’t likely to start spending that kind of money. A lot of drugs are going to be affected.” Students and research Irish Pharmacy News reached out to the School of Chemical Sciences in Dublin City University for their view on how Brexit will impact research and student output. Dr. John F. Gallagher is the Chair of the Chemical & Pharmaceutical Sciences degree and lectures in Inorganic Chemistry. Gallagher shares that the academy is already seeing evidence of the effects of Brexit, as there has been a noted increase in the numbers of visiting research students from non-EU origin, such as Brazil, Malaysia, Korea and Japan, among other nations, as students seek to conduct research in an English language working environment. Gallagher also predicts that there will be increased research opportunities with partners in France, Germany, Spain and Italy as UK participation rates decline significantly. “The education and training of University students and especially postgraduate students at the Masters and PhD level can and will adjust to the impact of Brexit. However, given the on-going decrease in funding for


third level research and training, it is important to realise that the ability to respond quickly to changes due to Brexit may be somewhat compromised unless we start reviewing the (bio)pharmaceutical sector in its entirety from undergraduate degree programmes, through postgraduate research and training through to employment.” Gallagher tells IPN that the UK is a major centre for (bio) pharmaceutical research and development and “ranks with Germany and France in terms of major contributions to the EU research and development budget.” These three nations provide approximately 60% of annual research funding and the UK currently benefits from this arrangement as skilled researchers pass unimpeded through its borders. They also benefit from funding pools that can be put towards both academic and industrial research. Gallagher says that a consequence of a drop in research funding will be that the

remaining countries (including Ireland) “may be asked to stump up more research money with resulting political ramifications”. Universities are also concerned about “the possibility of slower access to and delays obtaining laboratory (bio)chemicals should the logistics and supply chains get disrupted in the aftermath of a no-deal Brexit. This would have an impact on (bio) chemicals, radionuclides with a short half life (t�) as well as cost implications in respect of VAT and customs duty. Substantial delays will mean price increases and hamper research relying on sensitive (bio)chemicals. In terms of equipment purchases and servicing, the cost of maintenance and repairs will increase as many global manufacturers have European sites located in the UK. We can expect a substantial increase of costs in this regard.” No guarantee Back in Terenure, Ann-Marie Horan expresses concern for

students who are currently studying in the UK. “Traditionally a lot of Irish pharmacy students would have studied in England and the ones who are there at the moment are in limbo. What will their position be when they come back here? At the moment both countries acknowledge each other’s accreditation. In the event of a hard Brexit there is a big question mark over whether or not that situation will remain in place. There are many people now studying in the UK who went there with the intention of coming back to Ireland with their qualification to work, but there is no guarantee at the moment that this situation will continue. I would imagine that this is causing students and their families a lot of stress at the moment.” Horan wants the political powers to have consideration “for the health of all of the populations” and doesn’t believe that the headlines around stockpiling are going to solve anything. Medicines are not kept in huge

quantities by wholesalers and if Britain crashes out without reaching a deal, the mutual recognition arrangement will very suddenly cease to operate, meaning medicines that have been safely used here for years will suddenly not be authorised for use in the Irish market. “There are so many niche drugs that people are on and there isn’t a huge volume of them to hand, but to that one individual who does depend on it, it’s very important, so I just don’t see that these types of drugs will be stockpiled. In every pharmacy in the country there is one person on an unusual drug that is very important to the life of that person. We just want a smooth transition but the Brexiteers don’t seem to care about the economic or the social consequences. They aren’t really listening to arguments like that.”

News Totalhealth Pharmacy Group official sponsors of Connacht Rugby Summer Camps Totalhealth recently partnered with Connacht Rugby and the pharmacy group sponsored a series of summer camps held across Connacht during the summer months. A total of 18 camps, for boys and girls between the ages of 6-12, were held at clubs across the province from July to mid-August. No prior rugby experience was necessary to take part. Facilitated by fully accredited IRFU coaches, the Summer Camps gave the young people involved a chance to enjoy the sport of rugby in a fun, safe environment among children their own age. also owns McGuinness totalhealth Pharmacy in Roscommon town. Launching the initiative in the Galway Sportsground, home of Connacht Rugby, McGuinness said that the totalhealth Pharmacy Group was “delighted to have partnered with Connacht Rugby as the official sponsor of [their] Rugby Summer Camps happening in 18 locations throughout the province this summer.”

Totalhealth is a group of 74 independent pharmacies coming together under one symbol brand. Their aim is to help deliver "all the benefits of being part of a

large retail brand" to customers, while still being committed to the needs of the local community. Ollie McGuinness is a director of the totalhealth Pharmacy Group and

McGuinness continued, “Like Connacht Rugby, totalhealth Pharmacy is all about supporting communities. Totalhealth Pharmacy has 30 member pharmacies in the Connacht area so the opportunity to partner with Connacht Rugby on this project is a win-win for us.” Joe Gorham is the Domestic Rugby Manager at Connacht Rugby. At the launch Gorham

had the following to say. “We are delighted to officially launch this year’s Connacht Rugby Summer Camps in conjunction with totalhealth Pharmacy. The Summer Camps are a key cornerstone of what we here at Connacht Rugby are all about. Through our ‘Grassroots to Green Shirts’ vision, we want to get a rugby ball in the hands of every boy and girl in the province and have them experience the benefits of our great sport.” Gorham welcomed the children taking part in the camps, saying every child “[would] have a fantastic time.” He continued: "We are thrilled to have totalhealth Pharmacy on board as our new official partner and we look forward to our partnership growing into the future.”

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News Research says vegetables can reduce the risk of bowel cancer Scientists say they have discovered why some vegetables - including cabbage, broccoli and kale - can reduce the risk of bowel cancers. intestines, by studying mice and miniature bowels growing in the lab. Like the skin, the surface of the bowels is constantly being regenerated in a process that takes four to five days. But this constant renewal needs to be tightly controlled, otherwise it could lead to cancer or gut inflammation.

Professor Gitta Stockinger

That cruciferous veg is good for the gut has never been in doubt but a detailed explanation has been elusive. The team at the Francis Crick Institute found anti-cancer chemicals were produced as the vegetables were digested. The work focused on how vegetables alter the lining of the

And the work, published in the journal Immunity, showed chemicals in cruciferous vegetables were vital. The researchers investigated a chemical called indole-3-carbinol, which is produced by chewing such vegetables. “Make sure they're not overcooked, no soggy broccoli," said researcher Dr Gitta Stockinger. The chemical is modified by stomach acid as it continues its journey through the digestive system.

In the lower bowel, it can change the behaviour of stem cells, which regenerate the bowel lining, and of immune cells that control inflammation. The study showed diets high in indole-3-carbinol protected the mice from cancer, even those whose genes put them at very high risk of the disease. Without the protective diet, the gut cells divided uncontrollably. Dr Stockinger added: "Even when the mice started developing tumours and we switched them to the appropriate diet, it halted tumour progression.” Signs of bowel cancer include persistent:  blood in the stools  changes in bowel habits, such as going to the toilet more often  tummy pain, bloating or discomfort Dr Stockinger said the findings were a "cause for optimism".

She has reduced the amount of meat she eats and now consumes a lot more vegetables. She said: “A lot of dietary advice we're getting changes periodically, it is very confusing and not clear cut what the causes and consequences are. “Just telling me it's good for me without a reason will not make me eat it. “With this study, we have the molecular mechanisms about how this system works.” Prof Tim Key said: “This study in mice suggests that it's not just the fibre contained in vegetables like broccoli and cabbage that help reduce the risk of bowel cancer, but also molecules found in these vegetables too. “Further studies will help find out whether the molecules in these vegetables have the same effect in people, but in the meantime there are already plenty of good reasons to eat more vegetables.”

GSK launches the first once-daily single inhaler triple therapy for COPD in Ireland GlaxoSmithKline and Innoviva, Inc. have announced the launch of Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol ‘FF/ UMEC/VI’), the first once-daily single inhaler triple therapy for chronic obstructive pulmonary disease (COPD), in Ireland. Trelegy Ellipta is indicated as a maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a longacting β2-agonist. Trelegy Ellipta is a combination of three components: fluticasone furoate, an inhaled corticosteroid (ICS), umeclidinium, a long-acting muscarinic antagonist (LAMA) and vilanterol, a long-acting beta2-adrenergic agonist (LABA), delivered once-daily via GSK’s Ellipta dry powder inhaler. The approved dose is FF/UMEC/VI 92/55/22 mcg daily. Eimear Caslin, General Manager, GSK (Ireland) Ltd said: “GSK is very pleased to make Trelegy Ellipta available to doctors and

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appropriate COPD patients in Ireland. We know physicians require a range of treatments to meet individual patient needs and we believe Trelegy Ellipta is an important option for appropriate patients who may require triple therapy. This launch adds to our portfolio of once-daily respiratory medicines and reflects our relentless drive in COPD to ensure the right treatment for the right patient.” Dr Robert Rutherford, Consultant in Respiratory Medicine, University Hospital Galway, said: “COPD is one of the most common respiratory conditions in Ireland. The biggest threats to disease progression are continuing to smoke and getting repeated exacerbations where patients’

symptoms suddenly worsen often as a result of infection. Inhaled long-acting beta-2-agonists, anti-muscarinic agents and inhaled corticosteroids all have been proven to reduce the risk of exacerbations. These three drugs have now been combined into one inhaler in the Trelegy Ellipta device and this is an important addition to the medications used to treat the more severe COPD patient.”

‘FF/UMEC/VI’ 92/55/22mcg) achieved superiority to members of two different classes of dual combination therapy, Relvar (FF/ VI) and Anoro (UMEC/VI), on the primary endpoint of reduction in the annual rate of on-treatment moderate/severe exacerbations (p<0.001) and a range of other clinically important outcomes, including lung function and health-related quality of life.

Trelegy Ellipta is supported by data from the FF/UMEC/ VI development programme, as well as data from studies with FF, UMEC and VI either alone or in combination. In the landmark IMPACT study, published in the New England Journal of Medicine in April, Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol,

COPD is a common but serious lung disease that limits airflow to the lungs, interfering with normal breathing. It is thought to affect 384 million people worldwide. For people living with COPD, the inability to breathe normally can consume their daily life and make simple activities, like walking upstairs, an everyday struggle.


News Pharmacists concerned they lack knowledge to offer advice on scars and stretch marks New research conducted on behalf of Bio-Oil amongst pharmacists has highlighted a gap in knowledge, as 1 in 5 (17%) admit that they lack the knowledge and expertise to offer advice on scars and stretch marks. Despite the fact that nearly all of those surveyed (88%) are regularly asked about reducing the appearance of scars or stretch marks, more than half (58%) said they do not actively approach patients to offer advice without being approached first. As well as lacking the knowledge to offer advice, half (51.7%) said they worry they are being intrusive and one in 10 (10.3%) said they don't know how to approach people when it comes to discussing scars and stretch marks. Yet it is clear from the research that pharmacists are well-aware that educating people about real skin forms part of their role, with almost nine out of 10 (85%) admitting that healthcare professionals have a part to play in preventing body confidence issues. But concerns

have been raised about whether patients are left unprepared for scarring and stretch marks, with eight out of 10 (83%) agreeing that the quest for perfect skin leaves patients unprepared and therefore likely to find it much harder to accept skin imperfections as a result. The eruption of social and mass media over the last few years could be to blame for painting an unrealistic picture of body image, according to the new research. Nine out of 10 pharmacists surveyed believe that their patients have an unrealistic expectation of how their skin should look and it appears that our modern day emphasis on appearance and perfection could be to blame. Half of those surveyed (50.5%) blame the current trend for filtering photos shared on social

media as one of the main reasons that patients have unrealistic expectations of their skin. Almost half (48.4%) also agreed that patients are too used to seeing flawless skin represented in the media and two fifths (39.6%) believe that the increased emphasis on appearance in modern day culture is having a detrimental effect on skin expectations. But in addition to modern day culture, almost half (48.4%) believe that a general lack of awareness of skin imperfections and conditions is also to blame and that this impact can manifest itself in a number of ways, from causing emotional distress, to leading them to conceal their skin condition using clothing or make-up or even refusing to leave the house. Industry-leading pharmacist

Deborah Evans said: "We are increasingly seeing more and more patients coming into pharmacy as the first port-of-call for advice on skin conditions including scars and stretch marks and it is therefore crucial that we are prepared and confident to offer advice in this area. It is a concern that the research indicates that some pharmacists feel they lack the knowledge and confidence to approach patients and offer advice. However, opening up a conversation about skin health can take place at the end of a consultation or by asking people what concerns they may have about their skin, so it doesn't need to be daunting. With our current culture negatively impacting patient's views of what real skin looks like, our role in educating and supporting people about scars and stretch marks is becoming more important than ever."

Haven Pharmacy promotes arts and crafts Haven Pharmacy want to encourage children to be more creative and get involved in arts and crafts this autumn with the launch of their Healthy Minds Colouring Competition to be judged by a panel including legendary artist and TV personality Don Conroy. great way to encourage children to stretch their creativity in arts and crafts during Back to School time. The competition will have two separate age categories for kids aged 4–7 years old and 8–12 years old. Entrants are invited to showcase their skills and colour in an illustration drawn by judge Don Conroy, to be in with the chance to win some great prizes including a family holiday for two adults and two children worth ¤1,500 in a luxury suite in Delphi Adventure Resort in Connemara, Co. Galway. To enter the Healthy Minds Colouring Competition, just pop into your local Haven Pharmacy and pick up your entry form.

Don Conroy encourages children to get involved in arts and crafts Research commissioned by Haven Pharmacy has revealed that nearly one in three children spend a minimum of two hours daily in front of a screen whilst only 20% of children engage in arts and crafts every day. Haven’s research found an overwhelming 75% of parents

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to be worried about the potential negative effect technology may be having on their children’s mental and physical health. 80% of parents would like to see their children involved in more arts and crafts. Haven Pharmacy’s Healthy Minds Colouring Competition is a

Speaking at the launch of the competition Denise Carroll, Marketing & Communications Executive for Haven said “We know that parents are concerned about how technology effects their children’s physical and mental health and with children going back to school there is now an added pressure with school work, so it’s an ideal time to introduce this campaign. The Healthy Minds Colouring Competition has been devised to encourage young

children to spend less time in front of screens and to reignite their creativity in an era where technology is consuming so much of young people’s attention. Colouring has many different benefits including helping children to focus, relax and stimulate their imagination.” Having encouraged many children to express their creativity over the years Don Conroy is back judging the competition again this year. Speaking at the launch of the campaign Don said “I am delighted to be working with Haven again on this wonderful initiative. Although technology is brilliant for children it is as important as ever for kids to stretch their creativity through art. Colouring is a great starting point to spark an interest in the creative arts with children and a fun way for children to take a break from technology. We want to encourage parents and children alike, to take quality time together enjoy the simple pleasure of art and crafts.” For more information, visit www.havenpharmacy.ie or find your local Haven Pharmacy on Facebook.


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Feature

How pharmacists can help stop the spread of head lice A recent survey from Clonmel Healthcare’s brand Hedrin, revealed that 78% of families experience at least one outbreak of head lice in one year, but one in three parents have kept their child’s head lice a secret.

Although head lice in children is typical, and highly contagious in young children playing in close proximity, there still exists a stigma that parents aren’t doing everything they should to prevent it, and a myth that head lice occurs with bad personal hygiene.

lice early, and prevent their spreading,” said Amy Phillips, Product Manager at Clonmel Healthcare. “Once observed, head lice is an easy problem to solve, with due diligence, speed of treatment, and a range of products on shelf to suit every preference and lifestyle.”

with lice often spreading during playtime, sporting activities and sleepovers. Studies suggest that infections occur most often in primary school-aged children, with the peak age for infection around 7 to 8 years of age.

The reality is that head lice is common in all children, and with due diligence, parents can prevent head lice and they can ensure elimination of lice and their eggs before they multiply and spread.

How is it spread?

An itchy scalp is often one of the main symptoms of head lice (the itching is not caused by the lice biting the scalp, but by an allergic reaction to the lice). However, some people are not allergic to head lice, and therefore may not notice that they are infected. In some cases, a rash may appear on the back of an infected person’s neck, which is caused by a reaction to louse droppings.

In keeping such secrets, parents are inadvertently spreading the problem of head lice; with schools being the most common place for their spread, when children are in personal contact with others. “If parents take a peek once a week, they can catch head

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The female louse lay eggs which glue to the hair shafts. When the baby lice hatch, about 7 to 10 days later, the empty eggshells (nits) remain glued in place. Head lice become fully grown within about 10 days, and feed by sucking blood through the scalp. Once mature, a head louse can transfer from one head to another. Head lice is usually spread by direct contact, but can also be passed indirectly by sharing a hairbrush or comb. The condition tends to be more common in children,

Symptoms of head lice

How is head lice confirmed? The wet combing technique is often used to diagnose a current head lice infection. A diagnosis

of head lice is only confirmed if a living, moving louse is identified. The presence of nits (egg cases) is not an indication of a current infection or a need for treatment. When a head lice infection is confirmed in children, parents should identify close contacts of the child (anyone living in the home) and inform them to inspect hair, and treat immediately if a living, moving louse is discovered. Tips for treating head lice with wet the combing method • wash the hair with regular shampoo • apply lots of conditioner, this makes the lice wet and keeps them still • slot the teeth of the comb into the hair at the roots and draw it down to the ends of the hair • check the comb each time


Feature and remove lice by wiping or rinsing the comb • continue this process through each section of hair until the whole head is combed through • rinse off the conditioner and repeat combing while the hair is still wet • if moving lice are found check all family members for infection, alert close friends, and inform the child’s school. Treating head lice with OTC products Head lice can be difficult to

treat due to high re-infestation rates and their ability to develop resistance to the insecticides contained in some medications. The HSE says treatment should only ever be used when there is an infection, and never used as a preventive measure. There are various over-the-counter lotions and sprays available to treat head lice. Dimethicone, Cyclomethicone, and mineral oil producers are first-line treatments. The course of treatment usually consists of two applications of recommended preparations, applied seven days apart (a minimum of two applications of lotion are needed

to kill the lice over the hatching period because the lotions do not always kill louse eggs). Depending on the product, the length of time it needs to be left on the head can vary from 10 minutes to 8 hours. Hair should be checked two days after the final treatment, and a second course of treatment should not be started without evidence of a current infection. Children may continue to scratch following treatment, however, this does not mean they still have an infection as the treatments can also make the scalp flaky and itch.

What advice can community pharmacists offer? Community pharmacists are an important source of advice for the control of head lice infections. They can teach patients the technique of detection combing and advise about appropriate over-thecounter treatment options. Parents should also be advised to minimise the risk of infestation by doing a visual head check on their children once a week, and stressing the importance of not sharing hats, clothes, combs and pillows.

News Boots Ireland and Motech launch new service to support older people to live independently Boots Ireland has launched a new Home Assist range, designed to support Ireland’s elderly to maintain independent living. prone to medical conditions that effect movement such as arthritis or Parkinson’s disease; increased use of medications which can cause a sudden drop in blood pressure leading to a feeling of faintness or weakness; and an increased risk of trips and slips. Additionally, older people have a higher risk of serious injuries, disability, psychological consequences and death following a fall.

Dr Ciara Kelly, GP and broadcaster; Paul Flavin of Irish company Motech; Susan O’Dwyer, Pharmacist at Boots Ireland and James Doyle, Managing Director of Tunstall Emergency Response at the launch of the Boots Home Assist range With one in three people over 65 experiencing a fall each year, the Home Assist range provides round the clock monitoring that detects falls inside and outside the home, helping to promote both independent living and mobility. Home Assist is powered by Tunstall and utilises the Tunstall range of personal monitors which includes the Motech CareClip™, and is available in selected Boots pharmacies nationwide. Home Assist monitors users activity,

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alerts for falls, disorientation or a panic situation, regardless of where the user is, giving them the confidence to remain at home and stay active within their communities. Ireland has an aging population with over 637,567 people over the age of 65, with this figure expected to rise to over one million by 2031. The risk of falling increases with age for a number of reasons including muscle weakness, poor balance, gait or vision; being more

Catherine Cox, Head of Communications and Carer Engagement, Family Carers Ireland has welcomed the new Home Assist service. “Many older people want to remain in their homes and stay active within their community for as long as possible, but if someone has experienced a fall it can be difficult to overcome the fear of further falls. There also may be a feeling of social isolation resulting from lack of confidence to leave the house and go about their daily routine. Services such as Home Assist are vital to provide reassurances to both the older person, who know support is on hand, but also so families know that their loved ones are taken care of at all times.”

Dr Ciara Kelly, GP and broadcaster said, “One of the biggest things that contribute to falls in older people is our muscles growing weaker and our balance becoming poorer as we age. The best way to combat this and decrease your risk of falls and improve your quality of life is by exercising regularly, at your own pace. The great thing about Motech’s Careclip™, is that it is mobile and can be used outside the home, giving people that extra bit of security to go for their daily walk and remain physically and socially active outside the home to improve their overall health”. Susan O’Dwyer, Pharmacist at Boots Ireland said, “Care for patients is at the heart of everything we do at Boots Ireland. By joining up with telecare specialists Motech and Tunstall we are delighted to be able to bring the Home Assist proposition to communities around Ireland. It is our hope that the Home Assist solutions will facilitate more people than ever before to remain living in their own home whilst having the peace of mind of knowing that help is available 24/7 at the touch of a button.”


News O.R.S. Ireland celebrates partnership with the LGFA for a second year Official Hydration Partners O.R.S. Ireland and the Ladies Gaelic Football Association (LGFA) were delighted to celebrate their second year working together in partnership at the GAA National Games Development Centre in Abbotstown on Tuesday, 21st August. To coincide with the event O.R.S. and the LGFA also marked the launch of the new O.R.S. Sport - Performance Formula Hydration Tablets, by inviting the provincial Brand Ambassadors to attend the fun. O.R.S Sport is based on the W.H.O Hydration Electrolyte Formula but with extra sodium to make up for the higher sweat rate and salt loss experienced by athletes during intense exercise. O.R.S Sport also contains an additional Magnesium Electrolyte that contributes to normal muscle function, alleviates sore muscles and reduces tiredness and fatigue. The O.R.S Sport formula also contains Vitamin D and contributes to the maintenance of normal muscle function - both muscle contraction and repair. This is particularly of benefit to those who often train inside or during the winter months. O.R.S. is the exclusive global sports drink supplier to the LGFA, and provides this

innovative product to all of the organisations adult county teams and medical staff. O.R.S. play an active role in educating and supporting all of the teams under the LGFA umbrella and have always been known for their pro-active approach in helping affiliates in their hydration strategies, an area of elite sport which is becoming increasingly important. Ladies Gaelic Football Association CEO Helen O’Rourke commented: “In 2017, we were delighted to welcome O.R.S. to join our list of official partners. We have enjoyed an excellent relationship since then and the number of players using O.R.S. Hydration products continues to rise. During the hot weather that we experienced during the summer, keeping players hydrated was uppermost in the minds of inter-county managers, O.R.S. Hydration products were invaluable in that regard. This is an exciting time for

The provincial Brand Ambassadors are from L to R: Aisling McCarthy, Tipperary, Caroline O'Hanlon, Armagh, Aisling Curley, Kildare Grace Kelly, Mayo Photo Credit: David Fitzgerald, Sportsfile

Ladies Football and we continue to seek partners who match our ethos and values. In that regard, O.R.S. tick every box, and we look forward to working with them again in 2019.” Olivia Reilly, Marketing & Communications Manager for O.R.S. Ireland (Pharmed) said: “O.R.S. is delighted to continue its partnership with the LGFA into its second year. This partnership allows us to work closely together and align our objectives in aiding player performance and welfare.

The LGFA has experienced a huge surge in popularity and growth over the past few years, deservedly so and we are proud to say that we are involved in its continued development. These are exciting times for ladies Gaelic football and we are looking forward to the year ahead.” O.R.S. Sport - Orange Flavour 20 tablet tube, RRP ¤6.36 is available at leading pharmacies nationwide. For more information and to buy online visit www.orshydration.ie.

United Drug Wholesale Limited acquires Pharmax United Drug Wholesale Limited ("UDW"), the leading pharmaceutical full line wholesaler in Ireland and part of the McKesson Corporation, is pleased to announce the acquisition of a controlling interest in PMLX Limited (“Pharmax”), a compliance based buying group within the retail pharmacy sector. Pharmasave Holdings Limited (“TotalHealth”) will retain a minority shareholding in Pharmax. The transaction completed on the 8th August 2018. Pharmax: Pharmax is a buying group that puts the interest of independent pharmacy owners at its core. It is a pharmacist led and pharmacist devised procurement platform offering company brokered products to independent pharmacies in an efficient manner through partnerships with key manufacturers, suppliers and

supply chain experts. The company is working on a number of other initiatives and services that will benefit independent pharmacy owners. Commenting on the announcement, Paul Reilly, Managing Director, said: “We are very excited to announce

the acquisition of a controlling interest in Pharmax, the business is a good strategic and cultural fit, and increases the services that we can provide to our independent pharmacy customers and our supplier base. We look forward to sharing full details of our integration programme in the months ahead.”

Commenting on the announcement, Paddy Meehan MPSI, Founder, Pharmax, said: “We see United Drug as an excellent partner and with their scale and experience we can take our current offering to a much higher level to the benefit of the pharmacy community.”

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News Condoms recalled due to risk of breaking Pharmacists are being advised to withdraw several batches of condoms from shelves after Durex issued an urgent recall amid concerns they could burst during use. The Durex Real Feel and Durex Latex Free condoms are being recalled in Ireland and the UK after it was discovered they failed durability tests. The Health Products Regulatory Authority made the announcement after being alerted by Reckitt Benckiser, the makers of Durex condoms, that some batches could fail towards the end of their shelf life. The regulatory authority advises pharmacies and retail outlets to check the bottom of the outer pack of the condoms and discontinue sale of any affected products. Durex said it had found that some condoms made earlier this year were “not passing our stringent shelf life durability tests.” The company said: "The safety of our consumers always comes first, and this is reflected in our rigorous quality standards. “Our tests have shown that some batches which are currently on the market in UK and Ireland do not pass the requirements for burst pressure towards the end of the shelf life for the product,” the statement said. “There could be an increase in the

number of condoms that burst during application or use for the batches of condoms affected by this issue.”

said there were no immediate safety concerns.

1000474804, 1000434066, 1000430479, 1000430479.

“All affected product should be immediately removed from store shelves. Pharmacies should return all stock to their wholesaler. RB will contact wholesalers to organise collection of all stock.”

The expiry dates of the affected batches are between December 2020 and February 2021. They include Durex Latex Free 12 Pack, Durex Real Feel 6 Pack, Durex Real Feel 12 Pack, Durex Real Feel 18 Pack, and Durex Real Feel 18 Pack (RF Tag).

It has advised customers to seek advice from a doctor or pharmacist as soon as possible and no later than 72 hours if a condom splits, but the company

The affected batch numbers sold in Ireland are: 1000444367, 1000433145, 1000419930, 1000444367, 1000416206, 1000438054, 1000444370,

Ireland’s Health Products Regulatory Authority first issued the recall after being alerted by RB. The HPRA said consumers should check if their products have the same batch number as those outlined in the recall notice, and advised any customers with concerns to report them to the manufacturer and the HPRA, and to consult a pharmacist or doctor.

‘That’s when it becomes dangerous’ - navigating the healthcare/retailer divide in community pharmacy Community pharmacists are constantly navigating the tension between being healthcare providers and retailers, new research shows. A study published in the Journal of Pharmacy Practice and Research sought to identify the health professional retailer nexus in community pharmacy, and evaluate how pharmacists themselves manage the tension between these roles. Researchers from Massey Business School in New Zealand interviewed community pharmacy owners and managers, and found that several participants felt they had to balance a tension between their roles as healthcare providers and retailers “to meet commercial objectives”.

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One participant said retail was “a very important part of the business to keep us afloat.” The researchers also noted that several respondents initially rejected that any tension between the two roles existed, but later conceded competing values were at play. “The margins have been squeezed and it’s more difficult to make a buck,” said one. “It’s that fine balance,” said another. “The difference is when one overtakes the other. That’s when it becomes dangerous.”

Some participants said they did not personally experience any tension from performing their dual roles, but knew it existed in the pharmacy sector. One said there were examples of pharmacies that are “just in it for the money, trying to make lots of money.” Another participant said they would not hesitate in telling a patient to forgo a product and seek medical help instead. “In some instances, they are so sick that we say, look, don’t buy this. It’s a waste of money. You need to see a doctor. You’re that

sick that you should go and see a doctor because buying these type of things is just delaying the inevitable or masking signs of something that could be more wrong.” The respondents said they managed the tension by having informal discussions, training staff and focusing on 'solutions-based' selling. They said they believed it was inappropriate to motivate community pharmacy staff with incentives.


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Xylometazoline hydrochloride/ Dexpanthenol

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Septanazal® nasal spray with dexpanthenol not only unblocks the nose, but also heals and protects dry and irritated nasal mucosa. + Acts within 5–10 minutes + Long-lasting ease of breathing + Contains no preservatives Septanazal: The nasal spray solution contains xylometazoline hydrochloride and dexpanthenol. Indicated for adults and children over the age of 6 for reducing swelling of the nasal mucosa in rhinitis and as supportive treatment for healing the mucous membrane lesions, for the relief in vasomotor rhinitis and for the treatment of nasal respiratory obstruction after nasal surgery. Adults and children over 6 years of age: The usual dose of Septanazal for adults and children aged 6 years or over is one spray into each nostril up to 3 times a day. Regarding the duration of treatment in children, a doctor should always be consulted. Precautions: This medicinal product may be used only after a careful assessment of the risks and benefits in cases of: patients being treated with the monoamine oxidase inhibitors (MAOIS) and other drugs which potentially increase blood pressure, increased intraocular pressure, especially narrow-angle glaucoma, serious heart and circulatory diseases (e.g., coronary heart disease, hypertension), phaeochromocytoma, metabolic disorders (e.g., hyperthyroidism), porphyria and prostate hyperplasia. In chronic rhinitis it may be used only under medical supervision owing to the danger of the atrophy of the nasal mucosa. The prolonged use and overdose of decongestant sympathomimetics in particular may lead to reactive hyperaemia of the nasal mucosa. This rebound effect causes narrowing of the airways and, consequently, the patient uses the medicinal product repeatedly until its use becomes permanent. The consequences are chronic swelling (rhinitis medicamentosa) or even atrophy of the nasal mucosa. In less severe cases consideration can be given to discontinuing the use of the sympathomimetic in one nostril initially and, after the symptoms have abated, changing to the other side in order to maintain at least part of the nasal respiration. Direct contact of the medicinal product with the eyes should be avoided. In case of misuse or use of excessive amounts of the spray, the absorption of xylometazoline can cause systemic adverse effects, particularly in children (cardiovascular and neurological adverse effects) (see sections 4.8 and 4.9). Concomitant use of the product with medicinal products for local or systemic treatment of the flu and sympathomimetics contained in cough-and-cold medicines (e.g.: pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, xylometazoline, tramazoline, naphazoline, tuaminoheptane) is not recommended in order to avoid an increased risk of possible cardiovascular and neurological adverse effects (see section 4.5). Contraindications: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of the SPC, dry inflammation of the nasal mucosa, history of transsphenoidal hypophysectomy or other surgical interventions which expose dura mater. Septanazal for adults is contraindicated in children under 6 years of age. Fertility, pregnancy and lactation: Septanazal should not be used during pregnancy, as there is not sufficient data available concerning the use of xylometazoline hydrochloride by pregnant women. Septanazal should not be used during the lactation period, since it is not known whether xylometazoline hydrochloride is excreted in the breast milk. There is no data on the influence of Septanazal on fertility. Adverse reactions: Uncommon: hypersensitivity. Rare: palpitations, tachycardia, hypertension. Very rare: restlessness, insomnia, fatigue, headache, hallucinations, rebound congestion, nosebleed, convulsions. Not known: burning and dryness of nasal mucosa, sneezing. Shelf life: 2 years. Legal category: Medicinal product not subject to medical prescription. Marketing authorisation number: PA1347/058/002. Marketing authorisation holder: Krka, d. d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia. http://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA1347-058-002_19012017142039.pdf Date of Preparation: October 2017. Additional information is available on request from Krka Pharma Dublin Ltd. Unit 4A, Leopardstown Business Centre, Ballyogan Road, Leopardstown, Dublin 18. D18 KX88. Reference number: 02-02-2018. * Passàli D, Salerni L, Passàli GC et al. Nasal decongestants in the treatment of chronic nasal obstruction: efficacy and safety of use. Expert Opinion on Drug Safety 2006; 5(6): 783–90.

1/2018, Ireland, 63-2018, RB/MB.

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Feature

Helping pharmacies plan for the winter: cough, colds & flu When the cough, cold and flu season begins around October, pharmacists should be poised for the onset of repeated outbreaks and a surge in demand for products that can help ease the symptoms of winter ailments. Community pharmacies are in prime position to help ease seasonal pressures on the health system and one of the most effective ways to help keep people out of GP surgeries and A&E departments is to repeat the self-care message. Community pharmacies are a one-stop-shop for all those seasonal healthcare needs. Running a successful vaccination service Pharmacy vaccination services offer business owners the opportunity to expand their reach into the community as the most accessible and convenient area of the healthcare system. Neil Sokay is a pharmacist in Lynch’s totalhealth pharmacy in Kells. Sokay shared with Irish Pharmacy News his top tips on how to run a successful in-store vaccination programme. “All staff should be trained up in plenty of time ahead of the winter season, including CPR training, and kept up to date regarding new advancements in vaccination. It is very important to provide staff with training, whether as a refresher course or maybe something more in depth. We encourage one to one, peer to peer training, whether it is pharmacist or colleague led. All experienced staff should do a refresher course on the main symptoms and this should cover suitable medicines for different patient groups. Staff should also know when to refer and should be confident and knowledgeable when informing patients exactly what is wrong with them and how long they can expect to be unwell for.” Sokay says that time management is key when it comes to vaccinating the public. “Time management is also really important and a timetable for appointments should be adhered to as much as possible, in a customer-friendly way. It may be necessary to have a locum relief or second pharmacist on duty. You also need to make sure you have all the correct materials on site and to hand at all times, such as adrenaline shots, sharps boxes and online access to PCRS.” Sokay wants pharmacists to reach out to their communities. “Make

the pharmacy your patient's first stop when they are feeling unwell. As pharmacists we are very accessible, sometimes up to seven days a week with an appointment. We are very experienced as we commonly see from the very young to the very old presenting to our pharmacies with a number of symptoms. We have a wide range of OTC medicines that can cover the vast amount of symptoms presenting at Autumn/Winter. Most common winter ailments are viral in origin and can be treated cost effectively without a trio to your GP or out of hours service. Of course when it is necessary, we will refer on the more serious cases for immediate treatment.” Ann-Marie Horan is in the Fortfield Pharmacy in Terenure. “Winter can be a difficult time in pharmacy, for obvious reasons, so if you are doing a flu vaccination programme then now is the time to check what your training requirements are. People are in different training cycles, depending on when they started vaccinating. If you have face-to-face training, for example CPR, you have to be prepared and book in time and take a day off work. Order in your adrenaline injections early because they tend to go short by the time we start vaccinating. Then we will plan what kind of cough bottles to stock and as I am next to a school we will do a back to school window and we will feature children’s vitamins. The companies will come in with displays and out goes the sun creams in favour of winter remedies.” Planning for winter The changing season brings opportunities to re-organise your store, to rearrange fixtures and fittings and to develop a clear merchandising plan featuring beacon brands in both the P and

Neil Sokay, pharmacist in Lynch’s totalhealth pharmacy in Kells

GSL sections. Planograms are helpful guides that can be used to assist with arranging retail shelves to help maximise front-end sales. These visual plans, that are backed by research, show exactly where in the store certain products should be placed and they indicate the products that will increase profits and move quickly. Store plans also show how products should be arranged based on the general categories and subcategories with the most profitable products typically going onto the shelf at eye level, known as the ‘cone of vision’. Products that shoppers seek out no matter where they are, called destination items, can go on shelves outside of the cone of vision.

Have a look at the shelves that are devoted to winter remedies, both on the shop floor and on the medicines counter, and ask yourself the following questions: • Is it clear to customers and staff which products are suitable for children and which are for adults only? • Are your staff up-to-date and clear on the risk of analgesic overdose due to combination products? • Are staff aware of the sales restrictions for certain decongestants? • How could you make this fixture easier to understand and navigate?

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Feature • If no tissues are available, and as a last resort, cough/sneeze into the crook of your elbow and wash the garment as soon as possible. Influenza Influenza is the winter ailment most likely to drive sufferers to the GP or to A&E, and nearly half of them will require antibiotics. The European Commission estimates that the seasonal flu vaccine prevents somewhere in the region of 37,000 deaths per annum in Europe. Pharmacists have been authorised to administer the flu vaccine, once appropriately trained, since October 2011. The uptake on the flu vaccine has increased every year since and research from the NHS has shown that people are more likely to avail of the flu vaccination service if it is convenient, quick and locally available.

• Are all staff clear on the symptoms that should ring an alarm bell if mentioned by a patient with a cough, cold or flu? • Are details about your flu vaccination service clearly displayed? Cough & cold The term “common cold” is widely used to describe an upper respiratory tract infection of viral origin. Adults in general suffer from cold approximately two to four times annually while children can contract the virus three to eight times as their immune systems aren’t as developed. Distinctive symptoms means that people often diagnose and treat themselves through a combination of self-care and OTC products, without needing to go to the doctor. If there is no improvement then an appointment with a doctor should be arranged. A GP can do an investigation to rule out whether the symptoms are being caused by a more serious infection, such as pneumonia or glandular fever. All members of staff should be trained up on when to refer a patient for further medical attention, especially if they present with cold or flu-like symptoms that are accompanied by any of the following: high fever, vomiting, a non-blanching rash, photophobia,

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severe headache and/or confusion. Children presenting with high-pitched screaming, floppiness, bulging fontanelle, convulsions or stiff neck should go straight to A&E. There is no cure for a cold, but certain measures can be taken to improve comfort levels while the virus dissipates: decongestants, antihistamines and pain relievers might offer some relief from symptoms however they won't stop a cold from developing and will not shorten its duration. Vitamin C is useful for people in high risk groups who are at high risk of colds due to frequent exposure, for example, nurses or pharmacy staff. Echinacea and Zinc may also benefit patients during the cough and cold season however people should check with their doctors first as these can interfere with some medications. In general though, the best advice to patients suffering from a cough or cold this winter season is to rest, sip liquids, wash your hands, and to stay away from workplaces and school/college until symptoms have improved.

• Keep the area germ-free with regular cleaning, especially door handles, handrails and shared surfaces like phones. • Use your own cup, plates, cutlery and kitchen utensils. • Make use of disposable towels for hands, rather than sharing towels. Tips for people suffering with cough/cold/flu: • Drink plenty of fluids to replace what is lost through mucosal secretions and sweating. • Get plenty of rest; do not attend work/school until appropriate to do so. • Eat a low-fat, healthy diet and include high-fibre fruits and vegetables. • Researchers say that the mild anti-inflammatory properties found in chicken soup can help to reduce the inflammation and irritation of the airways.

Tips for preventing infection:

• Avoid dramatic fluctuations in air temperature: try to keep warm.

• Wash hands well and often, especially after touching the area near your mouth and nose and always before handling food.

• Avoid infecting others: sneeze/ cough into tissues to trap viruscontaining droplets. Throw away used tissues immediately and wash your hands.

As the vaccine can only be developed once the virus has been identified (which can take months), the European Commission and the European Medicines Agency work together to “speed up the marketing authorisation procedure once a pandemic has been declared”. In order for the flu vaccination programme to maintain its ongoing success, there must be a high level of uptake among those aged sixty five years and older. At risk groups should also be targeted by pharmacy teams and the EU urges member countries to commit to vaccinating 75% of at risk groups each year. Those most at risk of developing serious complications from the flu virus include the youngest and the oldest, pregnant women, persons with a BMI over 40, patients with pre-existing long term conditions such as heart, kidney, liver, neurological disease or diabetes, smokers, and patients who are immunosuppressed or immunocompromised. It can also disproportionately affect people with Down syndrome and the virus is known to spread quickly in congregated settings, such as nursing homes or supported living environments. The HSE estimates that over one million people should be vaccinated in Ireland for the programme to be fully effective. From the flu vaccine to OTC remedies to prescription antibiotics, winter is a good time to drive home the message that the local pharmacy is a one-stop-shop for all those seasonal ailments.


CALM YOUR COUGH FUGAHSRTELIEF

CO FROM JUST

* S E T U N I M 5 1

BE UNSHAKEABLE

BENYLIN NON DROWSY DRY COUGHS: Syrup Composition: Dextromethorphan hydrobromide 7.5mg/5ml. Each 5 ml of Benylin Non Drowsy for Dry Coughs Syrup also contains: Sorbitol solution (70%) E420: 325mg, Sucrose 1625mg, Glucose 2380mg, Sodium 4.4mg, Ethanol (96% v/v) 0.311ml. Pharmaceutical form: Syrup. A clear amber coloured syrup with a characteristic smell of peaches. Indications: BENYLIN Non Drowsy for Dry Coughs is indicated for the relief of non-productive irritating cough. Dosage: Adults and children 12 years and over: Oral. 15mg (10 ml syrup) 3-4 times a day. maximum daily dose: 40 ml syrup. Children under 12 years: This product is contraindicated in children under the age of 12 years. Hepatic dysfunction: Due to the extensive hepatic metabolism of dextromethorphan, caution should be exercised in the presence of hepatic impairment. Contraindications: This product is contraindicated in individuals with known hypersensitivity to dextromethorphan or to any of the excipients. Dextromethorphan should not be used in patients taking monoamine oxidase inhibitors (MAOIs), or within 14 days of stopping MAOI treatment (see section 4.5). There is a risk of serotonin syndrome with the concomitant use of dextromethorphan and MAOIs and the concomitant use of these medications may cause a rise in blood pressure and hypertensive crisis. This product is contraindicated in patients taking serotonin reuptake inhibitors (SSRIs). Dextromethorphan, should not be given to patients in, or at risk of developing respiratory failure. Benylin Non-Drowsy Dry Coughs, Syrup is contraindicated for use in children under 12 years of age. Special warnings and special precautions for use: Patients with the following conditions should not use this product, unless directed by a physician: acute or chronic asthma, a persistent or chronic cough such as occurs with chronic bronchitis or emphysema, or where cough is accompanied by excessive secretions. Cases of dextromethorphan abuse have been reported.. Caution is particularly recommended for adolescents and young adults as well as in patients with a history of drug abuse or psychoactive substances. There is no evidence of drug dependence at therapeutic doses. Use of dextromethorphan with alcohol or other CNS depressants may increase the effects on the CNS and cause toxicity in relatively smaller doses. While taking this product, patients should be advised to avoid alcoholic drinks and consult a healthcare professional prior to taking with central nervous system depressants. Dextromethorphan is metabolised by hepatic cytochrome P450 2D6. The activity of this enzyme is genetically determined. About 10% of the general population are poor metabolisers of CYP2D6. Poor metabolisers and patients with concomitant use of CYP2D6 inhibitors may experience exaggerated and/or prolonged effects of dextromethorphan. Caution should therefore be exercised in patients who are slow metabolizers of CYP2D6 or use CYP2D6 inhibitors. This product should be used with caution in atopic children due to histamine release. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this product. This medicinal product contains 6 vol% ethanol (alcohol), i.e. up to 240 mg per 5ml, equivalent to 6 ml beer, 2.5 ml wine per 5 ml. This can be harmful for those suffering from alcoholism. To be taken into account in pregnant or breast-feeding women, children and high-risk groups such as patients with liver disease or epilepsy. Patients who are taking other medication including cough and cold medicines and / or who are under the care of a physician, should consult their doctor / pharmacist before taking this product.. Undesirable effects: Adverse drug reactions (ADRs) identified during post-marketing experience with Dextromethorphan are included below. The frequencies are provided according to the following convention: Very common ≥1/10, Common ≥1/100 and < 1/10, Uncommon ≥1/1,000 and <1/100, Rare ≥1/10,000, <1/1,000, Very rare <1/10,000, Not known (cannot be estimated from the available data). Psychiatric Disorders - Rare - Confusional state. Not known – Agitation, Insomnia, Nervous System Disorders: Not known – Dizziness, Psychomotor hyperactivity, Seizure. Somnolence. Respiratory, Thoracic and Mediastinal Disorders: Rare – Bronchoconstriction, Dyspnoea Gastrointestinal Disorders: Not known - Abdominal pain, Diarrhoea, Nausea, Vomiting. Skin and Subcutaneous Tissue Disorders: Not known - Angioedema Pruritus, Rash, Urticaria. PA Number: PA 823/29/1. MAH: McNeil Healthcare (Ireland) ltd. Airton Road, Tallaght, Dublin 24, Ireland Date of revision of text: April 2018. Product not subject to medical prescription. Full prescribing information available upon request

IRE/BE/18-3307

* The onset of antitussive effects are realised within 15 to 30 minutes of oral administration.


Financial Feature

How the pharmacist can plan for income in retirement Continuing his six-part series, Robert McOwan continues his exploration of the financial lifecycle of the community pharmacist. Using his experience in both the business and pharmacy sectors, Robert works as a financial advisor offering both business and personal financial planning. This month he discusses planning for retirement. 3. Discretionary income – holidays, shopping, social events 4. Discretionary wealth/gifts – education funds, first time buyer deposit 5. Discretionary wealth/luxury items – travel, hobbies, shopping Reasons to Plan

Robert McOwan

Retirement Planning Many people agree that having a pension is very important but delay in doing something about it because they believe it is not very urgent today. However at some time in the future, it will become both very important and very urgent. Depending on when that happens there is a risk it may be too late. A consequence of this is potentially retiring from work without having the necessary income available and ready to use. Hopefully the information below will help with understanding how to make decisions regarding planning for income in retirement. In our last edition of IPN News, we published ‘Float Like A Butterfly’ which explained the four step cycle of financial planning. A quick recap is that for both employees and business owners, there are four financial planning steps; one is the early financial years, step two, the financial growth years and step three, the financial

64

consolidation years. During these steps regular income is earned and saving regularly, building assets and creating wealth are financial goals. These steps lead to a final step four and financial security in retirement, hopefully, based on the excellent financial planning in all previous steps. In this article there is a more detailed look at how to plan for income in retirement. This includes using Revenue Approved tax efficient methods of creating wealth from current income, to help ensure the standard of living enjoyed while working, is maintained when work stops and retirement starts. Hierarchy of financial needs in retirement 1. Essential income – utilities, household shopping 2. Emergency income – urgent travel, car repairs, medical costs

An important factor to consider is an increase in life expectancy. People can now look forward to spending up to a third of their lives in retirement, which is typically a time when it is not possible to earn a regular income. In addition the age profile of the Irish population is getting older, which means less money available to the Government in the future to pay for state pensions. The real expectation is that more people will be living their lives in retirement than there are people working. This is one of the reasons why the Government actively encourages people to save for their income in retirement. On offer to investors is attractive and immediate tax relief on contributions, tax free returns on investments and an option to take a tax free cash lump sum at retirement. Investing in a Pension Plan is an opportunity to make a very wise investment as there is no simpler, easier or more tax-efficient way of saving money In Ireland. What Pension Plan? • The most suitable pension plan depends on your employment status, for example; Personal Pension plans are only available to self-employed, employees who are not members of a company pension scheme. • Executive Pension Plans and Defined Contribution Schemes are available to business owners for their own use. These are also used to provide pension

benefits for employees who become members of a company sponsored executive pension plan or a defined contribution scheme Pension Contributions The amount of money invested in a pension plan is called a contribution. Many people underestimate how much they will need to contribute in order to provide an adequate income when they retire. One way to overcome this challenge is to decide on potential income needs and then start saving as soon as possible. While it is never too late to start a pension plan, an early start usually equals smaller contributions to be put aside each month to reach an income in retirement. The points below show some key steps to help with thinking about achieving income in retirement targets • Decide on retirement income goals • Calculate time between now and target retirement date • Set up a plan with affordable contributions • Measure progress of retirement plan Government Income Support in Retirement A full state pension, called a State Contributory Old Age Pension is paid to people who have made the required number of PRSI contributions during their working lives. If a person does not have the required number of PRSI contributions they may be entitled to a reduced State Contributory Old Age Pension. Old Age NonContributory Pensions are also available. This is a means-tested payment for people aged 66 or over who do not qualify for an Old Age Contributory Pension based on their social insurance record.


Age limits apply to receiving state pensions, for example, a person who was born on or after 1 January 1955 qualifies for a state pension at age 67. A person born on or after 1 January 1961 qualifies for a state pension at age 68. Pensions are paid for life.

Flexible Pension Fund Options at Retirement

Contributions Tax Relief

In the 1999, 2000 and 2011 Finance Acts the Minister for Finance made significant changes to pension legislation. This allowed owners of personal pensions and members of defined contribution scheme or contributors to executive pension plans to retain ownership of their pension funds. In addition, there are now more flexible Revenue Approved options available to how accumulated pension funds are used when people reach their selected retirement age.

By contributing to a pension plan it is possible to reduce personal income tax. This is true for personal contributions to a personal pension or member’s contributions to an executive pension plan or a defined contribution scheme. Tax relief is allowed by Revenue on all personal pension contributions at a person’s marginal rate of income tax. The following table illustrates the effects of tax relief on monthly contributions.

Please Note: the flexible options listed below are choices that only have to be made at retirement. The first priority is to build the pension fund which makes these options available. At retirement day, any option selected depends on current personal and financial circumstances. It is accepted that financial and personal circumstances and therefore income in retirement priorities may have changed since a pension plan was originally set up.

Personal Pension Plans flexible options are as follows:

It is important to note that any private pension planning in a personal pension, executive pension plan or a company scheme allows a person to have a pension income paid sooner than a state pension.

Standard Marginal Tax Tax Rate Rate @ 20% @ 40%

Gross monthly contribution ¤200

¤200

Tax relief

¤40

¤80

Net Cost

¤160

¤120

Tax Relief Limits The tax relief limits shown in the table below apply to personal contributions to any Revenue Approved pension plan: Age Limit attained (% of Net during Relevant tax year Earnings) Under 30

15%

30 - 39 20% 40 - 49 25% 50 - 54

30%

55 - 59

35%

60 + 40% Net relevant earnings are subject to an earnings limit of ¤115,000 for the years of assessment.

1. Invest the pension fund in an annuity which delivers a pension for life based on annuity rates at the time of retirement. 2. Invest the fund in an Approved Retirement Fund, subject to Revenue terms and conditions. (see point 6 below) 3. Take 25% of the pension fund as a tax free lump sum. 4. Invest the remainder of the fund in an annuity to provide a pension for life - or 5. Invest the remainder of the fund in an Approved Retirement Fund - or 6. If a pension of ¤12,700 per annum is not available, ¤63,500 of the fund must be invested in an Approved Minimum Retirement Fund until age 75 or alternatively, invested in an annuity which would provide a pension for life. 7. Subject to terms and conditions, an ARF or AMRF can be used to provide taxable income in retirement at a person’s marginal rate of income tax.

Financial planning for retirement 1. Think about income needs in retirement 2. Decide on a retirement plan start date 3. Get trusted expert advice 4. Allocate available funds to the plan 5. Review funds versus income goals regularly Executive Pension Plans & Defined Contribution Schemes Pension Options These are the same as those for Personal Pension Plans listed above, with one additional option available. • Take a tax free lump sum based on final salary and years of service If this tax free cash option is taken, the remainder of the fund must be used to purchase an annuity. Important point to note is that the tax free lump sums are subject to a limit of one and half times final salary and a lifetime limit of ¤200,000 (Finance Act 2011). Reasons to Start a Pension Plan 1. Tax relief at marginal rate on contributions (subject to revenue terms and conditions) 2. Investment returns are tax free. 3. Tax free lump sum at retirement. 4. Excellent options and flexible choices at retirement. 5. Flexible retirement dates. 6. Financial security and independence. Hopefully this article will have removed some of the mystery on how to organise a pension plan to support your income in retirement. It might be a good time to think about how to get started on building a pension fund to ensure all essential, emergency and discretionary income needs are comfortably met during retirement. This can be achieved by taking advantage now of the excellent Revenue Approved tax relief available on contributions to any pension plan. As a starting point, consider the steps listed in the

diagram as a starting point for your decision. In the meantime, if you have any queries about any of the information in this article please contact Robert McOwan M: 086 896 1223 Robert McOwan is a Personal Financial Advisor with Acorn Life. Acorn Life DAC is regulated by the Central Bank of Ireland. Acorn Life is a 100% Irish owned Life Assurance Company offering protection, savings and investment products designed for the Irish public. Deductions for charges and expenses are not made uniformly throughout the life of the products mentioned above, but are loaded onto the early period. This means that if you withdraw from the product in the early period, the practice of front-end loading will impact on the amount of money which you receive and you may not get back the full amount invested. Warning: If you invest in this product you may lose some or all of the money you invest. Warning: The income you get from this investment may go down as well as up. Warning: The value of your investment may go down as well as up. About the Author Rob McOwan is a Personal Financial Adviser with Acorn Life. Rob also has a strong connection to the Pharma Industry having worked alongside numerous pharmaceutical organisations to assist with the design and launch of key brands. He has significant experiences creating, building and supporting pharma companies within the Irish and European markets and in his current role is now ideally positioned to present financial advice within the pharmacy industry to owners and employees.


Help prevent the spread of Bacterial Conjunctivitis Conjunctivitis is a common condition which causes redness and inflammation of the conjunctiva- the transparent membrane that covers the white part of the eye and inner surface of eyelids. This condition may be the result of a bacterial or viral infection (infective conjunctivitis), contact with an allergen (allergic conjunctivitis) or irritant (irritant conjunctivitis). In a community pharmacy setting, the most commonly encountered forms of conjunctivitis are generally bacterial or allergic in origin. Also known as 'pink eye', conjunctivitis is a common eye problem, as it is extremely contagious, but it can be treated and avoided altogether by taking the relevant precautions. Conjunctivitis can happen at any age but university students, school children, teachers and nursery workers are more susceptible because they are in close proximity with others. Bacterial conjunctivitis is a common eye condition with an estimated 13 to 14 cases for every 1000 people per year. Caused by bacteria, this type of conjunctivitis can be responsible for considerable damage to the eye if it remains untreated. People often present with red, watering eyes and often complain of “sticky” eyelids particularly in the morning time upon waking. In bacterial

conjunctivitis the discharge is generally yellow or greenish in colour and affects one eye first before frequently spreading to the other eye. Symptoms can include slight soreness in the eyes and possible enlarged lymph nodes in front of the ears. Additionally, symptoms of upper respiratory infection may be present. Most cases do not require treatment and usually resolve in one to two weeks, but in a community pharmacy a number of OTC products can be recommended to alleviate symptoms. Propamidine isetionate drops or dibrompropamidine isetionate ointment such as Golden Eye, both anti-infective agents for use in the local infections of the eye, are indicated for the treatment of bacterial conjunctivitis. Drops are used during the day and

ointment at night. The use of lubricant eye drops may ease soreness and stickiness in eyes. The discharge may be removed gently with cotton wool and warm water. Sterile eye lid wipes are also available which allow effective removal of discharge from the eyes. If there is no significant improvement within two days or worsening of condition, referral to doctor may be necessary. As bacterial conjunctivitis is contagious, it is important to emphasise to patients the need to adhere to good hygiene to avoid spreading of this condition: Don't share facecloths, hand towels or hankies. Cover your nose when sneezing and avoid touching or rubbing your eyes.

Colour contact lenses or special effect contacts must never be shared with friends. If you work closely with others, you should frequently wash your hands. Carry a bottle of hand disinfectant in your bag or car. Follow your opticians' instructions about caring for your contact lenses and when to replace them. If you regularly go swimming, goggles can be worn to stop conjunctivitis being caused by micro-organisms and bacteria in the water. Contact lenses should be removed before having a shower so that bacteria cannot get inside your eyes and lenses.

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News Report indicates how pharmacists can remain competitive in their local market AIB has released its 2018 Pharmacy Outlook Report, which shows an improving outlook for pharmacists, but pressure remains on the sector. With over 1,800 pharmacies operating throughout Ireland, the importance of the sector cannot be underestimated, in terms of the contribution it makes to the healthcare needs of the population as well as the wider economy. The Pharmacy Outlook Report focuses on the trends within the pharmacy sector and how pharmacists can remain competitive in their local market. Alan Makim, Head of Retail & Franchising, Retail & Business Banking AIB said: “As the population grows older, the

demand for healthcare services will increase and this will present opportunities for pharmacists to grow their business in the future if they evolve with the changing trends in the sector.

offering that provides marketing, category management, and sophisticated business intelligence supports to optimise sales performance.

According to the survey 71% of pharmacists have joined a buying group, with 83% saying that this led to an immediate increase in their gross margin. This trend could be expected to continue if further pricing cuts are introduced.

“This frees the pharmacist up to concentrate on the service offering to customers, whether that’s in the form of better customer interactions, dispensary efficiencies or additional health and screening services which may, in some cases, add to revenue.”

Alan notes “Since joining a buying group, many pharmacists have graduated to a full franchise

Also in the Outlook, Jason Bradshaw, Partner, Corporate Finance, at JPA Brenson

Lawlor says: “With a majority of pharmacist looking to expand their business, 2017 was a buoyant year for M&A activity.” With 6,038 registered pharmacists 3,637 of whom are community pharmacists and 363 pharmacist assistants working in 1,851 community pharmacies throughout the country, the sector is benefiting from the general uplift in the economy but with an ageing population combined with an increase in chronic illnesses, it will face both challenges and opportunities in the future.

Charity publishes Top Tips for Better Eye Health ahead of World Sight Day 2018 Fighting Blindness has published its Top Tips for Better Eye Health to coincide with details of Retina 2018, the charity's annual public engagement day. Now in its eighth year, the event will be held on October 6th in Dublin, ahead of World Sight Day on October 11th. Hundreds of conference delegates, with a wide range of vision impairments, will come together from all over the country to connect with others with similar conditions and experiences. Experts at the cutting edge of sight loss research will be there answer questions and to outline the most recent clinical trial findings and treatment developments. Fighting Blindness has invested over ¤17 million since 1983 in more than 90 research projects. Kevin Whelan is the CEO of this pioneering charity. "The event will feature speakers on a range of hot-button topics, including clinical trials, genetic testing, and emerging therapies. There will also be a presentation on smart homes and how voice control technology is revolutionising life in the home for people with sight loss." Fighting Blindness research focuses on genes and gene therapy, cell technology and regenerative medicine, retinal implant technology, novel drug therapy and population studies. Supported by Novartis, Retina Public Engagement Day 2018 comes against a backdrop of the latest figures showing that there are approximately 224,000 people in Ireland who are living with vision impairment or blindness.

To register your attendance, please register online at www.retina.ie, or you can telephone 01 6789 004 or email research@fightingblindness. ie. A nominal fee of ¤10 applies while attendance is free to members of Fighting Blindness. Special guests will include sculptor Victoria Claire, who was diagnosed with the rare degenerative eye condition, retinitis pigmentosa (RP), at the age of 19. Visionaries Choir, Ireland's only choir for people with a vision impairment, will provide entertainment under choir-master Frank Kelly. Fighting Blindness: Top Tips for Better Eye Health 1. Have Regular Eye Tests It is recommended that people have an eye test every two years, or every year if aged over 50. A regular eye test can identify any early indications of diseases, some of which are treatable if caught early. 2. Don't Smoke Our eyes need oxygen to survive. Smoking reduces the amount of oxygen in our bloodstream, with the result that less oxygen reaches the eye causing damage to the retina and problems such as agerelated macular degeneration and diabetic retinopathy.

Kevin Whelan, CEO of Fighting Blindness 3. Wear Sunglasses Ultraviolet (UV) light from the sun's rays can cause damage to our eyes and so it is important to wear sunglasses when in the sun. Check they have a UV factor rating and block 100 percent of UV rays, and that they carry the CE safety standard. 4. Eat the Right Food Some foods can help protect

against certain eye conditions, like cataracts and age-related macular degeneration, due to the specific nutrients they contain. 5. Take Regular Computer Breaks If using a computer, take frequent breaks from the screen – at least once an hour. Resting the eyes can help you avoid headaches, eyestrain and soreness.

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Clinical Profiles NOVARTIS MARKS A NEW ERA FOR MIGRAINE PATIENTS WITH THE EU APPROVAL OF AIMOVIG®, A FIRST-OF-ITS-KIND TREATMENT SPECIFICALLY DESIGNED FOR MIGRAINE PREVENTION Novartis has announced that the European Commission (EC) approved Aimovig® (erenumab) for the prevention of migraine in adults experiencing four or more migraine days per month. Aimovig is the first and only treatment specifically designed for migraine prevention to be approved in the European Union, Switzerland, the US and Australia. It works by blocking a receptor called the calcitonin gene-related peptide receptor (CGRP-R) which plays a critical role in mediating the incapacitating pain of migraine. In the extensive clinical program of 2,600 patients, those on Aimovig experienced significant reductions in their number of migraine days per month, with a safety and tolerability profile similar to placebo1-3. Aimovig can be self-administered or administered by another trained person every four weeks with the SureClick® autoinjector pen, an established device commonly used for a range of different conditions. “Migraine matters. It is a painful, highly disruptive neurological disease that affects all aspects of life, from going to work to spending time with family and friends,” said Patrick Little, President of the European Migraine and Headache Alliance and CEO of the Migraine Association of Ireland. “A treatment specifically designed for migraine prevention is a much-welcomed innovation and could transform lives of patients for whom current therapies do not work or are not well tolerated.” Aimovig showed efficacy even in a difficult-to-treat population. It is the only CGRP-R pathway therapy specifically studied in patients who had failed on two to four previous treatments commonly used for migraine prevention6. Furthermore, in an interim analysis from a five year open label extension (OLE) in episodic migraine, it was demonstrated that more than one in four (26%), patients taking Aimovig 70 mg, who were still enrolled and assessed for migraine over month fifteen, were completely migraine free7. “Erenumab heralds a new era in clinical practice, bringing both a targeted mechanism for prevention and a deep understanding of migraine, which we have never had before,” said Dr Martin Ruttledge, Consultant Neurologist , Beaumont

Hospital, Dublin. “We will see sustained

Medicinal product subject to medical prescription.

relief from migraine for many of those who suffer with this debilitating disease.”

Clonmel Healthcare Ltd., Clonmel County, Co. Tipperary.

“Today's approval is groundbreaking for people living with migraine, their families and doctors” said Loretto Callaghan, Managing Director Novartis Ireland. “In clinical trials, Aimovig has consistently shown to be effective in preventing migraine and bringing relief from the grip of this disease. We are proud to be the first to reimagine migraine prevention and we are committed to ensuring Aimovig’s availability for those who could benefit from it “.

CHANGE IN FORMULATION TO VENEX XL 37.5 MG, 75 MG AND 150 MG PROLONGED-RELEASE CAPSULES, HARD (VENLAFAXINE) Clonmel healthcare wish to advice of a change in formulation to our Venex XL 37.5 mg, 75 mg and 150 mg Prolonged-release Capsules, hard (venlafaxine). The appearance of the capsule has also changed. NEW VENEX XL Venex XL 37.5 mg prolongedrelease capsules, hard: Light grey opaque / peach opaque, size ‘3’ hard gelatin capsules having thick and thin radial circular band on the body in red ink and thick and thin radial circular band on the cap in red ink. The capsule is filled with 3 white to off-white, round, biconvex, film-coated mini tablets of 12.5 mg each. Venex XL 75 mg prolonged-release capsules, hard: Peach opaque / peach opaque, size ‘1’ hard gelatin capsules having thick and thin radial circular band on the body in red ink and thick and thin radial circular band on the cap in red ink. The capsule is filled with 6 white to off-white, round, biconvex, film coated mini tablets of 12.5 mg each. Venex XL 150 mg prolongedrelease capsules, hard: Dark orange / dark orange opaque, size ‘0’ hard gelatin capsules having thick and thin radial circular band on the body in white ink and thick and thin radial circular band on the cap in white ink. The capsule is filled with 12 white to off-white, round, biconvex, film coated mini tablets of 12.5 mg each.

Further information is available on request and a copy of the summary of product characteristics is available on our website www.clonmel-health.ie

ACCORD HEALTHCARE LAUNCHES OLMESARTAN MEDOXOMIL/AMLODIPINE IN 3 STRENGTHS Accord Healthcare is delighted to announce the launch of Olmesartan medoxomil/Amlodipine 20 mg/5 mg, 40 mg/5 mg and 40 mg/10 mg in pack sizes of 28 film-coated tablets. This medicine is indicated for the following: • Treatment of essential hypertension. Olmesartan medoxomil/Amlodipine is indicated in adult patients whose blood pressure is not adequately controlled on olmesartan medoxomil or amlodipine monotherapy. Please refer to the Summary of Product Characteristics (SPC) available at www.hpra.ie or for Healthcare Professionals at www.accord-healthcare.ie for further information. For further information please contact Accord in Cork on 021-461 9040 or visit www.accord-healthcare.ie

ACCORD HEALTHCARE’S (INTAS) PELGRAZ® (PEGFILGRASTIM) GIVEN POSITIVE OPINION BY CHMP The Committee for Medicinal Products for Human Use (CHMP) has issued a positive opinion for Accord’s Pelgraz (pegfilgrastim), a pegylated granulocyte-colony stimulating factor (G-CSF) biosimilar in Europe1. Once approved, Pelgraz could be the first biosimilar pegfilgrastim to market in Europe intended to reduce the duration of neutropenia and the incidence of febrile neutropenia due to chemotherapy1. The World Health Organisation consider G-CSF essential therapies due to their impact on febrile neutropenia, chemotherapy dose delays, and dose density2. Neutropenia is still one of the most common reasons for reductions or delays in the chemotherapy schedule which impairs survival outcomes and quality of life for patients. Evidence shows that

daily G-CSFs are incorrectly administered in 42% of chemotherapy cycles, long acting pegfilgrastim has been shown to greatly reduce that figure to just 8%3. Binish Chudgar, Vice Chairman and Managing Director of the Intas Group stated “Accord launched its first European approved biosimilar product, Accofil (filgrastim), in 2015 and despite being the 6th entrant has become a leading supplier of this important medicine. Since then the product has been used over 2 million times and Accord has gained valuable experience in bringing biosimilar medicines to market. Our continued focus on bringing biopharmaceuticals to Europe has enabled us to potentially be first to launch a biosimilar pegfilgrastim, and as a potential first mover we expect to gain an even bigger market share with Pelgraz.” Accord will manufacture this medicine in its own state of the art production facility. The company has deep experience with biosimilar medicines and as of 2017 were assessed using IQVIA data to have the second highest number of biosimilars in phase III to approval in the world4. This reflects the strategy of a long-standing commitment in biopharmaceutical development, research and manufacturing. The CHMP positive opinion was based on Pelgraz’s substantial clinical development programme, which supported its biosimilarity with the reference product Neulasta® (pegfilgrastim)1. Paul Tredwell, Accord VP Speciality Brands, EMENA said “At Accord, our mandate is to deliver affordable medicines that make a real difference to patients’ lives. With approval and commercialisation, we hope to provide patients with the first pegylated biosimilar of pegfilgrastim that will reduce the strain on healthcare providers’ budget, while potentially improving the standard of care and associated outcomes for patients.” Tredwell concluded “Accord is providing affordable alternatives in some of the most complex areas of medicine and this medicine reflects our increased focus in speciality pharmaceuticals (including oncology, critical care, auto-immune, fertility and central nervous system conditions.) We already have an established footprint across 93% of European countries directly serving the European population with over 30 oncology therapies via our own commercial infrastructure, and this latest recommendation further underlines our commitment to oncology patients.”

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The same SMA® PRO range, now with a new look The same formulations, now with a new look Available from August 2018 IMPORTANT NOTICE: Breast milk is best for babies and breastfeeding should continue for as long as possible. You should always seek the advice of a doctor, midwife, health visitor, public health nurse, dietitian or pharmacist, or other professionals responsible for maternal and child care. Learn more about the SMA PRO range at www.smahcp.ie

Cleanmarine® Cardio 40+ is a comprehensive Omega 3, Multivitamin formulation to support heart health Cardio 40+ is the latest addition to the Cleanmarine range from Naturalife. It contains a nutritious blend of Omega 3 EPA and DHA, combined with organic Turmeric root extract, Vitamins K2, B6 and B12. Each ingredient has been selected based on extensive scientific research to support heart health. Turmeric (Curcuma Longa) Rhizome (100mg) is a key ingredient Cardio 40+, it is PARTNER dried from organic PRL AREinP&G’s NEW IRISH farming. Tumerones have a huge anti-inflammatory effect, they inhibit TNF α activation, protect cells from heavy metals damage, prevent aggregation of blood platelets, protect the liver and have anti-bacterial, anti-fungal and anti-microbial effects.

ALL P&G QUERIES, about PLEASE CONTACT THE RE 40 years and PRODUCT beyond concerned Cleanmarine® Cardio 40+ is ideal for Men and Women over FOR overall heart health, inflammation, cholesterol levels, blood REPRESENTATIVE: pressure levels, energy levels and tiredness and fatigue.

North Dublin/Leinster - Eoghan O Brien - 086 858 0562 - Eo

Cleanmarine Cardio 40+ is Marine Stewardship Council (MSC) approved which means it’s fully sustainable and fully traceable. In fact, MSC is the highest-ranking Ecolabel in the world and approved by The World Midlands/Leinster/South Dublin & East Coast - Tom Ryan - 0 Wildlife Fund (WWF). Each pack has a unique number which means it can be traced back to where the Krill Oil was sourced. For Professional information only

PRL ARE P&G’s NEW IRISH PARTNER

West of Ireland/ North West - Noel Hume - 086 858 0551 N

Cork/Kerry/Limerick - Frank McGovern - 086 382 7725 Fran

South East /Midlands - Contact the Office - 01 257 4650 pgs

FOR ALL P&G PRODUCT QUERIES, PLEASE CONTACT THE RELEVANT PRL BUSINESS DEVELOPMENT REPRESENTATIVE:

North Dublin/Leinster - Eoghan O Brien - 086 858 0562 Eoghan.OBrien@prl.ie Midlands/Leinster/South Dublin & East Coast - Tom Ryan - 086 858 0541 Tom.Ryan@prl.ie West of Ireland/ North West - Noel Hume - 086 858 0551 Noel.Hume@prl.ie Cork/Kerry/Limerick - Frank McGovern - 086 382 7725 Frank.McGovern@prl.ie South East /Midlands - Contact the Office - 01 257 4650 pgsales@prl.ie

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Arkopharma Akrovital® Pure Energy

Arkopharma Arkovital Pure Energy® 50+

Elastoplast 1-2-3 Wound Care Kit

Arkopharma Laboratories have developed their first innovative combination of 100% plant-based vitamins and minerals, which have been optimised for absorption by the body. This was achieved using a patented process of 100% water extraction, without using solvents or chemical ingredients. Arkovital® Pure Energy provides 9 vitamins and 5 minerals which are needed to preserve immune defences (including Iron, Selenium and Zinc) and help the body to keep in shape (Vitamins B2, B3, B5, B6, B9 and C). These plant bases include Guava, Amla, Lemon, Holy Basil, and Curry Leaf. contact info@pharmed.ie

A comprehensively developed combination of 10 vitamins and 5 minerals for the over 50’s. Extracted without solvents or chemical ingredients and derived exclusively from fruits and plants including Guava, Amla, Lemon, Holy Basil, Curry, Acerola, Grape, Marigold and Lichen. This formula provides the vitamins and minerals required to preserve immune system defences and bolster everyday vitality. It specifically helps to maintain bone health, normal vision and Grape extract provides Polyphenols which help to protect cells. contact info@pharmed.ie

STEP 1: CLEANSE with ELASTOPLAST WOUND SPRAY - an antiseptic cleanser for minor and chronic wound types.

RRP ¤22.95

RRP ¤24.95

STEP 2: PROTECT with ELASTOPLAST FABRIC PLASTERS - protects and cushions minor, everyday wounds. STEP 3: HEAL with ELASTOPLAST WOUND HEALING OINTMENT - enables up to two times faster wound healing by building a breathable protective film. https://www. elastoplast.co.uk


PHARMACY SUPPLY & SERVICES The Irish Prison Service (IPS) invites tenders for the provision of General Pharmacy Services to:  Castlerea Prison  Limerick Prison  Cork Prison This service will include the delivery of pharmaceutical care, on a patient centred basis, which complies with all professional, legal and ethical requirements. This contract will be managed by the Chief Pharmacist, Care & Rehabilitation Directorate, IPS. A separate tender competition will be held in respect of each prison location. Tender documents are available on www.etenders.gov.ie. Completed tender documents must be returned in the format detailed in the Request for Tender, by 12.00 on 24th September 2018 to the Irish Prison Service, Central Procurement Unit, IDA Industrial Estate, Ballinalee Road, Longford, Ph. 043 333 5100.

For further information, please contact Care & Rehabilitation Directorate, IPS, on 043 333 5195


Support your inner defense, feel the natural protection . Daily immune supportive formula . Unique combination of 7 active ingredients . Potent dose of elderberry extract, equivalent to 4g 1

of dried fruit - includes 250mg of beta 1,3/1,6 glucans ingredients per dose

. Contains zinc, vitamin C and vitamin D3 contributing to the normal function of the immune system1

For more information contact your SolgarÂŽ Territory Account Manager or call 0044 1442 890 355 solgar.co.uk 1. Vitamins C and D, and zinc and copper contribute to the normal function of the immune system. Food supplements should not be used instead of a varied balanced diet and a healthy lifestyle. SolgarÂŽ is a registered trademark.

September 2018 - Irish Pharmacy News  
September 2018 - Irish Pharmacy News