IPN 2023 October

Page 5: Chronic Disease Pilot launched in Meath

Page 6: Pharmacists and Managers make the Retail Grade

Page 8: New Research on Deprescribing Medicines

Page 10: Key Trends in Irish Pharmacy

Page 14: Funding for Major Study on Gut Bacteria

Page 16: Enhanced Community Care Conference

Page 20: World Hospice and Palliative Care Day

Page 34: When Menopause gets Complicated

Page 76: New insights into Epilepsy

PUBLISHER:

IPN Communications

Ireland Ltd.

Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

MANAGING DIRECTOR

Natalie Maginnis n-maginnis@btconnect.com

EDITOR

Kelly Jo Eastwood: 00353 (87)737 6308

kelly-jo@ipn.ie

ADVERTISING EXECUTIVE

Esther Elliott-Coulter: 00353 (87) 062 2025

Esther@ipn.ie

EDITORIAL/ EVENTS & MARKETING EXECUTIVE

Aoife Hunter: aoife@ipn.ie

CONTRIBUTORS

Anna Wolinska | Damien O’Brien

Dr Kirk Levins | Mark McPhilips

Janis Morrissey | Orla Cooney

Ciara Coveney | Loretta Dignam

Sarah Belton | Dr Julie Ling

Dr Deirdre Lundy

Dr Genevieve Ferraris

Dr John Waterstone

DESIGN DIRECTOR

Ian Stoddart Design

Foreword

Community Pharmacists across Ireland have welcomed the expansion of the free contraception scheme for young women. However, the Pharmacy Union has called on the government to make it easier and faster for young women to avail of the scheme by enabling pharmacies to provide convenient access to contraception without prescription from a pharmacy. This service is available to women in the UK, USA, Canada and New Zealand.

This is about giving women choice and promoting better health outcomes. Speaking on the day that free contraception became available to all women aged 17 to 30 Kathy Maher the Chair of IPU’s Pharmacy Contractors Committee called for greater choices to be provided. “The expansion of the free contraception scheme is an extremely welcome development and should be commended. However, with GPs across the country expressing concern about their excessive workloads the requirement for a GP prescription could make accessing the scheme difficult.”

Turn to page 5 for the full story.

In other news, October hosts World Hospice and Palliative Care Day, and on page 20 of this issue, Dr Julie Ling looks closer at palliative care in Ireland. Dr Ling is CEO of the European Association for Palliative Care/ Chair, Worldwide Hospice and Palliative Care Alliance. She notes, “Ireland has made huge advances in developing and strengthening palliative care. As we mark World Hospice and Palliative Care Day, this year’s campaign provides the opportunity to celebrate success but also to address the substantial gaps in access to palliative care services, to ensure that there is not only improved access to palliative care in Ireland but also to involve our communities.”

Women’s Health is the focal point for a special focus section from pages 24 to 53 and we have some excellent contributed articles including Dr John Waterstone, Medical Director with the Waterstrone Clinic, who gives readers an insight into the pharmacy role in subfertility; and Dr Genevieve Ferraris, GP and Menopause Specialist, The Menopause Hub. Dr Ferraris examines the use of testosterone therapy in menopausal women. This special focus supports the news that fully publicly-funded assisted human reproduction (AHR) treatment commenced last month. Eligible patients will be entitled to one full cycle of IVF (invitro fertilisation) or ICSI (Intracytoplasmic sperm injection) treatment, initially provided in HSE-approved private clinics of their choice ahead of the opening next year of the first public National Advanced AHR Centre.

I hope you enjoy the issue.

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

All rights reserved by Irish Pharmacy News. All material published in Irish Pharmacy News is copyright and no part of this magazine may be reproduced, stored in a retrieval system or transmitted in any form without written permission.

IPN Communications Ltd. has taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

Regulars

CPD: EYE HEALTH

FEATURE: FEMALE HEALTH

P41

P48

TEAM TRAINING: COLD & FLU P70

FEATURE: PSORIASIS

P78

CLINICAL PR: P80

Pharmacy Fees Restoration Talks Continue

Members of the Irish Pharmacy Union recently attended a meeting with the Department of Health as part of ongoing discussions on pharmacy services and pay restoration. They discussed the impact of increasing administration and bureaucracy faced by pharmacists daily as a key issue.

Members of the Irish Pharmacy Union who recently met with Minister for Health Stephen Donnelly including Susan O’Dwyer, Head of Professional Services, Tom Murray, Honrary Treasurer, Derek Reilly, Secretary General (Acting), Clare Fitzell, Head of Strategic Policy, Roisin Molloy, Head of Membership and Operations and Kathy Maher, Pharmacy Contracts Chair

HSE-Funded Fertility Clinics

People who are eligible and recommended for advanced fertility treatment services will be able to access HSE-funded services in many areas across the country from later this month. All eight private fertility clinics in Ireland will be providing services on behalf of the HSE to people who are recommended for treatment by one of the six HSE Regional Fertility Hubs. The HSE-approved clinics are located in Cork, Dublin, Galway and Kildare, with a number of them having satellite clinics in other locations around the country, where some care may be delivered.

The Minister for Health Stephen Donnelly recently responded to questions in the Dail around this issue to which he responded, “The regulations governing the pharmacy fee structure are set out in the Public Service Pay and Pensions Act 2017 (No. 34 of 2017) and in S.I. No. 639 of 2019, the Public Service Pay and Pensions Act 2017 (Payments to Community Pharmacy

Contractors) Regulations 2019, which put the current fee structure in place, with effect from 1 January 2020.

“Under Section 42(14) of the Public Service Pay and Pensions Act 2017 the pharmacy fee structure must be reviewed every third year after 2020. My Department is currently carrying out a comprehensive review.

Pharmacy – Share your Views

“Constructive engagement between Department officials and the Irish Pharmacy Union has taken place in that regard in recent months, and this engagement is continuing.

“I believe that there is a real opportunity to work collaboratively with community pharmacists, and with other healthcare providers, to make a significant difference to patient outcomes. Of course, any publicly funded pharmacy service expansion should address unmet public healthcare needs, improve access to existing public health services, and provide better value for money.”

Dr Cliona Murphy, Clinical Director with the HSE National Women and Infants Health Programme (NWIHP), said, “The fertility care pathway aims to support people in accessing services as close to where they live as possible, as the first step is to visit your GP, who can refer you to one of the six HSE Regional Fertility Hubs. This pathway ensures that fertility issues are addressed through the public health system at the lowest level of clinical intervention necessary.”

Many people who attend the Regional Fertility Hubs may not need to be referred for further advanced fertility treatments as treatments provided in the hubs will manage their fertility challenges.

The Health Information and Quality Authority (HIQA) is carrying out a survey with professionals in health and social care on the future of digital health and social care in Ireland. The evidence from the survey will be used to inform policy and digital developments in the area.

The project is a collaboration between HIQA, the Department of Health, and the Health Service Executive (HSE) and is being conducted in the context of EU targets where the public will have electronic access to their medical records by 2030. Under the Sláintecare health reform programme, the Government has goals around using digital technologies in health and social care. In addition, the Health Information Bill 2023 is currently in development. Furthermore, because of the COVID-19 pandemic, there have been

many changes in how people interact with services, for example through telehealth, remote health monitoring, and use of email and text.

Rachel Flynn, Director of Health Information and Standards said “HIQA wants to hear the views of professionals on these wideranging changes. We want to give professionals a platform to voice their opinions and have a meaningful impact on future developments in digital health and social care in Ireland. Therefore, we are asking professionals to complete the online survey for the

National Engagement on Digital Health and Social Care.”

HIQA wants to understand professionals’ opinions, attitudes, and comfort levels with digital health and social care, including digital services and the public having digital access to their own health and social care information. In addition, HIQA wishes to know the benefits, challenges, and gaps for both professionals in health and social care and the people they treat or care for.

Visit www.hiqa.ie for full details.

Dr Murphy continued, “We know that many people are unsure about the factors that can affect fertility, such as smoking, alcohol and weight, which is why we have worked with GPs to produce information leaflets. They will be available through GP surgeries, to support people with their understanding of what can affect their fertility, and things they can do to improve their fertility.”

The HSE will be actively monitoring and reviewing the demand on this service, and reviewing patient needs both in collaboration with our six Regional Fertility Hubs and with the network of HSE-approved private fertility clinics.

National Shared Care Record

eHealth Standards and Shared Care Records has commenced procurement for a HSE National Shared Care Record. NSCR will aggregate existing digital health information from various sources and present it in a secure and structured way to clinicians, patients, and carers.

It will play a key role in achieving the Sláintecare vision of patientcentred, integrated care by joining up fragmented and siloed digital records.

Initial population of the National Shared Care Record (NSCR) will be from existing digital data available in HSE National Systems and will be aligned to HIQA, EU and International Patient Summary models. Over time the NSCR will be augmented from other data sources, such as GP records once the Health Information Bill is enacted, and expanded with additional categories and details of data beyond the patient summary information, such as lab and screening results and key clinical documents, enabling improved clinical decisionmaking and self-management of healthcare.

One of the main challenges for the NSCR will be to extract, transform, and structure data from underlying source systems for display to clinicians and patients. Currently the approach to address data challenges is fragmented as several eHealth work streams are running in parallel involving data quality, record linkage, data standardisation, clinical terminologies, interoperability standards, reference data and data structure modelling.

To reduce risk and deepen understanding of these challenges, as well as to develop further insights into potential tooling and standards, the NSCR Project Team embarked on an 8-week collaborative “Build to Learn” (B2L) project with IIS and A2I-HIDs based on open standards using a collection of open-source components within existing controlled secure environments. The exercise was centred on deriving as much insight (to Learn) as possible to advantageously position the NSCR in preparation for a national deployment.

Pharmacy Welcome for Free Contraception Expansion

Women can visit their pharmacy at times that suit them in evenings or weekends. Women should have the choice to avail of this convenience to access contraception.”

There is widespread public support for allowing pharmacies to dispense the pill directly to patients Ms Maher explained. “Recent research conducted by B&A found that 86% of people in Ireland would welcome this development. Women should therefore have that choice to opt for a pharmacy if they wish.

Pharmacists are experienced in providing contraceptive care and have been safely providing the morning after pill, over the counter since 2011. The profession is trained and has the experience to review patients to determine if it is safe to dispense contraception without referring to a GP.”

Community Pharmacists across Ireland have welcomed the expansion of the free contraception scheme for young women. However, the Pharmacy Union has called on the government to make it easier and faster for young women to avail of the scheme by enabling pharmacies to provide convenient access to contraception without prescription from a pharmacy. This service is available to women in the UK, USA, Canada and New Zealand. This is about giving women choice and promoting better health outcomes. Speaking on the day that free contraception became available to all women aged 17 to 30 Kathy Maher the Chair of IPU’s Pharmacy Contractors Committee called for greater choices to be provided. “The expansion of the free contraception scheme is an extremely welcome development and should be commended. However, with GPs across the country expressing concern about their excessive workloads the requirement for a GP prescription could make accessing the scheme difficult.

“Pharmacies are easily accessible and located in practically every town and village in the country.

“The contraceptive pill is a safe medication; it is available directly from pharmacies in many other countries in the world.

Meath Pharmacies launch Pilot

Concluding Ms Maher said, “allowing pharmacies to dispense oral contraception direct to patients is a common-sense proposal. It would make the process faster and easier for the women involved, alleviate the pressure on GPs and therefore be cost effective for the health system. In essence it is a no brainer.”

In association with Heart Month, Healthy Meath have launched a free chronic disease risk management programme in community pharmacies in Kells and Oldcastle.

Leas Chathaoirleach of Meath County Council Cllr. Paul Mc Cabe pictured at the launch with (L-R) Cllr. Gillian Toole, Director of Services Barry Lynch, Director of Public Affairs and Communications, IPU Jim Curran, Healthy Ireland Coordinator for Meath Aisling O’ Donnell, Professional Services Pharmacist, IPU, Lara Marín Healthcare Development Manager Roche Diagnostics Sinéad Murphy, Pharmacist Kenlis Total Health Pharmacy Jai Sokay and Pharmacist Lynch’s totalhealth Pharmacy Neil Sokay

The purpose of the pilot programme is to provide free health checks to the population to identify risk behaviours that lead to the development of chronic diseases including diabetes and cardiovascular disease. Advice and support to manage and reduce identified risk factors aims to support a reduction in chronic disease burden in citizens of Meath. Funding is provided by Meath County Council under the Healthy Ireland Fund, supported by the Department of Health.

Healthy Meath is leading this initiative in partnership with a range of stakeholders, including the Irish Pharmacy Union, Kenlis totalhealth Pharmacy Kells, Lynch’s Total Health Pharmacy

Kells, McQuaids Pharmacy in Oldcastle, Roche Diagnostics and Healthy Ireland.

Neil Sokay pharmacist and owner of Lynch’s totalhealth Pharmacy is delighted to be taking part in the initiative noting that, “this is a great opportunity for the people of Kells and Oldcastle to get a free health check in their local pharmacy. We look forward to supporting people in identifying and managing their risk factors for chronic disease.”

Aisling O’Donnell, Healthy Ireland Coordinator with Meath County Council said “The free

chronic disease risk management programme is one of the steps Healthy Meath are taking to support people living in Meath to improve their health and wellbeing. Approximately 9,000 people die each year from cardiovascular disease in Ireland, deaths which in some cases can be prevented through early detection and improving lifestyle habits. This initiative is aligned with the Healthy Ireland Fund Local Strategy for Meath County Council which aims to reduce death from chronic diseases amongst the population in County Meath.”

Pharmacy - the Cream of Retail

Pharmacy leaders across Ireland have shown they are the cream of the retail crop, with shortlisting across a number of categories within the Retail Excellence Awards 2023. Over the past 25 years, the Retail Excellence Awards have been a beacon of recognition for outstanding achievements in the retail sector.

Could it be Sepsis?

Wednesday, 13th September marked World Sepsis Day and the HSE is encouraging people to learn about the signs and symptoms of sepsis, as early recognition and treatment is important.

McCauley Health & Beauty Pharmacy in Mahon Point.

Meanwhile, Noleen Murray of McCabes Pharmacy at Clarehall Shopping Centre has been shortlisted in the Top 5 for the Unsung Hero Award. This Award celebrates the unsung champions who go above and beyond for customers and businesses. These individuals embody commitment and excellence, making a lasting impact.

The HSE Sepsis Programme has developed information leaflets to help raise awareness of the signs and symptoms of sepsis.

Amy Regan of Adrian Dunne Pharmacy, Trim has been shortlisted as Manager of the Year with the Retail Excellence Ireland Awards. Amy has been shortlisted

with 4 other finalists as exceptional leaders who have redefined innovation and leadership.

Fellow finalist is another Pharmacy Manager, Michael Standen of

McCabes Pharmacy have another finalist listed in these Awards as Mia Keaveney of McCabes Pharmacy store in Dundrum has been shortlisted within the Top5 Rising Star of the Year Award.

Good luck to all the finalists, with the winners being announced at The Galmont Hotel, Galway on November 11th.

Life-Course Approach to Vaccination

A toolkit that encourages implementation of a “life-course approach” to vaccination by the pharmacy profession is published today by the International Pharmaceutical Federation (FIP). A life-course approach recognises that health is shaped by a series of events that occur throughout life, including vaccinations known to benefit specific age groups and vulnerable groups.

Disease prevention and health promotion is just as important during older age as it is in childhood, the authors of the toolkit write. For example, older adults are more vulnerable to more severe forms of several vaccine-preventable diseases, including influenza, COVID-19 and pneumococcal pneumonia. Other diseases, such as herpes zoster, can often be highly debilitating and painful in this group, diminishing quality of life and increasing dependence on painkillers. The World Health Organization Immunization Agenda 2030, recommends that all member states adopt a lifecourse approach to immunisation and the United Nations Decade of Healthy Ageing Action Plan 2021–2030 urges the scale up of age-friendly primary health care to provide a comprehensive range of services for older people, including

vaccination. Harnessing the power that pharmacists have to deliver the life-course approach to vaccination is key, the authors say.

The toolkit “Enabling equity in, access to and sustainability of life-course immunisation through pharmacy-based vaccination” outlines three key policy areas that need to be addressed:

1) Regulations and prescribing;

2) Service remuneration models; and

3) Access to data and vaccination records. For each area, case studies from different countries are presented along with enablers and barriers.

“Health equity is only achieved when there are no differences in the quality of and access to healthcare among all groups and at all ages in a society. This policy toolkit is aimed at FIP member organisations and seeks to accelerate pharmacy-based

life-course immunisation. Taking lessons from our members, the toolkit provides a universal list of enablers and barriers that organisations can use to track and monitor their progress towards this goal,” said FIP CEO Dr Catherine Duggan. She added: “FIP’s work on vaccination is based on the conviction that improving vaccination coverage and promoting a life-course approach to vaccination are global imperatives to which pharmacists can greatly contribute. The presence of pharmacies in every community, with long opening hours, allows for the easy, convenient access of community members to a health facility. For that reason, pharmacies can help diversify and simplify vaccination pathways, especially for working adults and older adults.”

Anyone with an infection can be at risk of sepsis, even those taking antibiotics however, this does not mean every infection will develop into sepsis. Those most at risk are aged 75 or over, have certain medical conditions such as cancer, COPD, diabetes, chronic kidney or liver disease, have a weak immune system or are very young children. Maternal sepsis is rare but can develop during pregnancy or up to 6 weeks (42 days) after the birth, a miscarriage or an abortion.

Dr Michael O’Dwyer, Clinical Lead, HSE Sepsis Programme, says, “It’s extremely important to recognise the symptoms of sepsis and to ask ‘could it be sepsis?’. But it’s as important to reduce your risk of developing it in the first place. There are things people can do to reduce their risk of sepsis, such as good personal hygiene, keeping up to date with your vaccinations, taking antibiotics as prescribed, and following medical advice recommended for chronic conditions.”

Signs and symptoms of sepsis in adults (including maternity) are:

S Slurred speech, new confusion, too sick to communicate, drowsiness.

E Extreme shivering, muscle aches, fever.

P Has not passed urine in the last 12 hours and does not feel like passing urine.

S Shortness of breath, lips tinged with blue, feels like your heart is racing, dizzy when you sit or stand.

I I feel like I’m going to die.

S Skin mottled and discoloured, new rash that is still visible when pressed on with a clear glass (glass test).

Amy Regan, Adrian Dunne Pharmacy, Trim

¤2.4m research on Deprescribing Medicines

Dr Frank Moriarty, Senior Lecturer at RCSI School of Pharmacy and Biomolecular Sciences, has received a €2.4 million Career Development Award from Wellcome to advance new methods to research deprescribing– the planned process of reducing or stopping medicines that may no longer be of benefit or may be causing harm.

Dr Frank Moriarty RCSI

people can respond very differently to these medicines, this will help support the monitoring and review of antidepressants to promote the best outcomes for patients with mental health conditions.

Improvements in healthcare mean people are living longer, and as they get older, people are often prescribed increasing numbers of medicines to prevent and manage disease. This increase in the number of medicines can lead to higher risk of medicine-related adverse effects. It is therefore important to develop robust approaches to identify medicines that might no longer be needed or

could be contributing to medicinerelated harm that can be safely stopped or deprescribed. The research funded in this award will harness the large amounts of information already collected as part of routine healthcare, such as GP and hospital visits. New methods from pharmacoepidemiology will be used to analyse these datasets, to improve our understanding of deprescribing practices. As the focus of healthcare shifts to more personalised medicine and patientcentered approaches, research in this area will inform the decisions of patients and their healthcare professionals and support optimal treatment. Ultimately, this will help people age better with the right medicines for them.

In addition, as part of the project, which will be known as DIAMOND (Developing Innovative Analytical Methods for research ON Deprescribing), a tool will be developed to identify patients most at risk of side effects from antidepressant medicines. Given

Commenting on the announcement, Dr Moriarty said “The support from this award will enable me to build a team to pave the way for high-quality deprescribing research and clinical practice. The evidence we hope to generate through innovative, data-driven approaches will improve the quality of healthcare to benefit population health. We are embedding open science in this project, by sharing our methods and tools for other researchers to use in future studies and maximise our impact.”

The grant award will run over 8 years, starting next year. As well as supporting research efforts and access to datasets, it will also facilitate the recruitment, training and development of new researchers.

“I would like to congratulate Dr Moriarty on this prestigious funding and acknowledge the support of Wellcome for awarding RCSI our first Career Development Award.

Haven Pharmacist’s Run for Charity

This is an important milestone which recognises our dedication to advancing cutting-edge research and fostering talented scientists” said Professor Fergal O’Brien, Deputy Vice Chancellor for Research and Innovation at RCSI.

“I look forward to seeing how this project will apply big data to a space where it has the exciting potential not only to improve medical practices but also to positively impact the lives of patients.”

Wellcome’s Career Development Awards are highly competitive grants supporting mid-career researchers’ career progression in biomedical science, health, and related fields. This award further enriches the RCSI research landscape, signifying the university’s continued commitment to excellence in scientific discovery and complementing previous successes in other Wellcome grant programmes. On this project, RCSI will collaborate with researchers from University College Cork, University College London, Queen’s University Belfast, the University of British Columbia and Complutense University of Madrid.

Huge congratulations to Pharmacist Padraig Murphy from Haven Pharmacy Murphy’s, Clonard who has just completed RUN65 for Wexford Marine Watch. Wexford Marine Watch, a voluntary organisation which provides Suicide Prevention Patrols along Wexford Quays, Estuary & Harbour, has received €18,000 euro from the RUN65 challenge.

The RUN65 challenge was undertaken by South East Radios Alan Corcoran and pharmacist Padraig Murphy. The men ran for a total of 65 days at several venues across the County to raise funds for the charity.

The money raised will enable the charity to continue their work and will go directly into recruitment and training.

Alan Corcoran and Padraig Murphy presenting the proceeds to Wexford Marine Watch

Alan Corcoran and Pharmacist Padraig Murphy

Pharmacist Padraign Murphy is congratulated by his pharmacy team and well wishers

Key Trends in Irish Community Pharmacy

Fitzgerald Power regularly update community pharmacy across Ireland as to the latest trends affecting the sector. Their quarterly reports offer valuable insight and expert analysis into how the Pharmacy and SME markets are performing. Every three months the team look at the key trends of certain sectors, and provide thorough breakdowns to help you get members get their heads around the numbers. The below is a summary of the latest analysis of the key trends in the Irish Community Pharmacy sector, prepared on a quarterly basis.

Revenue Pulse

Volume of sales

The volume of pharmaceutical sales, as measured by the CSO, increased by 0.3% in June 2023 against the same period last year.

CSO 0.3%

Summary Q2 2023

Irish economy

EY expects Irish GDP to increase by 4.8% in 2023 and 4.3% in 2024. Ireland is expected to outperform many economies around the world in 2023.

Irish pharmacy awards

Fitzgerald Power would like to congratulate all the winners in this year’s Irish pharmacy awards, but in particular John O’ Shaughnessy of Woods CarePlus Pharmacy on winning the Reckitt Community Pharmacist of the Year Award 2023.

Global economic trends

CSO

Rx Tracker

IQVIA data shows RX sales are up 6% in volume and 5% in value as against the same period last year.

The OECD has projected global GDP growth of 2.7% in 2023, which is the lowest annual rate since the global financial crisis and pandemic in 2020. Inflation remains high at 6.6% but is projected to fall to 4.3% by 2024.

Medicine supply issues

Ireland continues to be impacted negatively due to medicine supply issues in the last year, with 60% of respondents to an Azure Pharmaceuticals poll answering they had been impacted by medicine shortages in the past year.

Inflation

Inflation in the eurozone was 5.5% in June 2023, a decrease from 6.9% at the end of the previous quarter. Energy prices have continued to drive the decline.

Various 24%

Systemic Hormones 19%

Rx Tracker

.

IQVIA data shows RX sales are up 6% in volume and 5% in value as against the same period last year.

Diagnostic Agents 18%

Dermatologicals 17%

Musculo Skeletal System 14%

SOURCE: IQVIA

Top RX Classes by Growth

Market Pulse

It was a very strong quarter for sales, with Fitzgerald Power estimating 16 transactions completed in the 2nd Quarter of 2023. Fitzgerald Power provided advice on 14 transactions in H1 2023, which represents 70% of completed deals. (There were 20 transactions completed in H1 according to Fitzgerald Power research).

PSI data suggests there have been an equal number of openings and closures since January 2023, bringing the number of community pharmacies in Ireland to 1,906.

Top RX Classes by Value

32.3% 15.5% 11% 7.9% 7.3% x

Nervous System 32.3%

15.5%

SOURCE: IQVIA Alimentary T. & Metabolism

7.9%

11%

New Openings and Closures

7.9% Nervous

New Openings between 1st January ‘23 – 30th June ‘23 16

Systemic

Closures between 1st January ‘23 – 30th June‘23 16

Net Openings between 1st January 2023 – 3oth June 2023 0

SOURCE: PSI

SOURCE: FITZGERALD POWER

Local Professor at Forefront of European Guidelines

The European Society of Cardiology (ESC) has published new cardiology Guidelines on acute coronary syndromes (ASC). The expert-led taskforce delivering the Guidelines was chaired by Irish heart health expert, Professor Robert Byrne, Director of Cardiology at Mater Private Network and Professor of Cardiovascular Research at RCSI University of Medicine and Health Sciences.

the report states that healthcare providers must make a concerted effort to ensure that women receive evidence-based care.

3. Acute coronary syndrome is a spectrum of conditions

- Severity of ACS ranges from unstable angina (no irreversible heart damage) to various levels of myocardial infarction (heart attack), which can involve irreversible heart muscle damage. Despite this, management of conditions follows the same principals in each.

ASC is a key focus area of the new Guidelines, which provide detailed advice on treatment and will be instrumental in paving the way for doctors across Europe as they seek to improve patient care in the field of heart health, and in particular, the management of unstable angina and other related conditions.

Speaking from the European Society of Cardiology Congress in Amsterdam, Prof. Robert Bryne of Mater Private Network and RCSI University of Medicine and Health Sciences, commented, “Heart disease is the number one cause of death in women and men globally and as national leaders in cardiovascular care in Ireland, the team at Mater Private and RCSI University are passionate about propelling the field forward

to streamline patient care to drive better outcomes for patients.

“The new Guidelines highlight that time is critical to effective treatment and so, chest pain that lasts for more than 15 minutes and/or recurs within one hour should be taken very seriously. Other symptoms of cardiac distress include sweating, pain in the shoulder or arm, and indigestion. We recommend that anyone experiencing these symptoms contact emergency medical services immediately, day or night.

“Studies suggest that women go underdiagnosed for heart problems and thus we hope these Guidelines will serve as call to action to healthcare professionals to ensure female patients receive evidence-

United Drug launch New Podcast Series

based care at all times and remain alert to the symptoms when treating women.”

Six key takeaways from the report include:

1. Time is critical for treatmentAnyone experiencing chest pain lasting more than 15 minutes or recurring within one hour, along with other symptoms such as sweating, shoulder/arm pain, or indigestion, should call emergency services immediately.

2. Women are also at risk - It is a common misconception that acute coronary syndromes primarily affect men. Women are also at risk and should seek immediate medical help if they have symptoms. Knowing this,

4. Long-term management - After an ACS event, continuing care is critical. This is because patients are at increased risk of a repeat event. Medication and the adoption of proactive lifestyle changes such as diet, exercise, smoking cessation, and limiting alcohol will be a factor in preventing future events.

5. Acute coronary syndrome and cancer - Patients with cancer have a higher risk of ACS and the Guidelines include new recommendations for their management. This may involve balancing heart health and cancer treatments, including potentially interrupting cancer therapy if it is contributing to ACS.

6. Patient perspectives are vital - Healthcare professionals are encouraged to respect and incorporate patients’ preferences, needs, and values in clinical decisions. Patients should be informed about risks and options and be included in decision-making as much as their condition allows.

Following their successful webinar series, the United Drug team are launching a new series of podcast episodes. The podcast series, UD Talks, aims to provide meaningful insights and educational experiences to help pharmacists optimise their Retail Pharmacy and improve patient care in a more readily accessible fashion.

Designed to fit in with Pharmacist’s busy schedules, the UD Talk podcasts will be available to listen on your usual streaming platform. Each episode of UD Talks will feature guest speakers, thought leaders and industry experts to share their views on emerging pharmacy trends, assist with improving patient care and delivering unique insights. From illness awareness to strategies for optimising patient interactions, UD Talks will cover a wide array of topics relevant to pharmacy practice.

United Drug delivers best-in-class products, service, and business support for optimum patient care. Continuous updating and bringing innovation through developing the Knowledge Hub to keep customers updated on industry trends and insights.

To learn more about the podcast series and to subscribe please contact the United Drug Marketing team at udwmarketing@united-drug.com

Prof. Robert Byrne, Director of Cardiology at Mater Private Network and Professor of Cardiovascular Research and RCSI

Understanding Gut Bacteria

University College Cork (UCC) researchers have been awarded €2.7m by the European Research Council (ERC) to lead major studies on gut bacteria and the post-war history both of colonialism and of veterancy around the world.

Heart Attack Audit

The Irish Heart Foundation has welcomed the Irish Heart Attack Audit National Report 2021 by the National Office of Clinical Audit (NOCA).

exposed to air, some can make dormant structures called spores that are oxygen tolerant and can re-form a new actively growing bacterial cell when they reach the gut. SYNergize will develop an understanding of these sporeforming gut bacteria as a tool to target harmful pathogens.

The report was undertaken with 1,491 patients who had experienced a STEMI heart attack and had received treatment in a percutaneous coronary intervention (PCI) centre during 2021. 77% of those patients were male with a median age 61 and 23% were female with median age 67.

Dr Hilary Browne and Dr Dónal Hassett have been awarded ¤1.5m and ¤1.2m respectively from the ERC for their projects. Their ERC Starter Grants are awarded to early-career researchers, with 2-7 years of experience since completion of PhD, to lead innovative research.

Dr Hilary Browne is a Senior Staff Scientist in Dr. Trevor Lawley’s team at the Wellcome Sanger Institute based outside Cambridge in the UK. He will be joining the School of Microbiology and APC

Microbiome Ireland in UCC to lead his project entitled SYNergize – Understanding spore-forming gut bacteria biology to target pathogens.

The project SYNergize will study how beneficial gut bacteria transmit between people. Transmission of bacteria in our gut microbiome is constantly occurring, initially from our mothers when we are born and then later in life with the people that surround us. Despite most gut bacteria dying rapidly when

All Ireland Pharmacy Conference

The 10th All Ireland Pharmacy Conference (AIPC) will be held at Ballymascanlon House Hotel, Dundalk on 6th and 7th November 2023. The theme for this year’s conference is ‘Creating Momentum & Building Capacity’.

This conference is jointly coordinated by the Northern Ireland Centre for Pharmacy Learning and Development and the Irish Institute of Pharmacy. Its focus is to share good practice in pharmaceutical care and practice development across the primary and secondary care sectors. Pharmacists, technicians and qualified assistants are encouraged to exchange ideas for pharmaceutical service development in the Republic of Ireland and Northern Ireland.

Dr Hilary Browne said, “I am excited to conduct my ERC funded project alongside leading experts in gut microbiome research at UCC and APC Microbiome Ireland. This funding allows me to understand how spore-forming gut bacteria transmit between people and how this impacts their evolution and functions.”

Dr Dónal Hassett, Department of French, School of Languages, Literatures and Cultures, has received funding for a project entitled COLVET – Ex-soldiers of Empire: Colonial Veterancy of the Interwar world.

82% had at least one known cardiovascular risk factor, while 46% had high cholesterol, 44% had high blood pressure and 39% were smokers at the time of their heart attack.

According to the report, only 44% of patients called 999/112 for help within 60 minutes of onset of symptoms. However, time matters and calling an ambulance immediately will give the best chance of survival and quality of life following a heart attack. The paramedic will use an ECG machine to diagnose the heart attack and bring you to the nearest PCI centre to receive treatment. Patients will be twice as likely to be treated within the recommended time.

The report makes four key recommendations:

• Develop a public awareness campaign to encourage people with heart attack symptoms to call 112 or 999 immediately for emergency help in order to facilitate prehospital electrocardiogram (ECG) diagnosis of a STEMI.

• There should be a national and regional focus on quality improvement in the STEMI care pathway.

• Improve public awareness of the adverse impact of smoking on heart attack risk.

On the evening of Monday 6th November, the conference dinner will take place at 8.00pm and provides an opportunity to network with colleagues. The main conference proceedings will start at 9.30am on Tuesday 7th November and will involve parallel oral sessions and poster presentations. Visit www.allirelandpharmacyconference.com for full details.

• Support patients with STEMI to reduce the risk of further heart attack by increasing the rate of referral to cardiac rehabilitation phase 3. The report found that only 66% of those eligible for cardiac rehab were referred for treatment, despite their being a 90% target.

Dr Hilary Browne and Dr Dónal Hassett. Photo credit: Provision

Nicotine

An Unbeatable Way of Quitting Smoking *

*Provides significant improvement in quit rate vs patch alone. To verify contact: verify@perrigo.com Lindson N et al. 2019 Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Library. IRE NIQ 2023 15 NiQuitin CLEAR 24 hrs transdermal patches contain nicotine and are indicated for the relief of nicotine withdrawal symptoms including cravings as an aid to smoking cessation. Indicated in adults and adolescents aged 12 years and over. NiQuitin patches should be applied once a day, at the same time each day and preferably soon after waking and worn continuously for 24 hours. Apply a patch to non-hairy clean dry skin surface, a new skin site should be used every day. Therapy should usually begin with NiQuitin 21 mg/24 hrs and reduced according to the following dosing schedule: Step1 NiQuitin Clear 21 mg/24 hrs transdermal patches first 6 weeks. Step 2 NiQuitin Clear 14 mg/24 hrs transdermal patches next 2 weeks. Step 3 NiQuitin Clear 7 mg/24 hrs transdermal patches last 2 weeks. Light smokers (less than 10 cigarettes per day) are recommended to start at Step 2 (14 mg) for 6 weeks and decrease the dose to NiQuitin 7 mg/24 hrs for the final 2 weeks. In some instances (e.g. heavy smokers, those who have relapsed after NRT, or when one NRT product is not enough to control cravings), NiQuitin patches may be used in combination with a nicotine oral format (refer to the package leaflet for dosingguidance). Contraindications: non-smokers, hypersensitivity, children under 12 years and occasional smokers. Precaution: Supervise use if hospitalised for MI, severe dysrhythmia or CVA, if haemodynamically unstable. Use with caution in patients with active oesophagitis, oral and pharyngeal inflammation, gastritis, peptic ulcers, GI disturbances, susceptible to angioedema, urticaria, renal/hepatic impairment, hyperthyroidism, diabetes, phaeochromocytoma, seizures & epilepsy. Discontinue if severe persistent skin rash. Pregnancy and lactation: oral formats preferable to patches unless nauseous. Remove patches at bedtime. Side effects: sleep disorders, abnormal dreams, insomnia, headache, dizziness, nausea, vomiting, application site reactions, nervousness, palpitations, dyspnoea, pharyngitis, cough, dyspepsia, upper abdominal pain, diarrhoea, constipation, dry mouth, sweating, localised pain, urticaria, hypersensitivity, tremor, nervousness, palpitations, tachycardia, contact & allergic dermatitis, photosensitivity, arthralgia, myalgia, asthenia, malaise, influenza- type illness, fatigue, chest or limb pain, pain, seizures and anaphylaxis. Product not subject to medical prescription. PA 1186/018/004, PA 1186/018/005 & PA 1186/018/006

MAH: Chefaro Ireland

DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. Date of preparation: Feb 2023. SPC: https://www.medicines.ie/medicines/niquitin-clear-7-mg-24-hours-transdermal-patch-33085/spc https://www.medicines.ie/medicines/niquitin-clear-14-mg-24-hours-transdermal-patch-33083/spc https://www.medicines.ie/medicines/niquitin-clear-21-mg-24-hours-transdermal-patch-33084/spc NiQuitin Mini 2mg/4mg Mint Lozenges contain nicotine and are used for the treatment of tobacco dependence by relief of nicotine withdrawal symptoms and cravings. Indicated in adults and adolescents aged 12 years and over. NiQuitin Mini 2 mg are suitable for those who smoke 20 cigarettes or less a day. NiQuitin Mini 4 mg are suitable for smokers who smoke more than 20 cigarettes a day. Place a lozenge in the mouth whenever there is an urge to smoke, allow to dissolve completely. Do not chew or swallow whole. In heavy smokers, those who have relapsed after NRT, or when one NRT is not enough to control cravings, NiQuitin Minis may be used in combination with NiQuitin patches (refer to the package leaflet for dosing guidance). Abrupt cessation: Use a lozenge whenever there is an urge to smoke, maximum of 15 lozenges a day. Continue for up to 6 weeks, then gradually reduce lozenge use. Gradual cessation: Use lozenges whenever there is an urge to smoke in order to reduce the number of cigarettes smoked for up to 6 weeks, followed by abrupt cessation. Adolescents (12-17 years): only with advice from a healthcare professional. Should not quit with a combination NRT regimen. Contraindications: hypersensitivity to nicotine or any of the excipients, children under the age of 12 years and non-smokers. Precaution: Supervised use in dependent smokers with a recent myocardial infarction, unstable or worsening angina pectoris including Prinzmetal’s angina, severe cardiac arrhythmias, uncontrolled hypertensions or recent cerebrovascular accident. Use with caution in those with; stable cardiovascular diseases, diabetes mellitus, susceptibility to angioedema & urticaria, renal/hepatic impairment, phaeochromocytoma & uncontrolled hyperthyroidism, GI disease & seizures. Side effects: Nausea, mouth/ throat and tongue irritation, irritability, anxiety, insomnia, sleep disorders, dizziness, headaches, cough, sore throat, vomiting, diarrhoea, upper abdominal pain, GI and oral discomfort, flatulence, hiccups, heartburn, dyspepsia, dry mouth, constipation, ulcerative stomatitis, pharyngitis, pharyngolaryngeal pain, nervousness, depression, palpitations, heart rate increased, dyspnoea, rash, angioedema, pruritus, erythema, hyperhidrosis, urticaria, fatigue, malaise, asthenia, chest pain, anaphylactic reactions, hypersensitivity, tremor, dysgeusia, paresthesia mouth, seizures & epilepsy, dysphagia, eructation, salivary hypersecretion, influenza like illness. Product not subject to medical prescription. PA 1186/018/017 & PA 1186/018/012 MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

Date of preparation: Feb 2023. SPC: https://www.medicines.ie/medicines/niquitin-mini-2mg-mint-lozenges-35237/spc https://www.medicines.ie/medicines/niquitin-mini-4mg-mint-lozenges-33091/spc

“Since I quit, I enjoy a smoke-free life with my family” Paul

Enhanced Community Care Conference

The second national HSE Enhanced Community Care Conference (ECC) was held recently, and outlined how hospital attendances and admissions are down as a result of the ECC Programme.

• The investment of clinical frontline staff in the ECC Programme is unprecedented. Over 78% (2,733.2 WTE) of the planned whole time equivalent (full-time) staff have now been secured.

Opening the conference, Minister for Health, Stephen Donnelly TD, said: “The Enhanced Community Care Programme represents our unwavering dedication to providing exceptional healthcare to our communities.

“This crucial part of the Sláintecare Programme is a valuable resource providing both short-term and long-term benefits to the reform of healthcare delivery.

and daily operations. The core ethos of this ¤240m Programme revolves around delivering timely and effective treatments, while minimising unnecessary referrals and hospital admissions through a ‘home first’ approach, where safety and appropriateness are paramount. The substantial investment commitment by the Government - as well as the commitment shown by the HSE community to implement the ECC Programme - is now beginning to yield tangible results. The ECC Programme is redefining healthcare delivery, ensuring proximity to the communities we serve.”

As part of Sláintecare, ECC emphasises general practice, primary care, and communitybased services to provide care closer to home, reducing acute hospital attendance and admission. The work of the ECCs also plays a pivotal role in the Urgent and Emergency Care Plan 2023, as part of key hospitalavoidance measures.

Noel Ridge, a patient at the Galway Integrated Care Hub, where services are provided in an integrated fashion between GPs, practice nurses, community specialist teams and hospital specialist teams, highlighted how the hub had benefitted him: “I’ve had three heart attacks and been in the hospital nine times in the last 18 months. But I’ve come through it. The support I receive at the hub provides great comfort because I’m not waiting for hospital appointments that are months or a year apart.

“If I don’t feel well, I can call the hub right away and explain what’s happening. Overall, visiting the hub is much more convenient as it is closer to home and appointments are scheduled at specific times, which reduces a lot of stress.”

At the conference, held in Dublin Castle, healthcare professionals, policymakers, and stakeholders reflected on the significant progress made. The conference highlighted how service users are moving through the ECC’s integrated pathways of care, resulting in improved outcomes for people, and demonstrating

the transformative potential of integrated, community-based healthcare in Ireland.

• 91% of patients with chronic disease are, routinely, fully managed in primary care via the Chronic Disease Management in General Practice programme.

• GPs reviewed 309,778 patients, from January –July 2023, as part of the Chronic Disease Management Programme.

• Community Diagnostics Teams provided 196,988 radiology scans, between Jan –July. It is expected the total scans conducted will surpass the 253,172 conducted in 2022. This is extremely important as timely access to diagnostics meant an an 89% reduction in the number of patients requiring referral to emergency departments or acute medical units.

• In the first seven months of 2023, there were 48,230 patient contacts by the teams supporting older people - and 64% of their patients were discharged home, avoiding a potential hospital admission.

“The ECC programme has played, and will continue to play, an important role in ongoing planning for the Health Service, particularly through the development of alternative pathways, including ECC support for those at risk of hospital admission, expansion of GP out-of-hours service, and the implementation of pathways to support patient discharge.

“We will continue to press ahead with the full implementation of this ¤240m programme which underscores our commitment to placing patients at the heart of healthcare; providing care closer to home, while simultaneously alleviating pressure on our hospitals.”

Speaking at the conference, Bernard Gloster, CEO of the Health Service Executive said:

“The ECC Programme continues to demonstrate significant progress in its implementation

Keynote speaker at the event, Professor David Colin Thomé OBE, said: “In Ireland and the UK, we stand at a healthcare crossroads, grappling with evolving landscapes. With Ireland’s aging population and increasing chronic conditions, integrated care delivered closer to home becomes pivotal. Sláintecare’s ambition for a universal health service aligned with community care is impressive.

“The Enhanced Community Care Programme’s goal is bold and well-defined. By shifting focus to general practice, primary care and community-based services, the approach paves the way for comprehensive care pathways, care closer to people’s homes and a reduction in unnecessary hospital admissions.

Bernard Gloster, CEO of the HSE

“We will continue to press ahead with the full implementation of this ¤240m programme which underscores our commitment to placing patients at the heart of healthcare; providing care closer to home, while simultaneously alleviating pressure on our hospitals.”

Paul Reid, CEO, HSE

DON’T LET PAIN HOLD YOU BACK

*To verify contact verify@perrigo.com

ESSENTIAL INFORMATION

Solpa-Extra 500mg/65mg Soluble Tablets contains paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and adolescents over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Adolescents aged 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. Precautions: Particular caution needed under certain circumstances and medical advice sought for renal or hepatic impairment, Gilbert’s Syndrome, chronic alcoholism, glucose-6-phosphatedehydrogenase deficiency, haemolytic anaemia, glutathione deficiency, malnutrition or dehydration, the elderly, patients weighing less than 50kg. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Patients should be advised not to take other paracetamol containing products concurrently. Immediate medical advice should be sought in the event of overdose even if the patient feels well because the risk of irreversible liver damage. Excessive intake of caffeine should be avoided while taking this product. Interactions: warfarin and other coumarin, other medicines following the same metabolic pathway, cholestyramine, probenecid, chloramphenicol, metoclopramide, domperidone, sedatives, tranquilizers, flucloxacillin and some decongestants. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersensitivity reactions, very serious skin reactions, TEN, drug-induced dermatitis, SJS, AGEP, sterile pyuria. Unknown: nervousness, dizziness, neutropenia, leukopenia. Further information is available in the SmPC. Product not subject to medical prescription. Legal classification: P. PA 1186/017/001. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. Date of preparation: 02/2023. SPC: https://www.medicines.ie/medicines/solpa-extra-soluble-tablets-33783/spc IRE SOL 2023

Selling Online to Tomorrow’s Customer

Your online success starts with your customers. In a highly competitive market it is those who truly understand their customers and harness this knowledge who will achieve the most success.

Written by Orla Cooney, COO of Magico

could be particularly relevant for the pharmacy industry.

Expect Personalisation

Tomorrows online pharmacy customer will expect you to anticipate their needs. Use AI to analyse customers’ browsing and purchase history to suggest relevant over-the-counter medications, vitamins, and beauty products. Consider offering a “Frequently Bought Together” or “You Might Also Like” section for cross-selling and upselling based on individual preferences.

Organise the online store with dedicated sections for common health conditions (e.g., allergies, diabetes, heart health). Provide curated product collections and information related to each condition, making it easier for customers to find what they need. Offer loyalty programs or exclusive discounts on products that align with a customer’s purchase history or health needs.

Personalisation, whether though recommendations, loyalty or your email marketing strategy is expected by your customers but is also an excellent means of staying connected with your customers, by showing how much you understand them.

Demand Flawless Customer Care

Tomorrow’s customer will increasingly expect that they can access customer support on demand, live and automated chat is one tool that can bridge that gap and bring that rich customer experience of chatting to the instore team, online. Assist customers in finding the right products and addressing any concerns.

Global Connectivity

Tomorrow’s customers could be from anywhere in the world, to achieve success overseas online retailers will need to facilitate cross-border shopping and provide a seamless shopping experience. To be successful in a global market retailers will need to provide transparent shipping information, including estimated delivery times and costs for different countries. Clearly explain any international shipping policies, such as customs duties and taxes. Offer a variety of payment methods that are commonly used internationally, such as credit cards, PayPal, and digital wallets. It is also important to clearly communicate your international return and refund policies. This builds customer trust and helps them feel more confident about purchasing.

Socially Responsible

So who is tomorrow’s customer?

In this article we will explore some of the trends and characteristics of tomorrow’s online customer.

Digital Natives

Tomorrow’s online customers will consist of Digital Natives, customers who have grown up in a highly digital world. They will be very comfortable with technology as they will have been exposed to it from a very young age. Their mobile will be their preferred device for all online activities including shopping.

They will be more comfortable with voice activated search as more and more customers are using their smart speakers or assistants on their phones to search for products and shop online. Online retailers will

need to take this into consideration when optimising content and in particular product descriptions.

Tech Savvy Shoppers

Many pharmacies today are offering a range of online pharmacy services such as book a vaccination, e-prescriptions, online doctor and online photo printing. However tomorrows customer will expect more and are highly likely to engage with emerging technologies such as augmented reality (AR), virtual reality (VR), and artificial intelligence (AI). Savvy online retailers will be thinking about how they could enhance the online shopping experience by engaging the use of AR and or VR to help customers visualise products before purchasing.

For tomorrow’s customer, the experience from initial online engagement, to answering pre sales queries and after care service must be flawless. Customers will expect you to go above and beyond with personal touches such as personalised packaging and thank you for your order notes.

They will expect same-day or next-day delivery options, ambitious online retailers should be looking at the next frontier in order fulfilment. Warehouses and fulfilment centres are likely to employ more automation and robotics for tasks such as picking, packing, and sorting.

Drones and autonomous vehicles have the potential to revolutionize last-mile delivery, especially for smaller and urgent orders, this

Environmental and social responsibility will play a crucial role in the purchasing decisions of tomorrow’s customers. Everything from paperless offices to plasticfree packaging, consolidation of shipments and reducing the distance packages travel all contribute to how your target audience perceive your brand.

Influencer Effect

Social media influencers and peer reviews will continue to have a significant influence on tomorrow’s customers’ purchasing decisions. They will rely on authentic recommendations from sources they trust.

Shopping for tomorrow’s customers will not just be about acquiring products; it will be about the overall experience. Online pharmacy stores that create engaging, immersive, and memorable shopping experiences will stand out from their competition.

Celebrating World Hospice and Palliative Care Day

World Hospice and Palliative Care Day is an annual unified day of action to celebrate and support hospice and palliative care around the world. This year’s World Day theme is “Compassionate Communities: Together for Palliative Care” and takes place on Saturday 14th October 2023. This aims to highlight the important role that communities have in working compassionately to support the people requiring palliative care, their families, and the bereaved in their communities. In addition to World Day, Ireland is unique, and each year celebrates Palliative Care Week. This year it will take place from 11th – 16th September and the focus of palliative care week is ‘Living for today, planning for tomorrow’ (https://aiihpc.org)

Written by Dr Julie Ling, CEO, European Association for Palliative Care/ Chair, Worldwide Hospice and Palliative Care Alliance

Palliative care is an essential component of national health systems and an essential service within Universal Health Coverage reforms. Palliative care includes the physical, psychosocial, and spiritual care of people with lifelimiting conditions and aims to address pain and other symptoms by optimising their quality of life. Palliative care should be integrated early in the course of disease and should be available until the end of their lives and should consider how best to support bereaved families.

In 2014, the World Health Assembly unanimously passed a resolution to strengthen palliative care as a component of comprehensive care throughout the life course and should be

available to both children and adults. The World Health Assembly Resolution stated that palliative care is an ethical responsibility of health systems and a key component of universal health coverage. The continuum of universal health coverage under the United Nations Sustainable Development Goal number three includes Promotion, Prevention, Treatment, Rehabilitation, and Palliative essential health services. This also includes the allocation of funding for these services.

In a recent paper that ranked palliative care in 81 countries globally, Ireland ranked second.1 Ireland has a long and proud history of providing palliative care. The national palliative care policy developed in 2001,2 provided a comprehensive blueprint for the development of palliative care services. In subsequent years, many of the recommendations of the policy have been implemented. As a result, new posts have been developed, hospices have opened, palliative care education and training of health and social care professionals has been established and services have been developed in all regions of Ireland. In 2020, the programme for government, committed to publishing a new

Promoting Harm Reduction

palliative care policy for adults. This is expected in the coming months. A policy for children’s palliative care in Ireland was published in 2010 and this has resulted in improved access to palliative care for children and their families.3

Palliative care in Ireland has been enhanced through its recognition as a medical and a nursing specialty and its inclusion in the education and training of healthcare professionals with opportunities for both undergraduate and post-graduate training. In addition, a Palliative Care Competence Framework4 for all health and social care professionals has also been developed. Palliative care services are available throughout Ireland in all settings including hospitals, hospices and in the community as part of primary care. However, these vary within and between geographical regions nationally. Ideally palliative care should be available to all, regardless of their diagnosis, geographical location and yet in Ireland many people still do not have access to palliative care.

The OECD recently called for better care at end of life,5 they

found that despite many people preferring to die at home, half of deaths are in hospitals, and this is often due to a lack of home and community support. Whilst palliative care is available in the community in Ireland, the Lancet commission on the value of death suggests that to refocus death and dying as a part of life, greater community involvement is needed to compliment health and social care services.6 This is at the heart of compassionate communities. At the very simplest level, compassionate communities help to increase awareness of access to palliative care7 and recognise that health and social care services are important, but that care is also the responsibility of others.

Ireland has made huge advances in developing and strengthening palliative care. As we mark World Hospice and Palliative Care Day, this year’s campaign provides the opportunity to celebrate success but also to address the substantial gaps in access to palliative care services, to ensure that there is not only improved access to palliative care in Ireland but also to involve our communities.

References available on request

Marking International Overdose Awareness Day, the HSE in collaboration with St James’s Hospital is introducing Nalox-Home: a new pilot initiative designed to save lives and promote harm reduction among people who use drugs.

Nalox-Home provides free naloxone kits to patients who attend the St James’s Hospital Emergency Department (ED) and have experienced or are at risk of an opioid overdose. The pilot is a collaborative effort between the St James’s Hospital Emergency Medicine Department and Inclusion Health Service, and the HSE National Social Inclusion Office.

Nalox-Home includes a brief overdose awareness intervention delivered to patients at risk of opioid overdose, both upon discharge from the emergency department or after an inpatient admission. Central to the project is the prescription and provision of take-home naloxone, a medication that temporarily reverses the effects of opioids, providing a vital lifeline while awaiting medical assistance.

Speaking at an International Overdose Awareness Day webinar organised by the HSE, Professor Eamon Keenan, HSE National Lead, Addiction Services, said, “With opioids implicated in 7 out of 10 poisoning deaths identified by the Health Research Board’s (HRB) latest figures in 2020, and 57.5 per cent of those individuals accompanied by someone who may administer naloxone, the availability of naloxone can be crucial while waiting for medical care to arrive.

“By removing barriers to naloxone access, Nalox-Home offers hope through overdose awareness interventions and take-home naloxone for patients with a history of opioid use, as well as reducing stigma, supporting harm reduction and ultimately it will save lives.”

The end of erectile problems? Touch wood.

Sidena. Your new firm favourite.

ABBREVIATED PRESCRIBING INFORMATION

Product Name: Sidena 50 mg Tablets.

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

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

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

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

Contraindications: Hypersensitivity to sildena l or any of the excipients. Concomitant with ritonavir, nitric oxide donors or nitrates in any form, guanylate cyclase stimulators e.g. riociguat. In patients that sexual activity is inadvisable (e.g. severe cardiovascular disorders such as a recent (6 months) acute myocardial infarction (AMI) or stroke, unstable angina or severe cardiac failure). Refer these patients to a doctor. Patients with loss of vision in one eye due to NAION. Known hereditary degenerative retinal disorders. Severe hepatic impairment. Hypotension. Anatomical deformation of the penis. Women. Not intended if no erectile dysfunction.

Warnings and Precautions for Use: First diagnose erectile dysfunction and determine potential underlying causes (e.g. hypertension, diabetes mellitus, hypercholesterolaemia or cardiovascular disease), before considering pharmacological treatment. Consider the cardiovascular status of patients, since there is a degree of cardiac risk associated with sexual activity. Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death, ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and hypotension have been reported post-marketing in temporal association with the use of sildena l. Most, but not all, of these patients had pre-existing cardiovascular risk factors. Sildena l has vasodilator properties, resulting in mild and transient decreases in blood pressure. Caution: Patients with anatomical deformation of the penis (such as angulation, cavernosal brosis or Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). Advise patients that in case of priapism, prolonged erections (longer than 4 hours) or sudden visual defect, they should stop taking sildena l and consult a physician immediately. Administer to patients with bleeding disorders or active peptic ulceration only after careful bene t-risk assessment, as there is no safety information available. Interactions: Inhibitors of the cytochrome P450 (CYP) isoforms 3A4 (major route) and 2C9 (minor route) isoenzymes such as CYP3A4 inhibitors: Itraconazole, ketoconazole, erythromycin, cimetidine, HIV protease inhibitor saquinavir: May reduce sildena l clearance and increase sildena l plasma levels. Consider a starting dose of 25 mg. Strong CYP3A4 inducers e.g. rifampicin may increase sildena l clearance and decrease sildena l plasma concentrations. Grapefruit juice: May give rise to modest increases in plasma levels of sildena l. Nicorandil (Hybrid of potassium channel activator and nitrate): Due to the nitrate component it has the potential to have serious interaction with sildena l. Sildena l potentiates the hypotensive e ect of nitrates. Alpha blocker: Concomitant administration of sildena l may lead to symptomatic hypotension in a few susceptible individuals. Patients should be hemodynamically stable on alpha-blocker therapy prior to initiating sildena l treatment. Sildena l potentiates the antiaggregatory e ect of sodium nitroprusside in vitro. Not recommended in patients with a history of bleeding disorders or active peptic ulceration. Not recommended to use with other pulmonary arterial hypertension treatment containing sildena l.

Ability to Drive and Use Machinery: Minor in uence, dizziness and altered vision were reported. Patients should be aware of how they react to sildena l before driving or using machinery. Undesirable E ects: Very common: Headache. Common: Dizziness, visual disorders, visual colour distortion, vision blurred, ushing, hot ush, nasal congestion, nausea, dyspepsia. See SPC for more adverse e ects.

Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork. Marketing Authorisation Number: PA 0711/170/002. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417

E-mail: rowex@rowa-pharma.ie

Legal Category: Not subject to medical prescription.

Date of Preparation: Aug 2022

Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie) or by emailing Rowex pv@rowa-pharma.ie

Celebrating 40 years in business

Celebrating 40 years in business

Celebrating 40 years in business

2023 marks a very special anniversary for Wholefoods Wholesale, the largest distributor of natural foods and health care products in Ireland, celebrating 40 years in business. From very humble beginnings, Wholefoods has grown to a team of 100 staff with a portfolio of over 7,000 products

2023 marks a very special anniversary for Wholefoods Wholesale, the largest distributor of natural foods and health care products in Ireland, celebrating 40 years in business. From very humble beginnings, Wholefoods has grown to a team of 100 staff with a portfolio of over 7,000 products

To mark this anniversary, The Irish Pharmacy News caught up with Alan Martin (Managing Director), Ronan O’Flynn (Commercial Sales Manager) & David Morrin (Commercial Director) to discuss what sets Wholefoods apart from its competition and the future opportunities and challenges that lie in the years ahead.

2023 marks a very special anniversary for Wholefoods Wholesale, the largest distributor of natural foods and health care products in Ireland, celebrating 40 years in business. From very humble beginnings, Wholefoods has grown to a team of 100 staff with a portfolio of over 7,000 products To mark this anniversary, The Irish Pharmacy News caught up with Alan Martin (Managing Director), Ronan O’Flynn (Commercial Sales Manager) & David Morrin (Commercial Director) to discuss what sets Wholefoods apart from its competition and the future opportunities and challenges that lie in the years ahead.

To mark this anniversary, The Irish Pharmacy News caught up with Alan Martin (Managing Director), Ronan O’Flynn (Commercial Sales Manager) & David Morrin (Commercial Director) to discuss what sets Wholefoods apart from its competition and the future opportunities and challenges that lie in the years ahead.

How have consumers behaviors and attitudes changed in recent times?

How have consumers behaviors and attitudes changed in recent times?

How have consumers behaviors and attitudes changed in recent times?

AM: In the early stages of the pandemic, consumers became much more vigilant with maintaining optimal health. As consumers waited anxiously for access to a vaccine, awareness on the benefits of food supplements with a healthy diet

AM: In the early stages of the pandemic, consumers became much more vigilant with maintaining optimal health. As consumers waited anxiously for access to a vaccine, awareness on the benefits of food supplements with a healthy diet

AM: In the early stages of the pandemic, consumers became much more vigilant with maintaining optimal health. As consumers waited anxiously for access to a vaccine, awareness on the benefits of food supplements with a healthy diet

became more evident. As a trusted partner with a long heritage in the VMS category, Wholefoods was very well positioned to support pharmacies to adapt quickly to these opportunities.

became more evident. As a trusted partner with a long heritage in the VMS category, Wholefoods was very well positioned to support pharmacies to adapt quickly to these opportunities.

became more evident. As a trusted partner with a long heritage in the VMS category, Wholefoods was very well positioned to support pharmacies to adapt quickly to these opportunities.

ROF: A key focus for Wholefoods in recent years has been to regrow categories that were suppressed during the pandemic. Women’s health, Digestive health, Stress, and sustainability are key areas of growth. Menopause has traditionally been as a taboo subject. At Wholefoods, we partnered with fabÜ Laura Dowling - the fabulous Pharmacist and A.Vogel with Elaine Crowley to help raise awareness of the various symptoms associated with menopause and it’s great to see women comfortably discussing this life stage and seeking out natural treatments. Digestive health has shown enormous growth during and post pandemic. We have worked closely with Optibac to drive science based clinically supported solutions for Gut Health. Stress-related conditions have become more prevalent in recent years, and we have seen a

ROF: A key focus for Wholefoods in recent years has been to regrow categories that were suppressed during the pandemic. Women’s health, Digestive health, Stress, and sustainability are key areas of growth. Menopause has traditionally been as a taboo subject. At Wholefoods, we partnered with fabÜ Laura Dowling - the fabulous Pharmacist and A.Vogel with Elaine Crowley to help raise awareness of the various symptoms associated with menopause and it’s great to see women comfortably discussing this life stage and seeking out natural treatments. Digestive health has shown enormous growth during and post pandemic. We have worked closely with Optibac to drive science based clinically supported solutions for Gut Health. Stress-related conditions have become more prevalent in recent years, and we have seen a

ROF: A key focus for Wholefoods in recent years has been to regrow categories that were suppressed during the pandemic. Women’s health, Digestive health, Stress, and sustainability are key areas of growth. Menopause has traditionally been as a taboo subject. At Wholefoods, we partnered with fabÜ Laura Dowling - the fabulous Pharmacist and A.Vogel with Elaine Crowley to help raise awareness of the various symptoms associated with menopause and it’s great to see women comfortably discussing this life stage and seeking out natural treatments. Digestive health has shown enormous growth during and post pandemic. We have worked closely with Optibac to drive science based clinically supported solutions for Gut Health. Stress-related conditions have become more prevalent in recent years, and we have seen a

growth in the understanding of the gut brain axis. This has also resulted in growth in Stress category brands like Rescue Remedy and magnesium brands MAG365 and PrizMag. We have worked closely with Pharmacy groups to develop their intimate care category with clean sustainable product ranges. Pharmacy is the ideal location to discuss intimate conditions and to deliver solutions.

growth in the understanding of the gut brain axis. This has also resulted in growth in Stress category brands like Rescue Remedy and magnesium brands MAG365 and PrizMag. We have worked closely with Pharmacy groups to develop their intimate care category with clean sustainable product ranges. Pharmacy is the ideal location to discuss intimate conditions and to deliver solutions.

growth in the understanding of the gut brain axis. This has also resulted in growth in Stress category brands like Rescue Remedy and magnesium brands MAG365 and PrizMag. We have worked closely with Pharmacy groups to develop their intimate care category with clean sustainable product ranges. Pharmacy is the ideal location to discuss intimate conditions and to deliver solutions.

DM: The pandemic almost gave people an opportunity to ‘reset’ and be more mindful of their health. We saw a huge demand for immune-related products, such as vitamin D, vitamin C and echinacea but let’s not forget that COVID-19 and various lockdowns also took its toll on people mentally. The stress and sleep category has grown rapidly since 2020 and we continue to see demand for both herbal options such as valerian and ashwagandha but also for mineral supplements such as magnesium.

DM: The pandemic almost gave people an opportunity to ‘reset’ and be more mindful of their health. We saw a huge demand for immune-related products, such as vitamin D, vitamin C and echinacea but let’s not forget that COVID-19 and various lockdowns also took its toll on people mentally. The stress and sleep category has grown rapidly since 2020 and we continue to see demand for both herbal options such as valerian and ashwagandha but also for mineral supplements such as magnesium.

DM: The pandemic almost gave people an opportunity to ‘reset’ and be more mindful of their health. We saw a huge demand for immune-related products, such as vitamin D, vitamin C and echinacea but let’s not forget that COVID-19 and various lockdowns also took its toll on people mentally. The stress and sleep category has grown rapidly since 2020 and we continue to see demand for both herbal options such as valerian and ashwagandha but also for mineral supplements such as magnesium.

Wholefoods’ Managing Director Alan Martin (L), Commercial Sales Manager Ronan O’Flynn & Commercial Director David Morrin (R)

Wholefoods’ Managing Director Alan Martin (L), Commercial Sales Manager Ronan O’Flynn & Commercial Director David Morrin (R)

Wholefoods’ Managing Director Alan Martin (L), Commercial Sales Manager Ronan O’Flynn & Commercial Director David Morrin (R)

What sets Wholefoods apart from other wholesalers?

ROF: Education is a key pillar of our company strategy. We see our customers as our partners, and empowering our customers to recommend our products through the provision of high-quality training is the cornerstone of what we do. Most of our sales team are fully qualified nutritionists. There is a growing shift amongst the Irish public to better understand what they are consuming, and we believe that training both pharmacists and OTC staff will allow them to recommend our products with confidence. October will see Wholefoods embark on a national training roadshow across Dublin Cork & Galway, where we will give retailers the opportunity to receive product training from some of our most well-known brands such as A.Vogel, Teetha, Optibac, Eskimo, fabÜ & Kinvara Skincare. We also have a dedicated training video library that can be accessed by retailers via the company’s website and actively share content with customers who have their own inhouse libraries. We partner with key brands to provide remote virtual training sessions, as well as having dedicated full-time product trainers from Optibac, A. Vogel, Kinvara and Eskimo available for in-store training sessions. But it’s not just training and education, we also provide full marketing support to grow our brands in terms of merchandising materials, social media assets and specific Irish national advertising campaigns across TV, radio and digital. For example, this October will see Optibac probiotics run its first ever national TV advertising campaign in Ireland, and we believe that this will further support pharmacy sales for the Optibac brand.

DM: Our multi-channel approach very much sets us apart from other distributors and wholesalers. Wholefoods began its journey 40 years ago supplying health food stores. Our heritage and expert insights in the VMS category has allowed us to identify growing trends within this channel to identify and grow suitable brands for pharmacy and other channels. One trend that we have noticed in pharmacy is a growing interest in the healthy snacking & benefit foods categories and at Wholefoods, we’ve been able to take learnings from our health store & grocery sales channels to optimize the offering for our pharmacy customers. One of our key marketing goals for 2023 is to become more ‘visual’ and we have focused on creating more detailed buying guides across multiple categories to give pharmacies a better understanding of what we can offer, our Christmas Catalogue is a great example of this with 800+ products visually represented. We also have a very strong relationship with our sister company Allegro, we constantly collaborate to share learnings and best practices specifically within the pharmacy channel and command leading positions in OTC categories such as VMS, beauty, skincare & fine fragrances.

AM: Wholefoods is a strong supporter and champion of the natural products industry, in terms of working with our brand partners and retail customers to best serve the needs of the end consumer. The industry has been presented with many significant challenges in recent years, such as the COVID-19 pandemic and Brexit, and the flexibility, agility and commitment of our highly experienced team allowed us to but thrive against a challenging operational backdrop. In 2019, we worked very closely with the Irish Health Trade Association (IHTA) to protect our industry from government plans to implement a 23% VAT rate on all food supplements. We are proud to have played a very active role in participating alongside industry partners to positively influence Government policy in securing the reduced rate of VAT. We put an enormous value on our brand partnerships and to mark our 40th anniversary this year, we opened our doors to our retail customers by hosting an Open Day at the company’s premises in Dublin 10, which saw over 90 exhibitors from VMS, Skincare and Food brands connect with retailers from both health food stores and pharmacies. The enormous success of this event and the collaboration with our key partners underlines the joint success that we have enjoyed over four decades.

What challenges and opportunities exist in the years ahead for retailers supplying health & wellness products?

DM: European and domestic regulations surrounding the sale and marketing of food supplements are becoming increasingly stringent. Whilst this has the potential to limit some products and categories, it will have long-term benefits in promoting consumer confidence. Wholefoods have a very experienced team to ensure that VMS products placed on the market remain fully compliant against an ever-changing regulatory landscape. In April 2021, the Joint Committee on Health published an extensive paper on highlighting Vitamin D deficiency in Ireland and the role of supplementation. Whilst regulations may tighten, there remain opportunities in VMS as awareness, education and research continues to improve. At Wholefoods, we are well placed to support our customers to comply with any future regulatory changes that may arise.

One of the biggest challenges for any organization is finding ways to innovate. How have Wholefoods innovated in recent years?

ROF: Wholefoods see the OTC pharmacy sector as a key part of the growth in the natural products industry. In 2021, we launched our own range of nutritional supplements under the brand, ‘Nutri Nua’, which was developed in-house to meet the

demands for a clean, vegan, excipient free and sustainable vitamin range in pharmacy. Having analysed the pharmacy VMS category, we saw an opportunity for a high-quality range of products made in Ireland. 2021 was not an ideal backdrop to launch a new brand due to the pandemic, but this didn’t dampen the success of Nutri Nua which has far exceeded our expectations. We are so grateful to pharmacy retailers for the support they have given in launching an Irish brand over the past two years and we will continue to innovate with new product development under the Nutri Nua brand. Wholefoods have also worked in close collaboration with Laura Dowling, aka The Fabulous Pharmacist, to help develop and launch fabÜ, a range of supplements that combines the world’s best botanical extracts, herbs, plants and mushrooms with vitamin and minerals. We are so proud to be working with Laura to distribute fabÜ. She has done an amazing job to build the brand so quickly and we look forward to continuing to grow fabÜ for the remainder of 2023 and beyond.

What’s next for Wholefoods?

AM: The market is constantly changing, in terms of new product development but more importantly adapting to the needs of the Irish consumer. Wholefoods will continue to evolve to respond to these changes. The OTC market has rebounded much quicker and the value of the market is higher following COVID-19. The pandemic has really highlighted the importance of food supplements to help support and maintain our health and wellbeing. Wholefoods will continue to strive to support pharmacies through education, innovation, and the sourcing and introduction of new and exciting brands to Irish consumers. We are very well positioned to use our heritage, knowledge, and trusted relationships to capitalize on the changes in consumer trends and the needs of a more informed, curious and educated consumer. We have a proven model that supports retailers in managing an OTC category that is rapidly evolving and growing. Being one step ahead of consumer trends is our lifeblood and this is what retailers demand from us.

CELEBRATING 40 YEARS IN BUSINESS

Subfertility: Seeking Help in the Pharmacy

Written by Dr John Waterstone, Medical Director, Waterstone Clinic

Couples experiencing a delay in achieving a pregnancy may well talk to a pharmacist before seeing their GP or a gynaecologist. Pharmacists should be able to provide practical advice.

The following are some of the questions pharmacists may be asked and suggested answers:

When should we be trying?

o Every one or two days over the five days before ovulation.

How do I know when I’m ovulating?

o By the calendar, 14 days before the next period is due or using ovulation predictor kits (OPKs). These daily urine tests detect the LH surge, which precedes ovulation.

Are OPKs a ‘good’ idea?

o Yes, they are the best way to confirm that ovulation is occurring and to know when. They also concentrate minds and focus effort: couples shouldn’t waste any of the twelve opportunities per year to conceive.

Is it wise to get any other fertility test done after trying for a few months?

o A semen analysis is worth considering if it can be easily arranged. If semen quality is so poor that natural conception is extremely unlikely, the couple could be wasting valuable time.

At what point should I see a doctor?

o After 12 months is the accepted wisdom, but after 6 months if the woman is 37 or older, and straight away if she is 41 or more.

What doctor should I see?

o Medical practice has become very subspecialised and it is best to see a doctor who works all the time in a fertility clinic.

What tests will be carried out?

o A semen analysis; a set of hormone tests for the woman, some of which will assess egg numbers; a transvaginal (internal) ultrasound

scan to assess the uterus and ovaries. A test of fallopian tube normality is also likely.

At what point should fertility treatment be recommended if our subfertility is ‘unexplained’ (i.e. all tests indicate natural conception can happen, but it isn’t)

o After 18 months of unprotected intercourse, but sooner for patients who are older and/or have low egg numbers.

What are the different fertility treatment options?

o Ovulation induction followed by intercourse (OII) is for patients who seem to not be ovulating. Usually, tablets are used (Clomid or Letrozole, but occasionally low-dose FSH injections). The patients most commonly have PCOS.

o Intrauterine Insemination (IUI) is for patients with unexplained subfertility or mildly suboptimal semen. Low-dose FSH injections are used.

o IVF/ICSI can be used for all types of subfertility, often when simpler treatments have failed. High-dose FSH injections are given together with LHRH analogue injections. Multiple eggs are generated and collected. Embryos are produced and transferred or frozen.

Pharmacists may wish to familiarise themselves with the protocols used for OII, UI and IVF/ICSI and the medications involved. Information leaflets provided to patients by fertility clinics are a helpful resource.

Pharmacists should be aware that the most vital injection of all in an IVF/ICSI treatment cycle with regard to timing is the ‘trigger’. Patients must take this injection at exactly the right time: the exact interval varies between clinics, but generally, it is 35.5-36.5 hours prior to the scheduled egg collection.

Subfertility is stressful, and patients are desperate to do all they can to improve their chances of a baby, through natural conception or treatment. They often take supplements (‘nutraceuticals’) in the hope

Dr John Waterstone is Medical Director of Waterstone Clinic and has dedicated his medical career to women’s health and fertility.

He is committed to leading innovation in Reproductive Medicine in Ireland. He is a graduate of both the Science Faculty (Genetics) and Medical School of Trinity College, and began his career at the Rotunda Hospital, Dublin before training in Obstetrics & Gynaecology in teaching hospitals in London He is a Consultant Gynaecologist, specialising in fertility investigations and surgical interventions for resolving fertility issues.

that these will help. Those most likely to take nutraceuticals are women who have produced very low numbers of eggs with IVF (or had repeated failed cycles) and men with apparent suboptimal semen quality. Good evidence that any nutraceutical improves the chance of a baby is lacking; published studies tend to be of poor quality, too small, and too poorly controlled to allow firm conclusions.

Women may request or be recommended DHEA, Coenzyme Q-10 (CoQ-10), melatonin or growth hormone. One small randomised controlled study of CoQ-10 (200mg TDS for 60 days) versus placebo in IVF poor responders suggested an increased chance of a live birth.

There is speculation that ‘oxidative stress’ may be a causative factor when semen quality is suboptimal. Antioxidant treatment (i.e. with ‘Wellman’ type preparations) is often recommended. There is poor-quality evidence that such antioxidant treatment can improve success rates after IVF/ICSI. A number of antioxidants tend to be given together, including Vitamin E, Vitamin C, carnitine, M-acetylcysteine, CoQ-10, zinc, selenium, folic acid and lycopene.

Those with fertility problems are often stressed and emotional; they will both appreciate and benefit from the kindness they receive at their pharmacy.

Nutri Nua is a range of nutritional supplements designed to meet the needs of the Irish pharmacy that doesn’t compromise on quality, purity or ethics.

Exclusively available from Wholefoods Wholesale

Proudly developed, owned & distributed by Wholefoods Wholesale.

Celebrating 40 years in business in 2023.

New and Innovative Service for High Risk Ovarian Cancer Patients

The Advanced Nurse Practitioner led Gynaecology Oncology Family History Clinic is a new, innovative approach to the care of women with BRCA 1 and BRCA 2 germline alterations to manage their ovarian cancer risk reduction strategy. The new service established at The National Maternity Hospital and St Vincent’s University Hospital prioritises prevention of ovarian cancers in these patients, through risk reduction surgery. However, this is a complex issue for pre-menopausal women as it affects fertility and, surgery results in menopause.

Recent Irish research has established that information needs are important to women with BRCA (NCCP, 2023; Warner and Groake, 2022). In its Hereditary Cancer Model of Care document (2023), the National Cancer Control Programme describe the provision of accurate, consistent information as a key theme from research carried out with this patient group. Warner and Groake (2022) found that patients were disempowered by dealing with high levels of uncertainty in their care following BRCA diagnosis, as a result of inconsistent information given by different health care professionals. The NCCP (2023) also states those with a genetic predisposition to ovarian cancer should have access to clear information regarding the symptoms of surgical menopause and longer term health risks associated with this prior to surgery and, that patients should have access to expert, individualised advice regarding their options for menopause management (NCCP 2023). A recurrent theme from national and international literature is that women do not regret undertaking risk reducing salpingo-opherectomy but repeatedly highlight a lack of information sources particularly around the long term impact of prophylactic surgery in a variety of areas including fertility, menopause (and the use of

hormone replacement therapy) bone health, cardiovascular risk and cognitive protection.

The NCCP (2023) Hereditary Cancer Model of Care document describes the role of CNSs and ANPs as key to the provision of cancer predisposition services.

The ANP led Gynae Oncology Family History Clinic, the first of its kind nationally, was established in 2022 and is run on a virtual basis, reducing the need for patients to attend the hospital. From 1st Sept 2022 to 1st June 2023, 95 virtual consultations were offered by the Gynae Oncology ANP. These

Written by Sarah Belton, Advanced Nurse Practitioner in Gynaecology Oncology at The National Maternity Hospital

consultations bring specialist services to the patient in their own environment, a key aim of Slaintecare. Previously, these patients were seen in the Gynaecology clinic routinely. The new service has increased capacity within the Gynaecology service, at a time when there is significant demand. Patients with a genetic mutation predisposing them to cancer have a high burden of scans and clinic appointments to attend across multiple specialties. In the current cost of living crisis, each of these visits cost the patients’ time and money for fuel, car parking, time off work, potential childcare costs, etc.

As part of the Irish Cancer Society funded Women’s Health Initiative, thisisGO.ie was developed to provide a safe, online, personalised resource that provides current, reputable, relevant and evidence based information for Irish women with gynaecological cancer. Developed with patients, by patients and for patients the site is built on the principle that patient involvement and engagement must be embedded in every stage of the development process from conception to design to implementation. It includes a section dedicated to patients with BRCA mutations. Patients are recommended to consider risk reducing surgery from the age of 40 for BRCA1 mutation, and from the age of 45 for those with a BRCA2 mutation. This demographic is familiar with accessing content and information on mobile internet devices and using the established platform thisisGO.ie. Future development plans for the service include tailoring information on thisisGO.ie to cover patients’ individual status for hormone replacement therapy, as per the National Women’s Health Action Plan 2022 – 2023, as an example.

The National Cancer Strategy (DoH, 2016) recognised that cancer genetics in Ireland was under-developed and underfunded. However, recent support from the HSE Nursing and Midwifery Practice Development Unit to develop an ANP role, support of stakeholders across The National Maternity Hospital and St Vincent’s University Hospital, establishing a designated nurse led clinic, plus the development of thisisGO. ie patient resource have all contributed to an improved specialist service for patients. Involving service users to develop consistent, evidence based, relevant patient information would further improve the landscape for patients with BRCA mutations nationally, as thisisGO.ie is not restricted to a specific institution or health care setting.

The ANP led Gynae Oncology Family History Clinic has been awarded the Susanna Byrne Perpetual Award by the HSE Nursing and Midwifery Practice Development Unit in Dublin South, Kildare and Wicklow, for demonstrating commitment and excellence in improving the care delivered to patients/clients and their families.

“As part of the Irish Cancer Society funded Women’s Health Initiative, thisisGO. ie was developed to provide a safe, online, personalised resource that provides current, reputable, relevant and evidence based information for Irish women with gynaecological cancer”

Use of Testosterone Therapy in Menopausal Women

Menopause awareness is steadily growing, and more women are seeking information from friends, healthcare practitioners and social media to learn about menopause and HRT. An increasing area of interest in menopause is the use of testosterone and the perceived benefits thereof. Women may have heard that testosterone is ‘the missing hormone’ and will come to you asking for more information and or a prescription. It is helpful to understand when testosterone should be used, and the potential benefits and risks.

Written by Dr Genevieve Ferraris, GP and Menopause Specialist, The Menopause

product is also discussed, and recorded in their notes.2 IMC guidance on the prescription of unlicensed medication should be consulted. Of note, there is a 1% testosterone cream for women licensed in Australia (AndroFeme®) but which remains unlicensed outside of Australia.

Testosterone in women comes from three sources:1

1. The ovaries (25%)

2. The adrenal glands (25%)

3. Peripheral conversion of androstendione (from the ovaries and adrenal glands) into testosterone

Levels of testosterone decline gradually with age, with the greatest drop occurring in women between the ages of 20 and 40.2 By menopause, the levels have plateaued and remain mostly stable. Levels only drop abruptly after bilateral oophorectomy.3

Androgens in women are essential for development of female sexual anatomy and physiology,4 as well as modulation of sexual behaviour and desire.3

The decision of when to prescribe testosterone should be based on symptoms and not on serum levels of testosterone. Women may have low testosterone levels and remain asymptomatic –testosterone replacement in this case in not appropriate.4 Currently, the only prescribing indication for testosterone is in postmenopausal women with low libido which is causing distress (hypoactive sexual desire disorder).3

Hypoactive sexual desire disorder (HSDD) is defined as ‘persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity with marked distress and interpersonal

difficulty’.3 A biopsychosocial approach should be taken in women with low libido as it is very multifactorial. Other causes, including relationship difficulties, psychological concerns, physical symptoms, sociocultural issues and medication side effects should be assessed for and treated appropriately first.3,4

Thus far, studies to date have not demonstrated beneficial effects of testosterone in women for mood, cognition, energy and musculoskeletal health.4 There is a need for good quality studies with these health issues as primary outcomes, as some patients do report an improvement in these areas with the use of testosterone therapy.4 There is also very little data currently available on the use of testosterone in premenopausal women.4

NICE Menopause Guidelines suggest that before a woman is started on testosterone therapy she should be offered a trial of conventional HRT,4 as her symptoms may improve simply with the initiation of an appropriate HRT regime. The incidence of potential adverse side effects may also be higher in women who are on testosterone-only therapy.4

If testosterone is to be used in a patient, there are various preparations available. There are currently no licensed testosterone products available for women in Ireland and the UK. It is therefore reasonable to prescribe licensed male preparations for female patients and down-titrated to an appropriate female dose.3,4 It is important that when counselling patients on the benefits and risks of testosterone that the use of an unlicensed

Transdermal preparations provide the most physiologic form of replacement; intramuscular injections, subcutaneous pellets and oral preparations should be avoided in case of supraphysiologic levels and side effects.3 Transdermal preparations should be dosed to maintain premenopausal physiologic ranges – in most cases this will be one tenth of the prescription male dose.3,4 One of the most commonly prescribed products for women in Ireland is Testogel® 50mg sachets. Women should apply one tenth of a sachet (ie 5mg per day) once daily to the upper outer thigh or buttock. AndroFeme® is also available and is dosed as 0.5ml daily with a dosing applicator. It is applied in the same way as Testogel.

The most common side effects with testosterone are excess hair growth (especially in areas of gel application), acne and weight gain.4 These are reversible with dose reduction or discontinuation of the product. Male pattern baldness, voice deepening and clitoromegaly are very unlikely with physiologic doses.4 Clinical trials have shown no impact on lipid metabolism, cardiometabolic makers, liver function and breast density, however there remains a lack of long term safety data.3

Patients should be monitored for clinical response to treatment, with most patients noting an improvement in sexual function between 6 weeks and 3 months of use.3,4 They should then be followed up every 6 - 12 months, noting both benefits and any side effects.4 Treatment should be discontinued after 6 months of use if there has been no clinically significant improvement in symptoms.3

The British Menopause Society recommends that, prior to initiating treatment, women have blood tests to establish baseline testosterone levels (and to ensure that levels are not actually high before starting therapy).4 Total testosterone levels should then be repeated between 6 weeks and 3 months from starting, and thereafter every 6 – 12 months.4 Levels should be maintained within a physiologic range. Total testosterone levels, rather than free androgen index, provide a more accurate representation of response to treatment.

The menopause transition can be a difficult time in a woman’s life, and she may seek any treatment that could improve her symptoms. While testosterone does have a role to play in managing some of these symptoms, the benefits may have been oversold in the general media and we should remain mindful as practitioners as to when, why and how we prescribe it. However there are good guidelines that exist as above, and in patients where it is appropriate to prescribe testosterone we should not be afraid to do so.

References available on request

Hub

10-Point Plan for a Menopause Friendly Workplace

I set up The Menopause Hub – Ireland’s first-ever clinic solely devoted to helping women through the menopause and perimenopause – after finding out for myself the appalling lack of help available to women in their 40s and 50s whose bodies were beginning to change.

Later, I discovered that many highly qualified women in Ireland with significant talent and experience were either quitting – or on the brink of walking out on – successful careers simply because they were finding their menopause symptoms overwhelming and were not being supported by their employer.

4 in 10 women considered giving up work or cutting back their hours. And 1 in 10 women have left work due to symptoms. Employers cannot afford this loss of talent.

Menopause in the workplace remains an “overlooked cultural taboo that is mistakenly swept under the carpet”.

But the problem simply won’t go away if we just ignore it.

Some major – and forward-thinking – employers across Ireland and the UK are introducing menopause training programmes because they understand they must adapt if they want to retain highly skilled and experienced female employees.

They know it makes perfect business sense for them to do so.

A large number of organisations, however, remain behind the curve – but they can easily get up to

speed by following this simple 10-point plan:

1. First things first, speak to your staff by conducting focus groups or surveys. A confidential survey is an effective way to gauge attitudes across the workplace. Follow-up surveys can be carried out to evaluate the effectiveness of any subsequent training programmes.

2. Formulate a menopause policy for the organisation. But make sure it is communicated to everyone in the workforce after doing so, and that it becomes a living document which is regularly revisited and updated. Do not leaving it on the shelf, gathering dust. And make sure that it integrates with your other workplace policies.

3. Begin menopause awareness training programmes. These will help normalise the conversation around menopause. Education is key to eradicating any embarrassment people may have about discussing this complex subject. Menopause awareness for all colleagues will open up the conversation.

Written by Loretta Dignam, Founder & CEO, The Menopause Hub

4. Appoint Menopause Champions. Mental health first aiders are now commonplace in workplaces and act as a listening ear and sign-poster for employees. Menopause Champions can perform a very similar role and be the first port of call for any staff struggling with symptoms. However menopause training is essential for Menopause Champions.

5. Make sure senior executives show their support for new initiatives. Change begins at the top, therefore it is vital that your menopause in the workplace programme enjoys the strong and visible backing of the senior ranks. If senior leaders can talk about their direct or indirect experience of menopause this will give permission for others to open up. Don’t under estimate the power of senior role model in the menopause conversation.

6. Involve male employees. Male allies are vital because menopause impacts us all, directly or indirectly at some point in our lives – it is not solely a woman’s issue.

7. Menopause training for line managers and supervisors. Management needs to know exactly what the symptoms of menopause are and how they can affect colleagues. Managers and supervisors need to feel confident discussing the impact of menopause and they need to know how to have a confidential and empathetic conversation with their team members. They also need to understand the range of supports, reasonable accommodation and reasonable adjustments available.

8. Training for the HR team is also required. Employers need to understand the legal implications of not responding appropriately to the problems faced by staff experiencing menopause or perimenopause. In addition, risk assessments may be necessary for some roles as well as involvement of Occupational Health.

9. Be flexible. No two women are the same, and neither is their menopause. The introduction of reasonable adjustments and accommodations in the workplace will go a long way to help affected employees manage their menopause –and keep them in their jobs. Tailored support mechanisms could include flexible working arrangements, regular breaks, access to cold water, bathroom facilities, a restroom, cold running water, time off for medical appointments, ability to adjust temperature via air conditioning, a desk fan or a window, and paid leave of absence. For organisations where a uniform is required, a change in the design, fit, and fabric may be necessary.

10. EAP - Consider including menopause specific supports in employee assistance programmes. Some menopausal members of staff may require access to medical support, counsellors, and specialist menopause clinics.

Diabetes in Pregnancy

Pregnancy is a normal physiological process and often an eagerly anticipated life event. Medical conditions can develop in pregnancy, such as Gestational Diabetes (GDM), or pregnancy may exacerbate pre-existing medical conditions such as Pre-Gestational Diabetes (PGDM). Diabetes is the most common significant medical condition to affect pregnant women with up to 12% of pregnancies in Ireland affected by diabetes. This article aims to briefly outline diabetes in pregnancy and look at advances in the management of diabetes in pregnancy.

Written by Ciara Coveney, Registered Advanced Midwife Practitioner, Diabetes in Pregnancy at The National Maternity Hospital

and improve quality of life. Frequently used devices include Continuous Glucose Monitoring Sensors (CGMs), Continuous Subcutaneous Insulin Pumps (more recently closed loop hybrid systems) and smart insulin pens.

also poses challenges to diabetes teams to navigate an ever evolving world of medical devices and manage pregnancy outcomes using technologies such as insulin pumps and sensors.

Pre-Gestational Diabetes

Pre-Gestational Diabetes Mellitus, Type 1 Diabetes Mellitus (T1DM) and Type 2 Diabetes Mellitus (T2DM) occurs in 1-2% of all pregnancies, with rates of new diabetes diagnosis rising in women of child bearing age. PGDM confers significantly greater risk for both the mother and developing fetus but by providing comprehensive Multidisciplinary Team (MDT) care this can help reduce adverse outcomes. Rates of pre-eclampsia, macrosomia, caesarean section, congenital malformation and perinatal mortality are well established to be increased in this group compared to women without glucose abnormalities. We also see greater evidence of vascular disease e.g. nephropathy, retinopathy and hypertension in this cohort of women which further increases the risks of pregnancy complications.

The number of women presenting with T2DM in pregnancy is increasing in line with a worldwide upward trend in obesity and T2DM now accounts for 30% of women with PGDM in pregnancy. Women with T2DM are more likely to be living with obesity, hypertension and taking pharmacological agents that are contraindicated in pregnancy.

Pre-conceptual care is of significant importance in this group to optimise diabetes management and pharmacological management of any pre-existing co-morbidities prior to achieving pregnancy.

Women with PGDM fall within the specialist care pathway within the National Maternity Strategy and require specialist care, booked from early pregnancy, often earlier than the traditional 12 week booking visit. The MDT is comprised of obstetrics, endocrinology, specialist midwifery, dietitians, lactation consultants, ultra-sonographers and ophthalmologists. Women require frequent review in the specialist diabetes clinic, often every 3-4 weeks, in comparison with standard antenatal combined care. The complexity of care required for women with PGDM due to complications and complexity of disease is demanding.

The advent of diabetes healthcare technology has provided both women and healthcare professionals with information to allow for accurate and contemporaneous dosing of insulin on a background of dynamic hormone changes and insulin resistance. Diabetes technology describes devices that are used by women with diabetes to help achieve glycaemic control

The current NICE guidelines recommends that all pregnant women with PGDM are offered CGMs and upcoming guidance will suggest that all women attempting to achieve pregnancy are offered closed loop hybrid insulin pump. Insulin pump therapy has demonstrated effectiveness in lowering HbA1c prior to and during pregnancy and can be beneficial in cases of impaired hypoglycaemic awareness. The National Maternity Hospital provides a comprehensive service for women using Continuous Subcutaneous Insulin Pump Therapy (CSII) and continuous glucose monitoring (sensor) technology. The provision of this service requires expert training and continuous professional development to keep up to date with the multiple technology advances being made in diabetes care internationally. The use of diabetes technology

Current figures show that over 50% of women with T1DM attending The National Maternity Hospital are now using insulin pumps and even higher rates of CGMs are observed. Although the numbers of women with PGDM in the service are small compared to the GDM cohort they are under the care of the service from 6 weeks’ gestation and require weekly MDT input.

Gestational Diabetes

Gestational Diabetes (GDM) is diabetes with first onset or recognition during pregnancy. Maternal insulin resistance increases during pregnancy to ensure sufficient nutrition to the developing fetus and may result in impaired insulin action. GDM is a dynamic condition of variable severity and the most current Irish data suggests a prevalence of 12.4% of all pregnancies are affected by GDM. Women are

often screened based on identified risk factors and some centres have implemented universal screening for all pregnant women. The increase in GDM prevalence is in line with global upward trends in obesity, advanced maternal age and a decrease in physical activity levels. GDM is one of the most common medical conditions to be diagnosed in pregnancy and results in an increased likelihood of pre-eclampsia, birth injury and caesarean section. Offspring of women with GDM are more likely to have a higher birth weight, neonatal hyperinsulinemia, birth trauma and intrauterine death. Lifestyle modification, a combination of medical nutritional therapy and physical activity are the cornerstone of treatment for GDM. These services are often delivered by specialist midwifery, dietitians and endocrinology and are shown to be highly effective in managing GDM. Whilst a yearly increase in gestational diabetes is expected, the numbers of women controlled with conservative measures i.e. lifestyle intervention

remains constant in The National Maternity Hospital (~75%) however a proportion of this cohort will require pharmacological treatment. The midwifery led team changed the care pathway for women diagnosed with gestational diabetes in The National Maternity Hospital. Our virtual care pathway means that following the initial diagnosis of GDM, women are educated via a live webinar in the comfort of their own surroundings with a specialist midwife and dietitian. Each woman is then followed up with virtual telehealth clinic appointments using the “Attend Anywhere” platform, the frequency of which is tailored to each woman’s gestation and needs.

The diabetes midwifery team sourced a blood glucose monitor, which is bluetooth enabled and syncs to an app that autopopulates to a patient master list. Consequently, for every virtual appointment, each woman’s synched information is readily

available. This, in conjunction with the electronic health record, facilitates a comprehensive midwifery led consultation. Our colleagues from the Department of Clinical Nutrition and Dietetics also participate in the virtual “Attend Anywhere” clinic. This allows women access to both specialist midwives and specialist dietetics during the same appointment. It addition, this care pathway allows for immediate escalation to the advanced midwife practitioner to review for pharmacological treatment requirement. If insulin therapy is indicated, each woman receives same day education on insulin administration and safety via this virtual platform, enabling immediate commencement of insulin therapy.

From there, women can be referred to Endocrinology and Obstetric care within the diabetes in pregnancy specialist clinic if required. With the twinning of “Attend Anywhere” and the new remote glucose monitoring, the midwifery team aim to deliver evidence-based care on a more personal and easily accessible level

New Irish Life Health Research

More than half of women in Ireland are worried about a female health issue, regardless of the stage of life they are in, according to a new survey. This relates to concerns around contraception, fertility and infertility, menstrual issues as well as perimenopause and menopause. The research was commissioned by Irish Life Health, one of Ireland’s leading health insurance providers. Irish Life Health today announced a new first of its kind female health GP consultation benefit dedicated to meeting the demand for more specialised health services for women.

The survey, which was carried out amongst women aged 18+, revealed insights into perceptions of female healthcare in Ireland. Over half of respondents believe female healthcare is not well serviced in Ireland, while 38% are finding it difficult to get fast access to specialist female health expertise.

The research also revealed the main concerns among different age groups of women in Ireland, which found:

• four in ten 18-24-year-olds in Ireland are worried about menstruation issues

• four in ten 25-34-year-olds are worried about fertility issues

• almost half of 35-54-yearolds are worried about perimenopause or menopause

While the research shows there are significant levels of concern about female health issues, the responses demonstrate confidence in taking action. 89% of women believe they know their body better than anyone, and more than 8 in 10 women are eager to understand more about their health.

The Female Health Consultation benefit by Irish Life Health is the first of its kind in Ireland, offering members access to GPs who specialise in female health, for support and advice in the areas of menstrual health, fertility, contraception, perimenopause and menopause, amongst others.

Dr Maire Finn, one of the specialist GPs delivering this service for Irish

Life Health, comments, “These statistics are not surprising to me as a GP as every day in my practice I hear women’s concerns about their menstrual cycle, their fertility, menopause, and the impact these issues have on their everyday lives. This research tells us that women feel they know their bodies but equally want to know more about health matters that relate specifically to them. It shows that there is work to be done to provide more specialised care in the area of women’s health. This new female health service that Irish Life Health is launching, is a timely and important step in providing the specialised care and information that all women need and want.”

In announcing the new benefit, Liz Rowen, Head of Marketing, Irish Life Health said, “Our research showed that women understand their own bodies, and they know when something isn’t right, but a large proportion of them don’t have the opportunity to talk to someone who really understands their individual concern. Our members will now have the opportunity

to transform the service for women and enhance access to services.

At present we are at the write up stage of a research study to evaluate maternal and neonatal outcomes following the implementation of the virtual pathway of care. This aims to examine the use of assistive healthcare technology i.e. Attend Anywhere and bluetooth enabled healthcare technology. We are also evaluating maternal and pregnancy outcomes including interval to treatment, rates of pharmacological treatment, mode of delivery and induction rates. In addition, relevant neonatal outcomes will be evaluated including birth weight, NICU admission rates and neonatal hypoglycaemia rates. This study is the first of its type and size in Ireland that will examine real clinical outcomes for virtual care pathways and we are hopeful it will provide data to support the safe and widespread use of virtual care pathways to improve access to healthcare.

to have their health concerns heard through a dedicated and specialised female health service, which is available on all Irish Life Health hospital plans from the 1st of September.”

Other key findings from the research include:

• Only half of women (51%) feel like they truly understand their menstrual cycle

• 62% of women get their health information from family and friends, while 59% source their information through social media and online platforms

The new specialist female health GP consultation service will offer Irish Life Health members a GP consultation by phone or video, a recommended course of action and, if needed, an in-person appointment at one of Centric Health’s specialist female health clinics across Ireland.

*Research conducted by Red C in July 2023, featuring a panel of 500+ female representatives aged 18+.

Pharmacy Role in Women’s Intimate Health

Vulvovaginal candidiasis (thrush)

Vulvovaginal candidiasis, or thrush, is the most common cause of vaginitis (inflammation of the vagina) and vulvovaginitis (inflammation of the vulva and vaginal region). Candidiasis is typically caused by an overgrowth of the fungal yeast Candidia albicans. The National Institute of Healthcare Excellence (NICE) states that C.albicans accounts for 80-92% of cases with a number of other fungal yeasts accounting for the remaining cases.

Candidiasis is very common, with 70-75% of women experiencing the condition at least once and 40-50% of women reportedly experiencing it two or more times throughout their lives. It is estimated that Candida species could be isolated from 20% of vaginal swabs form otherwise healthy, asymptomatic women of reproductive age at any one time.

The lactic acid producing Lactobacillus species causes the acidic pH range of the vagina, although the vaginal microbiome is diverse. The composition of the vaginal microflora is dynamic and increased change occurs during

menstruation and sexual activity. The majority of women are thought to be colonised with Candida species without symptoms at some point in their lives thus it is thought that the dynamic nature of the vaginal microbiome is a critical factor that leads to colonization by Candida, as well as contributing to it becoming pathogenic. There are a number of risk factors that have been identified as leading to colonization and/or symptomatic candidiasis:

• Hormonal changes (e.g. pregnancy, combined oral contraceptive pill/ hormone replacement therapy, menstruation.

• Immunosupression (e.g. HIV, corticosteroids)

• Antibiotics (particularly broad spectrum)

• Sexual activity (e.g. sexual intercourse, orogenital contact)

• Diabetes (particularly when poorly controlled as high blood sugar levels lead to better conditions for the yeast to grow)

• Changes in vaginal pH

• Vulvardermatosis

• Genetics

There are a number of typical symptoms and signs of thrush:

• Pruritis

• Cheesy discharge

• Irritation (redness, swelling)

There are a range of OTC products available in pharmacies that pharmacists can recommend after establishing that a woman has presented with symptoms of thrush. Azole creams and pessaries inhibit Candida yeast cells from transforming into hyphae and are available OTC. Oral treatments are available on prescription only.

Pregnancy can increase the chances of women developing thrush. It is not harmful to the baby and can be treated with topical treatments and pessaries. Pregnant women should be advised to return if their symptoms have not resolved within 7-14 days.

Various lifestyle factors may contribute to the development of thrush and the discomfort associated with symptoms. Women should be advised to wear

loose-fitting, cotton underwear, to use fragrance-free and soap-free cleansers and to have showers rather than baths. Advise women to keep their genitals clean and dry as Candida species, like most fungi, thrive in moist, warm environments. Dietary changes such as reduced sugar intake and use of probiotics have been noted to increase the rate of clinical cure and reduce short-term relapse. The effectiveness of probiotics is however, strain dependent.

Bacterial vaginosis (BV) Bacterial vaginosis is a common cause of abnormal vaginal discharge in women of reproductive age. It is characterized by a white, nonirritating, malodorous vaginal discharge. This discharge commonly smells ‘fishy’ and this odour is often more noticeable after sexual intercourse. Women who experience repeated episodes of Bacterial Vaginosis may benefit from using lactic acid vaginal gels to facilitate the restoration of the normal vaginal flora. Repeated episodes are more frequent in women who practice vaginal douching.

The diagnosis is made clinically on the basis of the description and appearance of the discharge. Typically, the normal pH of the vagina increased from <4.5 to above 4.5 and up to 6.0 reflecting the replacement of normal lactobacilli with anaerobic organisms.

Patients diagnosed with BV should be advised to avoid contributing factors including vaginal douching, use of shower gel in the genital area, and use of antiseptic agents or shampoo in the bath. Patients should also be counselled on smoking cessation and safe sex practices to reduce instances of BV. Goals of treatment include relief of symptoms, reduction in postoperative infection, and reduction of STIs.

Without treatment, BV resolves spontaneously in up to one-third of non-pregnant and one-half of pregnant individuals. Nonpregnant women who are symptomatic or those undergoing gynaecological procedures or surgeries that involve the vagina should be offered treatment. Non-pregnant women with asymptomatic BV do not usually require treatment. Screening for

BV is not recommended as part of regular antenatal care, however if a pregnant woman is incidentally found to have asymptomatic BV, the woman’s obstetrician should be consulted as to whether treatment is appropriate. Pregnant women diagnosed with BV who are symptomatic should be treated. Nitroimidazole antibiotics are usually prescribed orally to treat BV. Lincomycin is prescribed orally and/or topically. There is no benefit in treating male partners.

Genitourinary syndrome of the menopause (GSM)

Genitourinary syndrome of the menopause (GSM) or vulvovaginal atrophy, results from estrogen loss and is often associated with vulvovaginal complaints e.g. dryness, burning, dyspareunia (pain during sexual activity) and even pain and sensitivity when wiping post urination. Urinary frequency and bladder infections may also occur.

It is important to consider the age of a women when she presents to the pharmacy with symptoms such dryness, excessive watery discharge, burning or pain during sexual activity. Advise on soap free cleansers, vaginal moisturisers and lubricants may be beneficial. These products are widely available OTC in pharmacies.

The use of locally applied estrogen (either cream, gel or pessaries) in perimenopausal or post-menopausal women can considerably reduce symptoms of GSM. For some women oral or transdermal hormone replacement therapy (HRT) will be required.

Many women with GSM (up to 80%) do not seek medical care or advise so it is important that when a woman presents to the pharmacy that the appropriate questions are asked and that she is referred to her GP when appropriate.

Women’s intimate healthcare is a large and very relevant topic and one where Pharmacists can make a positive and lasting impact on the health of the women they are dealing with every day.

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

Many women present to the pharmacy with symptoms of irritation in the vulvo-vaginal area. Itching, soreness, dryness and discharge can be caused by a number of issues including, but not exclusively, thrush, bacterial vaginosis or genitourinary syndrome of the menopause.

Powerful anti-inflammatory pain relief

For muscle and joints when associated with strains and sprains

Motusol Max (diclofenac sodium) 2% w/w gel Abbreviated Prescribing Information. Presentation: White to almost white, homogeneous gel. 1g of gel contains diclofenac as 23.2mg diclofenac diethylamine corresponding to 20mg of diclofenac sodium. Indications: Local symptomatic treatment of pain in acute strains, sprains or contusions following blunt trauma. For short term treatment only. Dosage and administration: For cutaneous use. Apply to affected parts of the body thinly and gently rub into skin. Wash hands after application unless area to be treated. Allow gel to dry on skin before applying bandages. Adults and adolescents aged 14 years and over: depending on the size of the affected site, apply a cherry to walnut size quantity 2 times a day (preferably morning and evening). Should not be used for longer than 1 week without medical advice. Children: no data in children and adolescents under 14 years of age. Elderly: no dosage adjustment required. Monitor patient carefully. Renal and hepatic impairment: no dosage adjustment required. Contraindications: Hypersensitivity to active substances or excipients; patients with a history of hypersensitivity reactions such as asthma, bronchospasmus, urticaria, acute rhinitis in response to acetylsalicylic acid or non- steroidal anti-inflammatory drugs (NSAIDs); open injuries, inflammations or infections of the skin as well as on eczema or mucous membranes; in the last trimester of pregnancy; in children and adolescents under 14 years of age. Precautions and warnings: Systemic undesirable effects cannot be excluded if applied on larger areas of skin over a prolonged period of time. Must only be applied to intact, not diseased or injured skin. Must not come into contact with eyes and oral mucous membranes. Must not be taken orally. May be used with non-occlusive bandages, but not with airtight occlusive dressing. Consult doctor if symptoms worsen or do not improve after 3-5 days. Patients suffering from asthma, hay fever, swelling of nasal mucous membranes (so called nasal polyps) or chronic obstructive pulmonary disease, chronic respiratory infections (particularly associated with hay fever-like symptoms), and patients with hypersensitivity to painkillers and anti-rheumatic medicinal products of all kinds are rather at risk to asthma attacks (so called analgesic intolerance / analgesic asthma), to local skin or mucous membrane swelling (so-called quincke edema) or to urticaria than other patients when treated with Motusol Max. In these patients, Motusol Max may only be used under certain precautions (emergency preparedness) and direct medical supervision. The same applies for patients who are also allergic to other substances e.g. with skin reactions, itching or urticaria. Discontinue treatment if skin rash occurs. Photosensitivity can occur with the appearance of skin reactions after exposition to sunlight. Avoid children coming into contact to the skin areas where the gel has been applied. Contains butylhydroxytoluene which may cause local skin reactions or irritation to the eyes and mucous membranes. Contains fragrance with benzyl alcohol (0.15mg/g), citral, citronellol, coumarin, eugenol, farnesol, geraniol, d-limonene and linalool which may cause allergic reactions. In addition, benzyl alcohol may cause mild local irritation. Interactions: None known. Pregnancy and lactation: Should not be used during first and second trimester unless clearly necessary. Contraindicated during third trimester. Should only be used during breast-feeding under advice from a healthcare professional and should not be applied on the breasts, nor elsewhere on large areas of skin for a prolonged period of time. Effects on ability to drive and use machines: No or negligible influence. Adverse reactions: Hypersensitivity, angioedema, dermatitis bullous, Common: dermatitis (including contact dermatitis), skin rash, erythema, eczema, pruritus. Consult the Summary of Product Characteristics in relation to other side effects. Overdose: Wash skin with water where applied. If ingested, apply general therapeutic measures normally adopted to treat poisoning with non-steroidal anti-inflammatory medicinal products. Gastric lavage and use of activated charcoal should be considered. Legal category: Pharmacy.

When Menopause gets Complicated

Background - As a person begins to experience ovarian hormone disruption (perimenopause) through to and beyond their final menstrual period (post menopause) they may be affected by a variety of symptoms.

Written by Dr Deirdre Lundy Specialist in Women’s Health and Menopause at The National Maternity Hospital

The most commonly mentioned symptoms include vasomotor flushing and/or sweating, mood changes (low mood, irritability, feeling overwhelmed), joint aches & pains, fatigue, etc. Urogenital symptoms like vaginal dryness; which might in turn cause discomfort (particularly during exercise or intercourse) can be a problem at this time. Some (peri) menopausal people suffer a worsening in their pre-existing GU problems such as frequency of urination or more frequent UTI’s. These and the more than 50 additional complaints attributed to menopause may have a severe impact on the patients’ quality of life, conversely there are some lucky people who notice very little disruption at this time. It is very hard to predict who will have a rough time in menopause and who won’t but as clinicians we are trained to offer a sympathetic ear and try to help where we can.

For many decades offering menopause support in the form of Hormone Replacement Therapy (HRT) tablets was common practice. But, in 2002, after the publication of an editorial discussing early results of the Women’s Health Initiative (WHI) trial in the USA, concerns were raised about that trial’s use of equine estrogen tablets blended with the synthetic progestagen ‘medroxy provera acetate’ (MPA) and raised risk of breast cancer as well as thrombotic events including CVA and MI.

During the following 10-15 years many clinicians feared prescribing HRT and a lot of patients weren’t too keen on having to use it. Demand fell, interest in training in menopause waned and patients were left with very few options. Things did slowly improve after the shock waves of the WHI subsided a little. It was known back then but subsequent studies have now affirmed that not all HRT is the same.

Concerns that were raised about the connection with HRT use and breast cancer were somewhat offset by analysis of the absolute risk vs the relative risk. The WHI data showed an increased risk of breast cancer diagnosis with use of oral equine estrogen +MPA HRT use in the order of 1.27. This is about the same risk attached to drinking 2 units of alcohol a day and much lower than the risk attached to being overweight/ obese. So this does not dismiss risk - there is an association - but helps put risk into perspective.

Roehm E. A Reappraisal of Women’s Health Initiative

Estrogen-Alone Trial: Long-Term Outcomes in Women 50-59 Years of Age. Obstet Gynecol Int. 2015; 2015:713295. doi: 10.1155/2015/713295. Epub 2015

Jan 1. PMID: 25685151; PMCID: PMC4313058

Other information from more recent trials on HRT use and breast cancer risk data examined the effect of the choice of HRT

progestagen on risk. It is thought that more modern, less androgenic progestagens particularly micronised progesterone and dydrogesterone, seem to have less of an impact on breast cancer risk than the powerful MPA used exclusively in the WHI study.

Fournier A, Berrino F, ClavelChapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2008;107(1):103-111.

doi:10.1007/s10549-007-9523-x

Concerns we had about orally ingested estrogen (e.g. the COCP or oral HRT) do not appear to apply to the low dose, transdermal 17 beta estradiol - the type typically used in modern transdermal HRT. Orally administered estrogen affects the thrombin system and can increase the risk of VTE but modest doses of TD 17 beta estradiol have a neutral effect on clotting.

So in recent years, not only is the fear of HRT use abating, we are seeing the demand for menopause consultations and HRT products outstripping supply. Hamoda H, Panay N, Pedder H, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reprod Health. 2020;26(4):181-209.

doi:10.1177/2053369120957514

This has been challenging. Clinicians have not always kept up their confidence surrounding menopause guidelines so may be worried about offering up to date advice. Even for general practitioners with expertise, advising on menopause management options and prescribing HRT (and alternatives) is not really supported in primary care. There are no special considerations for what can be a lengthy and nuanced consultation and perhaps ‘first menopause/ perimenopause visit’ should be added to the chronic disease payment schedule. Added frustration for prescribers is ongoing as the demand for high quality TD estrogens and the more ‘breast friendly’ progestagens has been so high, many patients find that they cannot reliably access their HRT in Irish pharmacies. www.hse.ie/eng/about/who/cspd/ ncps/medicines-management/ guidance-on-shortages/mmpguidance-for-prescribers-on-hrtshortages-september-2022.pdf

Typical Menopause vs ‘Complex’ Menopause

When a person develops symptoms that may be attributable to (peri) menopause there are many well established therapies available. There is no single, best answer when it comes to maintaining wellbeing and improving symptoms in menopause, but the fact remains HRT has been proven most effective for vasomotor symptoms caused by hormonal fluctuations at this transitional time. Maclennan AH. Evidence-based review of therapies at the menopause.

Int J Evid Based Health. 2009 Jun;7(2):112-23. doi: 10.1111/ j.1744-1609.2009.00133. x. PMID: 21631851

But what about prescribing HRT to people with underlying medical conditions? What are the rules?

Well, that’s a little tricky.

Research on (peri) menopause and HRT and their impact on serious medical conditions is staggeringly poor. We are only beginning to see female biological variables being taken into consideration as part of mainstream health research & pharmaceutical studies. Yakerson, A. Women in clinical trials: a review

Menopause

of policy development and health equity in the Canadian context. Int J Equity Health 18, 56 (2019). https://doi.org/10.1186/s12939019-0954-x

Studies on using HRT in groups of people with serious underlying medical conditions are very few and far between. In the absence of actual data, experts look to see what (if any) impact menstruation, pregnancy and use of hormonal contraceptives might have on specific medical conditionsthen try to work out what impact menopausal changes and HRT use might be gleaned from this information. Not ideal and often unhelpful.

So what do we know about use of HRT for females with menopausal symptoms who have background medical issues? There are some guidelines when it comes to chronic manageable conditions as well as the more serious situations where if at all possible referral to a colleague with specific menopause training is advised. The British Menopause Society is generally regarded as the ‘go-to’ resource for up to date guidance and advice in Ireland. They have been enormously supportive of colleagues both in Britain and Ireland. www.bms.org.uk

They advise that expert advice should be sought in a variety of situations including women with complex medical backgrounds (such as women with breast cancer, personal history of venous thrombosis or personal history of stroke, ischemic heart disease, etc.).

Menopause itself is often triggered by medical intervention for serious disease and its treatments.

People with female hormonesensitive cancers may undergo oophorectomy on medical advice which can cause sometimes very troublesome menopausal symptoms and if done before 40 yrs. of age could go on the undermine future health outcomes. ESHRE guideline group. ESHRE Guideline: management of women with premature ovarian insufficiency. Hum Reprod. 2016 May;31(5):926–37

Pelvic radiotherapy and certain forms of chemotherapy can cause temporary or even permanent ovarian failure. Anti-endocrine therapies are often prescribed for females with estrogen sensitive malignancies - most commonly but not exclusively, breast cancer. These medicines improve cancer outcomes but (depending on the patient) the side effects and the menopausal symptoms they can trigger disimprove quality of life and often limit compliance with the prescribed therapy. Meade E, et.al. Survivorship care for postmenopausal breast cancer women in Ireland: What do women want? Eur J Oncol Nurs. 2017 Jun;28:69–76

Being diagnosed with cancer when already using HRT may become a problem and oncologists might sometimes advise discontinuation of the HRT leading to a rapid return of menopausal symptoms.

Menopausal symptoms can be managed with hormonal, nonhormonal and non-pharmacological therapies. MHT is the most effective method of managing menopausal symptoms but may not be suitable for all after a cancer diagnosis as the role of hormone receptors in many types of cancer and their

treatment may complicate the discussion about when MHT should or should not be used.

There is a growing list of therapies and medications that have been shown to be useful in relieving some of the symptoms of menopause for women who are either on anti- estrogen therapies or who have been advised to avoid standard HRT. The British Menopause Society offers guidelines on their “Tools for Clinicians” webpage. Interestingly one of the management options with the best range of meno symptoms relief is Cognitive Behavioural Therapy which has been shown to be effective over placebo in helping with vasomotor flushing and sweating, fatigue, weight gain, musculoskeletal (MSK) pain and sexual function Franzoi MA, et al Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer. Lancet Oncol. 2021 July but access to one on one CBT is limited and so some people may be directed to on online therapy and/ or smart phone apps to seek relief. Other strategies that have been shown to be helpful include:

- SSRI’s & SNRI’s which may help some people with vasomotor symptoms, mood and MSK issues

- Anticonvulsants like gabapentin may help with vasomotor flushing

- Antispasmodics like Oxybutynin can also help with both vasomotor flushing and urinary issues

- Antihistamines with sedating properties may help with sleep disruption

Other options that have shown benefit include yoga and acupuncture, gently physical activity and exercise and hypnosis. Franzoi MA, et al Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer

New medical therapies designed to reduce vasomotor flushing specifically for people with a breast cancer diagnosis are being launched to market in Europe in 2024. The root cause of VMS appears to be linked to heightened signalling of certain neurotransmitters (particularly neurokinin B & its receptor (neurokinin 3 & 4 receptors)

- these affect the autonomic thermoregulatory pathway. A group of drugs known as the NK3R antagonists can block NK3R related VMS seemingly as effectively as HRT. The Oasis 4 trial is helping to explore one of these NK antagonist drugs. They are recruiting here in Ireland at time of writing. https:// findoasisnow.com/gb-en/hcp

Applying the research

In our Complex Menopause Clinic at The National Maternity Hospital we aim to offer patients time to discuss the symptoms of menopause that are affecting people with comorbidities or a past diagnosis that might limit typical menopause options. This is a new service funded by the HSE’s National Infant and Women’s Health Program. We are one of six clinics operating around the republic of Ireland.

We try to validate the patients’ individual experience (as some people sadly seem to have been given little forewarning about what the menopausal effects of procedures and treatments for cancers). We explore lifestyle issues and offer support there where we can. We take them through the varied non-HRT strategies that could bring them some relief and allow them improve their QoL. We prescribe where appropriate and review them after 3 months to see if there is any improvement - if they are still struggling we try something else. Some of our patients never really regain their optimal QoL- some we barely help at all I worry - but most patients have expressed a gratitude for having been given a safe space to be listened to, to discuss their symptoms and worries and to be offered treatments wherever we have them.

What women can do to love their hearts

In recent years, there has been a welcome focus in the national conversation around women’s health issues, be it reproductive health, menopause, or cancer screening. However, there has been a glaring gap. One in four women dies from heart disease and stroke each year – the same as men and, incredibly, six times more than die from breast cancer. That’s over 4,000 mothers, daughters, and sisters each year in Ireland. There is a false belief that cardiovascular disease (CVD) is a man’s disease but there are many female-specific factors that affect a woman’s risk, including menopause and hypertensive disorders of pregnancy. However, the good news is that 80% of premature heart disease and stroke is preventable through healthy lifestyles.

Written by Janis Morrissey, Director of Health Promotion, Information and Training, Irish Heart Foundation

women seek help earlier, advocate for themselves, and potentially save lives.

and stay connected to friends and family. If you are struggling, contact your GP.

But too many women aren’t aware of these facts and many health professionals are also missing these important messages.

According to the Lancet Women and Cardiovascular Disease Commission, heart disease and stroke in women has been underresearched, under-diagnosed, and under-treated.

• under-researched (women have been left out of clinical trials)

• under-diagnosed (women often present with more unusual signs of CVD and can receive an incorrect diagnosis. Rather than the classic version of a heart attack where someone is seen clutching their chest, the symptoms of a heart attack in women can be quite vague making it hard to diagnose. They can include nausea, tiredness,

shortness of breath, back pain or tightness in the jaw rather than the more familiar scenario of a crushing pain in the chest that shoots down one arm).

• under-treated (women can be under-treated or treatment can be delayed if they are under-diagnosed. Many treatments are made for men and not adequately researched in women).

The combined effects place women at a distinct disadvantage. While research and healthcare systems must evolve to address these gender-specific challenges, and economic disparities as a significant driver of inequality must be tackled, public awareness also plays a pivotal role. The Irish Heart Foundation has developed the Her Heart Matters campaign to help

NEWS - New FIP Hub

Most women already know what makes a healthy lifestyle, but the many demands of modern life can get in the way. IPSOS polling conducted for the Irish Heart Foundation found that almost one-third (30%) of women say they do not have enough time each day to focus on their health. However, this September the Irish Heart Foundation is calling on women to put themselves first and make their heart health a priority. It’s not just up to women themselves, so we are also calling on anyone with a woman in their lives to talk, share and empower women to look after their heart health.

Mindset

Getting into the right frame of mind is essential for change. You need to feel ready and have clear, powerful reasons for making a change. As part of the Her Heart Matters campaign, the Irish Heart Foundation has created a free Self-Care and Wellbeing Journal to support women to reflect on their lifestyle habits and prepare for meaningful change.

Stress

While stress is a normal part of life, it can be negative when it starts to impact day to day tasks. Many women are juggling multiple demands, and this can be particularly challenging during menopause. Try to keep a regular sleep routine, be physically active

Physical Activity

Regular physical activity is one of the greatest tools for preventing heart disease and stroke as well as helping to reduce some menopause symptoms. Getting at least 150 minutes a week of moderateintensity activity is recommended for good health. This can be broken down into three 10 minutes sessions. Try to add musclestrengthening exercises too.

Nourishing

your Heart

Research shows that a Mediterranean-style diet can help to reduce heart disease and stroke and help manage menopause symptoms. Like the Irish Food Pyramid, a Mediterranean-style diet is based around fruit and vegetables, whole grains, beans and other pulses, nuts, and seeds. It includes some olive oil, fish, seafood, and poultry, and is low in sugar, salt, processed foods, and red meat.

Start the Conversation

Be part of the movement of women and men who want to see change and protect all women from one of Ireland’s biggest killers. Talk with your sisters, mothers, daughters, and friends, share the campaign with them, and empower them to make changes

For information and practical support, visit irishheart.ie.

Last month (September) marked the launch of the new FIP Hub after an 18-month phased transition from its previous Workforce Development Hub (established following the Nanjing Conference outcomes 2016).

The FIP Hub will bring together experts to generate intelligence, and provide evidence-based resources and tools to inform and support the FIP Development Goals in practice. The FIP Hub transition was initiated under the presidency of the late Dominique Jordan who introduced the vision of “One FIP” and is continued under the stewardship of FIP Bureau and acting FIP president Paul Sinclair.

In association with membership engagement and outreach across FIP, the hub will provide an opportunity for access to enhanced collaboration, the federation says. While the pursuit of individual FIP Development Goals remains integral, the hub harnesses expertise and passion to deliver tangible outcomes ranging from publications and reports to events and surveys, it adds.

Vitamins for Immunity

Women’s Supplements

Multivitamins have become increasingly popular, not only during Winter months but also throughout the whole year. More and more customers are using multivitamins year-round, and appreciate the benefits of doing so.

The convenience of only having to take one tablet or sachet per day to receive a selection of vitamins and minerals is appealing to customers, rather than having to take multiple tablets per day.

As mentioned above, there is a substantial choice of products available which have been specifically tailored for men and women.

Women’s supplements contain a higher dose of iron, which is beneficial due to the loss of blood during the menstrual cycle.

The majority of supplements contain Vitamin C, Vitamin D, Vitamin B12, Vitamin E, Magnesium, Folic Acid, Zinc and Iron. Some then contain extra ingredients such as Ginseng which would be targeted for those who lead a very active lifestyle and need the surplus energy boost. Supplements can be taken at any stage of life, however there are age specific products availablefor example those supplements that are targeted towards the over 50’s. These specific supplements tend to contain extra calcium and Vitamin D, which are very helpful at supporting bone health as we age. Certain supplements for the over 50’s will also contain Lutein, which helps to prevent agerelated macular degeneration. The vast array of choices for taking vitamins and supplements, including tablets, sachets, chewable sachets, liquids and gummies, ensures that every customer can choose the product that works best for them and their health goals.

Vitamin D

Vitamin D has become a mainstay with regards to the health and wellbeing of the population here in Ireland. As the pandemic progressed and the emergence of more information and research about the Coronavirus emerged, there was a significant increase in the requests for Vitamin D. Since then, there has been lots of engagement with the public who are eager to know more about the role of Vitamin D.

Vitamin D helps regulate antimicrobial proteins that can

directly kill pathogens as well as Vitamin D also regulates many other cellular functions in your body. Its anti-inflammatory, antioxidant and neuroprotective properties support immune health, muscle function and brain cell activity

Vitamin D also has a significant role in the absorption of calcium which the body needs for building and maintaining healthy bones.

Vitamin D isn’t naturally found in many foods, but it can be found in fortified milk and fatty fish such as salmon, mackerel and sardines. Direct sunlight is also significant as the body makes Vitamin D by converting a chemical in the skin into an active form of the vitamin (calciferol).

With the weather here in Ireland and the significant decrease in sunlight as we come into the winter months, it is easy to see how the demand for Vitamin D has increased here and why Vitamin D has been recommended at all stages of life including newborn infants.

The recommended daily amount of vitamin D is 400 international units (IU) for children up to age 12 months, 600 IU for people ages 1 to 70 years, and 800 IU for people over 70 years.

Vitamin D is available in a wide range of formulations providing a greater variety of choice depending on the patient’s preference. Oral drops and sprays are available for infants and for adults which can result in quicker absorption. Chewable and gummy formulations may increase the compliance amongst younger children. Tablets are readily available, and some patients may prefer the convenience they provide.

Vitamin C

Vitamin C (ascorbic acid) is a nutrient your body needs to form blood vessels, cartilage, muscle and collagen in bones. Vitamin C is also vital to your body’s healing process.

It is an antioxidant that helps protect your cells against the effects of free radicals, which are produced when your body breaks down food or is exposed to tobacco smoke and radiation from the sun, X-rays or other sources. Free radicals might play a role in heart disease, cancer and other diseases. Vitamin C also helps your body absorb and store iron.

Vitamin C can be obtained from a healthy diet as it is present in citrus fruits, berries and spinach. Severe Vitamin C deficiency can lead to a disease called scurvy, which causes anemia, bleeding gums, bruising and poor wound healing.

The recommended daily amount of Vitamin C is 75 milligrams for adult women.

Vitamin C is available in many formulations ranging from chewable tablets, oral tablets and effervescent tablets. It is common to see Vitamin C products also containing zinc to help the immune system and there definitely is an increase in requests for such products coming into the winter months.

Zinc

Zinc is essential for the body’s growth and development and wound healing. It also helps regulate immune function, exhibits antioxidant activity, and helps support a balanced inflammatory response in the body.

It helps the immune system and metabolism function and is also important for wound healing and sense of taste and smell.

Your immune system needs zinc to function properly. A zinc deficiency reduces your ability to eliminate pathogens, mount a response against threats, and produce antibodies. It has been shown that if zinc is taken soon after cold symptoms appear, it may also shorten the length of a cold.

The recommended daily amount of zinc is 8 milligrams (mg) for women.

Zinc is available on its own mainly in tablet form but is quite popular in a chewable form combined with Vitamin C. The combination products appear to be more popular amongst customers due to the ease of taking a single tablet.

Magnesium

Magnesium keeps the immune system strong, helps strengthen muscles and bones, and supports many body functions from cardiac functions to brain functions.

The amount of magnesium recommended is 270mg a day for women (19 to 64 years).

Care should be taken as high doses (more than 400mg) for a short time has been shown to cause diarrhoea. Having 400mg or less a day of magnesium from supplements is unlikely to cause any harm.

Magnesium is available in tablet form at varying strengths and also in sachet form as a soluble powder for consumption.

All the above vitamins and minerals are commonly contained in multivitamins, and it is crucial to check with the patient if they are taking any vitamins and minerals before recommending products to ensure that they do not exceed the recommended dose.

There is an array of multivitamins available in various formulations for all ages and even gender specific for male and females containing tailored vitamins and minerals required for certain functions of the body e.g. increased iron for women.

CPD

60 Second Summary

Community pharmacies are often the first point of contact for patients with eye-related complaints, making pharmacists vital frontline advisers. In Ireland, the urgency of eye health awareness is underscored by the estimated 270,000 citizens living with vision loss or blindness—a number expected to rise.

Key issues include conjunctivitis, blepharitis, Age-Related Macular Degeneration (AMD), diabetic retinopathy, and glaucoma. Lifestyle factors like diet, exercise, and avoiding harmful habits like smoking and excessive drinking can play a significant role in eye health.

Crucial advice for your patients extends from food choices rich in antioxidants to eyeprotective gear. Additionally, pharmacists should be wellversed in recognizing ‹red flag› symptoms for immediate referral to specialists.

Digital eye strain, or computer vision syndrome (CVS), is another growing concern that can be managed through various OTC options and practical advice.

Frequent eye tests, especially for higher-risk demographics, are critical. Proper contact lens hygiene and regular screenings for patients on hydroxychloroquine are also key. This article provides a comprehensive overview for pharmacists to effectively advise and refer patients, contributing to early detection and prevention of avoidable sight loss.

AUTHOR: Written by Mark McPhillips, Pharmacist & Owner, Mark’s Pharmacy, Ardee

Mark McPhillips is an Ireland-based pharmacist owner with over 20 years experience with 10 years in hospital pharmacy, specialising in pain management. A certified NLP trainer and coach, he is passionate about professional development and empowering fellow pharmacists.

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

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

3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required?

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

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

Management of Eye Health

In community pharmacies, eye complaints are a common reason for patient visits, making pharmacists crucial frontline advisers on eye health. Typical eye conditions that patients present with include conjunctivitis and blepharitis. Common symptoms to watch for in eye conditions include changes in visual clarity, redness, pain, discharge, and sensitivity to light (photophobia). Optometrists emphasize the importance of proactive eye care, advocating for regular sight tests as a preventive measure. These tests are vital for early detection of potentially severe eye diseases such as cataracts, glaucoma, diabetesrelated eye conditions, and AgeRelated Macular Degeneration (AMD). Timely intervention can help prevent over half of all avoidable sight loss, underscoring the importance of regular eye checks in safeguarding the nation›s vision. Pharmacists should be equipped to advise patients on modifiable lifestyle factors that contribute to sight loss, helping them reduce their risk. This article provides guidance on how to identify patients in groups at risk for sight loss, advising them on lifestyle modifications and available treatments. It also highlights ‹red flag› symptoms and offers direction on when

and where to refer patients for specialized care. There are an estimated 270,000 Irish people living with vision loss or blindness. It is estimated that 50,000 more people will have impaired vision and five thousand more people will lose their sight within the next five years.1 Blindness and vision loss has a major health, social and economic impact. The risk of vision loss increases with age and in 10 years, one million Irish citizens will be aged 65 or older.

Age-related macular degeneration (AMD), diabetic retinopathy, cataract, and glaucoma are the main causes of sight loss in Ireland. Over 75% of sight loss is preventable with early diagnosis and treatment.1

In the realm of eye health, pharmacists play a pivotal role in advising patients on lifestyle modifications that can mitigate the risk of sight loss.

Diet

Antioxidants such as lutein, abundant in greens like kale and spinach, as well as in colourful fruits and vegetables, can stave off retinal damage, cataracts, and Age-Related Macular Degeneration (AMD). Foods recommended for eye health include:

• Broad leaf greens such as kale and spinach

• Brightly coloured fruit and veg such as corn, carrots, orange sweet peppers and oranges

• Oily fish like salmon, tuna and mackerel

• Broccoli

• Eggs

Exercise

Exercise is another modifiable variable. A sedentary lifestyle is a known risk factor for several eye conditions, especially in those over 60. Programs like RTE›s Operation Transformation and community activities like Park Run are excellent resources for patients to get moving and possibly reduce risks associated with arterial diseases, high blood pressure, and diabetes.

Alcohol & Smoking

Alcohol and smoking are detrimental not only to general health but specifically to eye health. Excessive alcohol can exacerbate eye conditions, while smoking is the second-largest risk factor for macular degeneration and increases cataract risk.

Family History

Understanding one›s family eye health history can be a pre-emptive measure, particularly for conditions like glaucoma, which are often hereditary. Early detection can lead to effective management.

Sun

Sun protection is more than skin-deep; it›s crucial for eye health as well. Sunglasses with UV protection and the CE mark are recommended to mitigate damage from ultraviolet rays. Most brands of prescription glasses now contain a UV filter, but not all sunglasses provide adequate protection. Patients should be counselled to ensure their sunglasses are either CE or BS marked (i.e. proof of conformity with European or British standards, respectively), and are the appropriate filter category for their use (filter categories range from 0 to 4, where 4 is the darkest lens)

Reduce screen time

The surge in digital device usage has escalated the prevalence of computer vision syndrome (CVS), characterized by eye strain, dry or painful eyes, difficulty in focusing, and other non-ocular symptoms. As pharmacists, it›s essential we understand the available over-the-counter treatments and environmental management techniques for these conditions. For instance, the 20:20:20 rule can be advised for screen fatigue. Various ocular lubricants can address dry eyes. Employers› should be aware of their obligation for eye tests for heavy screen users should also be communicated to patients.

For more severe symptoms, prescription-based topical antiinflammatory medications may be required. If patients complain of double vision, a referral to an optician is advised. Over-thecounter solutions come in various formulations such as sprays, drops, gels, and ointments, and patients should be counselled on the most appropriate choice for their condition. Overall, a comprehensive approach to CVS can greatly assist patients in managing this increasingly common issue.

Regular eye tests

Pharmacists can play a key role in emphasizing the necessity of regular sight tests, generally recommended every two years for most adults. However, higher-risk

What is the 20-20-20 rule?

The 20-20-20 rule is a simple and widely recommended guideline designed to reduce eye strain and fatigue caused by looking at a computer screen or other digital devices for extended periods of time. According to the rule:

- Every 20 minutes, look away from your screen.

- Focus on an object at least 20 feet away.

- Do this for at least 20 seconds.

The idea behind the rule is to give your eyes a short but effective break, reducing the symptoms associated with Computer Vision Syndrome (CVS), such as eye strain, dry eyes, headaches, and blurred vision. Looking at something far away relaxes the focusing muscles inside the eye, reducing eye fatigue.

groups, including individuals with specific ethnic backgrounds e.g. Afro–Caribbean or Asian patients or those aged 40 and above with conditions like diabetes or high blood pressure, may require more frequent testing. These patients should be directed to their local optician for a sight test if they have not had one recently or have vision-related concerns. Additionally, it›s worth noting that some patient groups may be exempt from sight test fees.

Contact lens hygiene advice

application protocols, adhering to recommended lens-wearing durations, and attending annual aftercare appointments. In case of symptoms like redness or pain, patients should consult an optometrist immediately.

Screening

with glaucoma treatment, as approximately 50% of patients are non-compliant. Identifying and helping patients overcome barriers to treatment can prevent poor clinical outcomes and the complications of unnecessary polypharmacy. It is important to check eye drop technique.3

Eye Drop Technique

1. Check the expiry date on the eye drop bottle and shake if required;

2. Wash your hands before opening the bottle;

3. Lie down or sit down and tilt your head back;

4. Make a fist with one hand and use your knuckles to pull your lower eyelid downwards. Hold the eye drop bottle with your other hand, and place your wrist on your knuckles;

5. Look up and squeeze one drop into your lower eyelid, making sure the nozzle does not touch your eye, eyelashes or eyelid;

Age-related macular degenera�on (AMD)

Age

Key points include washing hands before handling lenses and avoiding tap water for cleaning due to the risk of sight-threatening infections. Specific lens solutions, as advised by optometrists, should be used, and lens cases should be regularly cleaned and replaced. Wearing lenses while swimming or bathing is generally not advised. Other guidelines include not sharing lenses, following makeup

Pharmacists should remind patients taking hydroxychloroquine or chloroquine to undergo regular eye screenings due to the risk of hydroxychloroquine retinopathy. Notably, at least 7.5% of such patients will experience some retinal damage after five years of medication use. Annual eye screenings are particularly critical for patients consuming more than 5mg/kg/day for over five years, in line with the «rule of five.»2

Eye drop compliance

Pharmacists should address the issue of low compliance

There are two types of AMD:

6. Close your eye and press gently on the inner corner of your eye for 30–60 seconds to ensure the drop is fully absorbed.

EYE CONDITIONS

Amblyopia

Amblyopia, commonly known as «lazy eye,» affects 3-4% of children1 and results from inadequate visual development during early years. Treatment is most effective when started during infancy or early childhood; after age nine, significant improvement is unlikely. While amblyopia is often difficult to diagnose, vision screening is recommended by age four, or earlier in the presence of eye «wandering» or a family history. Treatment typically involves patching the stronger eye to encourage use of the weaker eye. Eye drops may be used as an

An Amsler Grid is a simple symptoms of Wet AMD. However for an eye examination . separately with reading blurring or distortion of the indicate the presence of examined promptly by their

An Amsler Grid is a simple test designed to pick up symptoms of Wet AMD. However it is not a substitute for an eye examination . The patient checks each eye separately with reading glasses on. If they notice blurring or distortion of the lines on the grid this could indicate the presence of Wet AMD and they should be examined promptly by their eye doctor.

1. Dry AMD: Most common (80-90%) and milder form. Lifestyle changes ea�ng a diet rich in lutein can slow progression.

-related macular degenera�on (AMD) is a leading cause of vision loss

It affects central vision, impac�ng ac�vi�es like reading and driving but usually vision intact. Early diagnosis and treatment result in beter outcomes.

alternative. Untreated amblyopia can result in irreversible poor vision in the affected eye. Early detection and treatment with patching are generally successful in improving vision.

Age-related macular degeneration (AMD)

Age-related macular degeneration (AMD) is a leading cause of vision loss in people over 50 in Ireland. It affects central vision, impacting activities like reading and driving but usually leaves peripheral vision intact. Early diagnosis and treatment result in better outcomes.

There are two types of AMD

1. Dry AMD: Most common (8090%) and milder form. Lifestyle changes like quitting smoking and eating a diet rich in lutein can slow progression.

2. Wet AMD: Less common but more severe. Characterized by abnormal blood vessel growth, leading to rapid vision loss.

Diagnostic tests like Fluorescein angiograms and OCT scans help in identifying AMD. While no medical treatment exists for Dry AMD, Wet AMD can be treated with Intravitreal injections that stabilize or improve vision.

Lifestyle changes and specific supplements containing vitamins C and E, zinc & copper, and lutein and zeaxanthin are recommended. in slowing the progression of AMD. Regular eye exams are crucial for early detection, especially for those over 50 or with a family history of AMD.

In summary, AMD is a serious condition that can lead to

significant vision loss, but early detection and modern treatment options have improved the prognosis significantly.

Cataracts

Cataracts, a common cause of visual impairment, particularly among the elderly. In the United States, over 70% of individuals above the age of 70 have some degree of cataract. In Ireland, cataract surgery is the most performed operation.

What are cataracts? The eye functions like a camera, with the retina acting as the film at the back and the lens located at the front, just behind the pupil. A cataract is a condition where the lens becomes cloudy, affecting vision. The lens, composed of proteins and fluid, is responsible for focusing light. The proteins in the eye›s lens are aligned in parallel to permit uninterrupted passage of light. The pupil changes size to regulate light reaching the retina, while the lens automatically adjusts to enable clear vision at different distances. Three types of cataracts are outlined: nuclear, cortical, and subcapsular, each affecting different parts of the lens and having unique symptoms and rates of progression.

1. Nuclear Cataract: Affects the central core of the lens and is commonly associated with aging. It develops slowly, sometimes taking many years to significantly impact vision.

2. Cortical Cataract: Forms in the peripheral part of the lens, resembling bicycle wheel spokes. It can take time for these ‹spokes› to grow centrally

and affect vision. Often, doctors notice signs before vision is impacted.

3. Subcapsular Cataract: Occurs at the back of the lens and typically affects people with diabetes or those on steroid therapy. It features a ‹stippling› on the lens surface, resembling a semi-opaque bathroom window, and can develop quickly, potentially obstructing vision within a year.

Each type develops at different rates and locations in the lens, affecting vision in unique ways. Symptoms can range from blurred vision and light sensitivity to ‹second sight,› a temporary improvement in near vision. The following are risk factors that are said to be associated with cataract formation.

• Ultraviolet light has been said to damage the proteins in the lens and induce cataract. Eye doctors advise the use of sunglasses and wide-brim hats to protect against UV light exposure. A UV protective coating on your sunglasses is probably a good thing to have.

• Poor nutrition is a cause of cataract formation and the prevalence of cataract increases geographically as one travels towards the equator from the poles. The strength of sunlight also increases as you get nearer the equator which may also be a factor.

• Steroids and some other drugs are implicated in cataract formation.

• Other risk factors include too much salt, alcohol, air pollution and smoking. Again all these processes are difficult to prove.

• Diabetes mellitus There is evidence to show that diabetics are more prone to cataract formation especially those suffering from Type 2 diabetes. Treatment often starts with prescription changes for glasses but ultimately requires surgery for severe cases. The timing for surgery can vary based on lifestyle needs, such as driving. Surgical procedures are mostly straightforward, usually taking about 20 minutes and requiring post-operative care like eye drops and short-term protective eyewear. In summary, cataracts are a prevalent vision problem with various types and symptoms. They are largely age-related but can be influenced by lifestyle factors. While the exact causes remain unclear, cataract surgery is a common and effective treatment, especially in medically advanced countries.

Conjunctivitis

Conjunctivitis is the inflammation or infection of the eye›s white membrane and inner eyelids. It ranges from mild to severe and comes in various types: viral, bacterial, and allergic. Viral conjunctivitis is the most common, self-resolving but highly contagious; bacterial conjunctivitis is less common and requires antibiotics; allergic conjunctivitis features itchiness and is best treated by avoiding allergens or using overthe-counter eye drops. More severe cases may require prescription

Cataract

NORMAL RETINA DIABETIC RETINOPATHY

medication and consultation with an eye doctor. It›s important to note that not all red eyes are due to conjunctivitis; other causes like dry eyes and foreign bodies can also lead to redness.

Diabetic retinopathy

Diabetic retinopathy is a common complication of diabetes, affecting the blood vessels in the retina and potentially causing vision problems.

It is a leading cause of new blindness in adults in Ireland. The condition is more prevalent in long-term diabetics, and its risks are exacerbated by factors like pregnancy and high blood pressure. Regular eye check-ups are crucial for early detection and management. Laser surgery is a common treatment method. In Ireland, the government funded Diabetic Retina Screen program offers free retinopathy screenings for diabetics aged 12 and older, using specialized digital photography. Those with diabetes should ensure they are registered for this program.

Further information on the screening programme is available at http://www. diabeticretinascreen.ie/

Glaucoma

Glaucoma, a leading cause of blindness. Glaucoma damages

the optic nerve, and its severity varies depending on eye pressure and other factors. The condition is categorized into four main types: chronic, acute, secondary, and developmental. Early detection through regular eye tests is crucial for effective treatment, which is usually done through eye drops, laser treatment, or surgery. Glaucoma is expected to increase by 33% in Ireland due to an aging population.1 Those most at risk are individuals over 60, those with a family history of the disease, and people of African and Hispanic ethnicity. Treatment cannot reverse the damage but can prevent further loss of sight. It›s important to get regular eye tests, especially if you are over 40 or have other risk factors like diabetes or a family history of the condition.

Eye injury

Prevention of eye injuries is crucial and can be achieved through various means. For young males at risk of assault-related injuries, involving law enforcement and social services can help. Protective eyewear should be used in sports and workplaces to reduce injuries. Additionally, eyewash stations should be readily available in areas at risk for chemical injuries. Company management should also implement preventative strategies to improve eye safety.

When to refer

Summary: Over-the-counter treatment in pharmacies for common eye issues mainly focuses on symptoms like redness and soreness. However, pharmacists should be wellinformed on treating Dry Eye Disease (DED) and minor eye infections. They should also be alert for red flag symptoms that warrant immediate referral.

Red Flag Symptoms for Pharmacists:

• Visual Loss: Any sudden or gradual loss of vision

• Pain: Acute or chronic eye pain

• Flashing Lights, Floaters, or Halos: Visual disturbances that are not typical.

• Headaches: Especially if severe and accompanied by other eye symptoms

• Co-existing Conditions: Diabetes or hypertension along with eye symptoms

Note: These symptoms may indicate a severe eye condition that requires immediate medical attention. Pharmacists should promptly refer patients presenting with any of these red flag symptoms to an eye specialist.

Conclusion

Eye health is an integral part of overall well-being and an area where pharmacists can make a significant impact. As the first line of advice for patients, community pharmacists play an essential role in early detection, preventive care, and timely referrals for a variety of eye conditions. In the Irish context, where vision loss and blindness are pressing public health concerns, the role of the pharmacist extends to educating the community on lifestyle modifications—from dietary choices to exercise and screen time management—that can mitigate the risk of avoidable sight loss. Equipped with knowledge on ‹red flag› symptoms and proper management techniques, pharmacists can be instrumental in reducing the rate of vision impairment in the community. The adoption of comprehensive strategies and staying updated on latest guidelines can enhance the quality of care provided, thus safeguarding the nation›s vision.

References available on request

The journey to triple protection in type 2 diabetes mellitus1†

INVOKANA® is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise:

> as monotherapy when metformin is considered inappropriate due to intolerance or contraindications

> in addition to other medicinal products for the treatment of diabetes

For study results with respect to combination of therapies, effects on glycaemic control, cardiovascular and renal events, and the populations studied, see sections 4.4, 4.5 and 5.1 of the Summary of Product Characteristics (SmPC).1

† Improvement in glycaemic control and reduction of cardiovascular and renal morbidity and mortality are integral parts of the treatment of type 2 diabetes.1

1. INVOKANA® Summary of Product Characteristics June 2023.

Invokana (canagliflozin) 100mg & 300mg film-coated tablets

Abbreviated Prescribing Information: Please consult the Summary of Product Characteristics (SmPC) for full prescribing information. Presentation: Canagliflozin 100mg and canagliflozin 300mg, film-coated tablets.

Use: Adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise: (1) as monotherapy when metformin is considered inappropriate due to intolerance or contraindications, or (2) in addition to other medicinal products for the treatment of diabetes. Dosage and administration: Oral administration. Recommended starting dose is 100mg once daily, preferably taken before the first meal of the day. Tablets should be swallowed whole. In patients needing tighter glycaemic control and tolerating canagliflozin 100mg once daily, dose can be increased to 300mg once daily if eGFR ≥ 60 mL/min/1.73 m2 [Refer to SmPC for dose adjustment according to eGFR]. Care when increasing dose in patients ≥ 75 years of age, patients with known cardiovascular disease (CVD), other patients for whom the initial canagliflozin-induced diuresis poses risk. Correcting volume depletion prior to initiation of canagliflozin is recommended. Consideration of a lower dose(s) of insulin/insulin secretagogue if using canagliflozin as an add-on therapy is recommended. Elderly (≥ 65 years old): Renal function and risk of volume depletion should be taken into account. Paediatric population: The safety and efficacy of canagliflozin in children under 18 years of age have not yet been established. Contraindications: Hypersensitivity to the active substance or any of the excipients.

Warnings and Precautions: [Refer to SmPC for more detail] Renal impairment: Limit dose to 100mg once daily in patients with eGFR < 60 mL/min/1.73 m2. Regardless of pre-treatment eGFR, patients on canagliflozin may experience an initial fall in eGFR that attenuates over time. Monitor renal function prior to and after initiating canagliflozin. Also monitor after initiating concomitant products that may reduce renal function. Patients at risk of volume depletion: Canagliflozin induces osmotic diuresis which may reduce intravascular volume and decrease blood pressure (BP). Caution should be exercised in patients for whom a canagliflozininduced drop in BP could pose a risk. Advise patients to report symptoms of volume depletion. Canagliflozin is not recommended for use in patients receiving loop diuretics or who are volume depleted. Diabetic ketoacidosis (DKA): Rare cases of DKA, including life-threatening and fatal cases, have been reported in patients treated with SGLT2 inhibitors. Presentation of DKA may be atypical. Risk of DKA appears to be higher in patients with moderately to severely decreased renal function who require insulin. Assess patients immediately if symptoms occur, regardless of blood glucose level. Where DKA is suspected/diagnosed, discontinue canagliflozin immediately. Treatment should be interrupted in patients hospitalised for major surgical procedures or acute serious medical illnesses. Monitor ketones (preferably blood ketones) in these patients. Before initiating canagliflozin, consider factors in patient history that may predispose to DKA. DKA may be prolonged after discontinuation. Canagliflozin should not be used for treatment of patients with type 1 diabetes. Lower limb amputations: Before initiating canagliflozin, consider factors in patient history that may increase risk for amputation. Consider careful monitoring of patients with a higher risk for amputation, and counsel patients. Consider stopping canagliflozin in patients who develop events which may precede amputation. Necrotising fasciitis of the perineum: (Fournier’s gangrene): This rare but serious and potentially life-threatening event requires urgent surgical intervention and antibiotic treatment. Advise patients to seek medical attention if they experience a combination of pain, tenderness, erythema, or swelling in the genital or perineal area, with fever or malaise. Urogenital infection or perineal abscess may precede necrotising fasciitis.

If Fournier’s gangrene is suspected, discontinue canagliflozin and institute prompt treatment. Elevated haematocrit: Monitor haematocrit levels in patients with an already elevated haematocrit. Elderly (≥ 65 years old): Elderly patients may be at a greater risk for volume depletion, are more likely to be

* If further glycaemic control is needed, the addition of other anti-hyperglycaemic agents should be considered. § Continue dosing until dialysis or renal transplantation.

treated with diuretics, and to have impaired renal function. Genital mycotic infections: Vulvovaginal candidiasis, and balanitis/balanoposthitis were reported in clinical studies. Urinary tract infections (UTIs): Complicated UTIs including pyelonephritis and urosepsis have been reported. Temporary interruption of canagliflozin should be considered. Cardiac failure: Experience in New York Heart Association (NYHA) class III is limited, with no experience in clinical studies with canagliflozin in NYHA class IV. Urine laboratory assessments: Patients taking canagliflozin will test positive for glucose in their urine. Lactose intolerance: Patients with galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption should not take this product. Interactions: Diuretics: may increase risk of dehydration and hypotension. Insulin and insulin secretagogues: risk of hypoglycaemia; consider lower dose of insulin or insulin secretagogue. Effects of other medicines on Invokana: Enzyme inducers (e.g. St. John’s wort, rifampicin, barbiturates, phenytoin, carbamazepine, ritonavir, efavirenz) may decrease exposure of canagliflozin; monitor glycaemic control. Consider dose increase to 300 mg if administered with UGT enzyme inducer. Cholestyramine may reduce canagliflozin exposure; take canagliflozin at least 1 hour before or 4-6 hours after a bile acid sequestrant. Effects of Invokana on other medicines: Monitor patients on digoxin, lithium, other cardiac glycosides, dabigatran. Inhibition of Breast Cancer Resistance Protein cannot be excluded; possible increased exposure of drugs transported by BCRP (e.g. rosuvastatin and some anti-cancer agents). Pregnancy and lactation: Do not use canagliflozin during pregnancy or when breast-feeding. Discontinue canagliflozin when pregnancy is detected. Effect on fertility unknown. Effects on ability to drive and use machines: Canagliflozin has no or negligible influence on ability to drive and use machines. However, patients should be alerted to the risk of hypoglycaemia when canagliflozin is used as add-on therapy with insulin/insulin secretagogue, and to the elevated risk of adverse reactions related to volume depletion. Side Effects (SEs): Adverse reactions are based on the pooled analysis of placebo-controlled, clinical studies. Very Common (≥ 1/10): vulvovaginal candidiasis, hypoglycaemia in combination with insulin or sulphonylurea. Common (≥ 1/100, <1/10): balanitis or balanoposthitis, urinary tract infection (pyelonephritis and urosepsis have been reported post-marketing), constipation, thirst, nausea, polyuria or pollakiuria, dyslipidaemia, haematocrit increased. Uncommon (≥ 1/1,000 to < 1/100): dehydration, dizziness postural, syncope, hypotension, orthostatic hypotension, photosensitivity, rash, urticaria, bone fracture, renal failure (mainly in the context of volume depletion), blood creatinine increased, blood urea increased, blood potassium increased, blood phosphate increased, lower limb amputations (mainly of the toe and midfoot) especially in patients at high risk for heart disease. For less frequent side effects see SmPC. Pack sizes: 30 x 1 film-coated tablets. Legal category: POM. Marketing Authorisation number: EU/1/13/884/001-004 (100mg) and EU/1/13/884/005-008 (300mg). Marketing Authorisation holder: Janssen-Cilag International NV, Turnhoutseweg 30, B-2340, Beerse, Belgium Marketed by: A. Menarini Pharmaceuticals Ireland Ltd. Further information is available on request from A. Menarini Pharmaceuticals Ireland Ltd., Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin A96 T924 or may be found in the SPC.

Date of preparation: July 2023.

Adverse events should be reported. Healthcare professionals are asked to report any suspected adverse events via: HPRA Pharmacovigilance Website: www.hpra.ie. Adverse events should also be reported to A. Menarini Pharmaceuticals Ireland Ltd. Phone no: 01 284 6744

Pelvic Pain in Women

Written by Dr Kirk Levins, Chronic Pain Medicine Consultant

Vulvodynia

Introduction

Female pelvic pain is a complex and often debilitating condition that affects millions of women worldwide. This condition can have a profound impact on a woman’s quality of life, causing physical discomfort, emotional distress, and even disruption of daily activities. It can originate from various structures within the pelvis, including the reproductive organs, urinary system, musculoskeletal system, or gastrointestinal tract. Two common conditions causing pelvic pain are vulvodynia and endometriosis.

Vulvodynia is a chronic pain condition that primarily affects the vulva, the external genitalia of the female reproductive system. The term “vulvodynia” encompasses various types of vulvar pain disorders that share common features, including pain, burning, stinging, or discomfort in the vulvar area. This pain can be spontaneous or provoked, such as during sexual intercourse or when pressure is applied to the vulvar region. Vulvodynia can be classified into two primary categories, generalized vulvodynia and vestibulodynia (provoked vulvodynia). Generalized vulvodynia involves pain throughout the entire vulvar area. Women with generalized vulvodynia may experience constant or intermittent discomfort. Vestibulodynia is characterized by pain or discomfort primarily at the vaginal entrance or vestibule. It is often provoked by touch or pressure, such as during sexual intercourse or tampon insertion. The exact cause of vulvodynia remains elusive, and it is believed to be a multifactorial condition influenced by a combination of factors.

Women's News

Management of vulvodynia can be difficult however combined conservative and interventional approaches have shown promise. Conservative management involves pelvic floor physiotherapy, oral medication such as tricyclic antidepressants, and lifestyle changes. Interventional approaches involve autonomic nerve blocks and ultrasound guided targeted injection of botulinum toxin into the pelvic floor.

Endometriosis Pain

Endometriosis is a chronic and often painful gynecological disorder that affects millions of women worldwide. It is a complex gynecological disorder characterized by the presence of endometrial-like tissue outside the uterus, often leading to chronic pelvic pain and various other symptoms. Pain in endometriosis can manifest in several forms. Two common forms are dyspareunia (painful intercourse) and pelvic girdle pain.

Dyspareunia in endometriosis is a complex and multifaceted issue that requires a comprehensive approach to diagnosis and management. Understanding the interplay between the physical, psychological, and hormonal factors involved in this symptom is essential for healthcare providers to offer effective interventions and support for women with endometriosis. Ultrasound guided

New Research on Women’s Heart Health

injection of Botulinum toxin to the pelvic floor has shown promise in treating dyspareunia due to endometriosis.

Pelvic girdle pain (PGP) refers to discomfort and pain experienced in the area of the pelvis, specifically in the joints and ligaments that support the pelvic region. It is likely caused by a combination of factors including inflammation, high levels of estrogen causing an increase in joint laxity and pain perception, postural changes due to the pain of endometriosis and muscular. Pelvic girdle pain typically presents with pain in the buttock that is exacerbated by transitioning from sitting to standing. The pain can radiate to the level of the knee. Pelvic girdle pain often responds well to injection and lesioning of the nerves supplying the joint.

Dr Kirk Levins is a Chronic Pain Medicine consultant working across SVPH, NMH, NRH and SVUH. He has spent the last 6 years treating women with pelvic pain at both St. Vincents University Hospital and at the NMH. He is also a keen researcher and holds degrees in Chemistry and Neuroscience. He has won awards for his research including the American Academy of Pain Medicine award for research and the Abbvie scholarship. He is involved in several research collaborations with institutions in New Zealand, USA, and the Netherlands.

Research carried out by Blackrock Health has found that women are almost half as likely to seek medical attention for heart related symptoms than men. Only 16% of women claimed that they went to a hospital A&E to address heart related symptoms, versus 31% of men.

The findings revealed that heart related symptoms are often dismissed as a sign of ageing amid confusion over what constitutes an urgent cardiac issue. The research, conducted among a nationally representative sample of 1,010 members of the general public aged 18 and over, found that 25% of people took no action when they experienced heart related symptoms, and 24% thought their symptoms were a general symptom of getting older.

Concerningly, nearly 1 in 5 people (18%) surveyed, ignored potentially

life-threatening cardiac symptoms, as they thought they would improve in time. As part of their ongoing Show Your Heart Some Love campaign, Blackrock Health is encouraging people to learn more about potentially concerning cardiac health symptoms.

Dr Carla Canniffe, Consultant Cardiologist at Blackrock Health said, “Cardiac symptoms are not always recognised by patients when they occur. If left untreated, they can lead to potentially life-threatening situations. This

research highlighted several concerning trends; many people simply aren't acting in response to cardiac issues when they experience them, and women in particular, are less likely to seek medical assistance. Symptoms of heart conditions are often confused with other diseases or dismissed by patients as part of ageing or something they have to live with. Accurately recognising and addressing cardiac symptoms is essential to improving patient outcomes nationwide."

"During Irish Heart Month, we want to encourage people to learn more about the key symptoms associated with cardiac problems so that people know what to look out for, and to know when something is not right.”

The research found that while over three quarters (77%) of adults claim to have experienced one of the heart related symptoms outlined above, only 53% of those who have experienced cardiac symptoms claim they contacted their doctor.

Female Health and the Pharmacy

The area of female health is a complex and diverse area and it is a hugely important category in Pharmacy, as for many women, the pharmacy is their first stop when seeking out products for their health, both intimate and otherwise.

This article is centred around a number of specific areas that are particularly relevant to pharmacists who treat patients in community pharmacies.

Many of the issues that female patients present with in Pharmacy are sensitive issues and they will need to be dealt with in an open yet delicate manner, so it is important that a pharmacist know what they are, and the best method of treating them.

Below, Irish Pharmacy News outlines some of the ailments that women with period or fertility problems, or reproductive health issues are likely to be experiencing if they present to a pharmacy.

Period problems

Problems in a woman’s menstrual cycle, called menstrual irregularities, are commonplace. Periods may be too regular, to infrequent, or event unpredictable or painful.

If not caused by pregnancy, these menstrual irregularities may be a sign of a gynaecological condition or problem.

Premenstrual Syndrome (PMS)

There are many conditions that cause period problems with one of the most common problems being premenstrual syndrome (PMS).

PMS refers to a collection of physical, psychological and emotional symptoms related to a woman’s menstrual cycle.

Symptoms include abdominal bloating and cramps, breast tenderness or swelling, stress or anxiety, headache, joint or muscle pain, fatigue, irritability, and mood swings.

Most women with PMS (about 80%) experience one or more of these symptoms at some point.

Symptoms generally disappear before the menstrual cycle begins, however an estimated two to five percent of experience significant premenstrual symptoms characterised by severe mood swings and other symptoms related to emotions.

It is important that when a pharmacist is helping a patient with PMS they treat the patient with care and understanding. It is also very important for pharmacists

to inform their patients that there are also alternatives to OTC medications when dealing with symptoms of PMS.

The alternatives such as advice on lifestyle and diet changes to alleviate symptoms, should be discussed in private with the patient.

In addition, a pharmacist may recommend natural supplements like vitamin B6 and omega oils like Krill oil, which have been shown to be very beneficial in treating PMS related symptoms.

Amenorrhoea

This refers to the absence of menstrual periods in a woman during her reproductive years.

Amenorrhoea is either classified as either ‘primary’ (menstrual periods not having started by age 16 years) or ‘secondary’ which is the absence of menstrual periods in a woman who has previously been menstruating for six months or more.

The frequency of primary amenorrhoea in the population is about 0.5-1.2%, while the frequency of secondary amenorrhoea is approximately 5%.

Patients may have headaches, visual disturbance or tiredness caused by diseases affecting the pituitary gland in addition to the absence of menstrual periods.

Amenorrhoea can be caused by a number of factors in a woman’s life including excessive exercising, an eating disorder, severe stress, hormonal or genetic problems. Treatment depends on the underlying cause and it is usually advisable to refer the patient to her GP for further investigation.

Oligomenorrhea

Oligomenorrhea is a condition in which a woman experiences infrequent menstrual periods, and occurs in women of childbearing age.

Some variation in menstruation is normal, but a woman who regularly goes more than 35 days without menstruating may be diagnosed with oligomenorrhea. Periods usually occur every 21 to 35 days.

Like amenorrhoea it is not a disease but it is a symptom of a

larger condition e.g. Polycystic ovary syndrome (PCOS). Again, the patient should be referred to her GP in cases such as this.

Dysmenorrhoea

It is common for women to experience an ache in their lower abdomen, back and tops of the legs, especially in the first few days of your period, known as Dysmenorrhoea.

The first two days are usually the worst. Some women have more pain than others.

Pharmacists can give a patient painkillers or anti-inflammatory painkillers such as ibuprofen usually ease the pain if it is troublesome.

The cause of the pain in most women is not fully understood. Sometimes conditions such as endometriosis can make period pains become worse.

Pharmacists should advise women suffering from Dysmenorrhoea to see a doctor if: The pain becomes gradually worse in each period; Pain begins a day or more before the onset of bleeding; Pain is severe over the whole time of the period. It is important to note, however, that sometimes dysmenorrhoea may be caused by infection, endometriosis, fibroids or ovarian cysts.

Treatment must be tailored to the specific problem; therefore, a definite diagnosis must be made.

Menorrhagia

Menorrhagia refers to abnormal or heavy bleeding which is different to normal menstrual bleeding.

Typically a hormone imbalance the cause of menorrhagia, particularly in adolescents and women approaching the menopause. It is advised that pharmacists refer patients to a GP if they present experiencing Menorrhagia.

Primary Ovarian Insufficiency

Premature ovarian failure - also known as primary ovarian insufficiency - is a loss of normal function of a woman’s ovaries before age 40. If their ovaries fail, they don’t produce normal amounts of the hormone oestrogen or release eggs regularly.

The most common result of this is infertility.

Sometimes Primary Ovarian Insufficiency is referred to as premature menopause, but the two conditions aren’t the same. Women with premature ovarian failure can have irregular or occasional periods for years and might even become pregnant. Women with premature menopause stop having periods and can’t become pregnant.

Restoring oestrogen levels in women with premature ovarian failure helps prevent some complications, such as osteoporosis, that occur as a result of low oestrogen.

Women with POI may have no periods or may get them infrequently.

If a patient presents in Pharmacy with symptoms relating to POI then referral to her GP is advisable as in some cases oestrogen replacement therapy will be prescribed.

Female infertility

Female infertility is also common for women to present to a pharmacy with. Both a lack of ovulation, or infrequent ovulation are the two most common problems when it comes to female infertility. These can be caused by PCOS, POI, hypothalmic amenorrhoea, or pituitary gland problems.

If a woman is experiencing pituitary gland problems it means that their glands are releasing too much prolactin, which is a hormone that affects oestrogen levels.

Age is also a major factor when it comes to infertility, as the number of eggs produced by a woman’s body decreases as she gets into her 30’s. In addition, female infertility can be as a result of tubular blockage, endometriosis or male factor infertility.

Other hormone related conditions such as an underactive thyroid gland, diabetes, obesity and occasionally Cushings syndrome can affect female fertility.

Problems with Ovulation may be treated using fertility drugs such as FSH or LH, which work like natural hormones and help to bring it about.

Pharmacists prescribing drugs to women experiencing ovulation problems typically choose clomiphene, gonadotropin therapy, human chorionic

gonadotropin (Hcg), bromocriptine or cabergoline.

PCOS, along with causing period problems, is also a major cause of female infertility. Women with PCOS have increased androgen (male hormone) levels, leading to an imbalance in the hormones that regulate ovulation and normal egg development.

Signs and symptoms include an irregular menstrual cycle, excessive hair growth on the face and body, and obesity.

Treatment of PCOS can vary from patient to patient, but a woman’s ovulation cycle can be restored in many cases through a combination of medication and lifestyle changes.

Some women can become pregnant after they have been diagnosed with POI, however this is unlikely.

Contraception options

The pharmacy is the first stop for women who are looking for contraception. Over half of all pregnancies are unplanned, so it is important that both women and men are made aware of the various contraception options that are available to them.

Women who wish to avoid an unplanned pregnancy can be advised by their pharmacist to use condoms, a contraceptive implant, intrauterine system (IUS), an intrauterine device (IUD), progestogen-only pill, or a diaphragm or cap.

The most effective method of contraception is the IUD; however, a woman must be referred to her doctor for this.

Pharmacists may also provide emergency contraception to women who have recently had unprotected sex in the form of the morning after pill.

Although IUD is most effective, many women prefer not to have to be subject to invasive treatment, preferring to take a pill.

The most effective oral contraceptive on the market is Ulipristal Acetate (ellaOne), which has been demonstrated to be effective up to 120 hours after unprotected sexual intercourse, and which acts by modifying the activity of the natural hormone progesterone which is necessary for ovulation to occur.

Although it is advised that women should not use emergency contraception frequently, providing emergency contraception is nonetheless an integral service provided by pharmacists with regard to women’s reproductive health, and pharmacists should be

aware of the products and options available to women.

Last month, Minister for Health Simon Harris announced that medical card holders would now have access to emergency contraception without prescription, ending what the Irish Pharmacy Union (IPU) called a ‘two-tier system’. It is expected that this will result in greater compliance, and less unplanned pregnancies. Pharmacists had been allowed to supply the emergency contraception to women without a prescription since 2011.

Pregnancy

When a woman is pregnant, she can experience extreme discomfort at times, and a pharmacist can suggest or supply products to ease her pain or distress.

Nausea and vomiting often develop by five to six weeks of pregnancy. The symptoms are worst around nine weeks, and typically improve by 16 to 18 weeks of pregnancy. However, symptoms continue until the third trimester in 15 to 20 percent of women and until delivery in 5 percent of women.

To ease the symptoms of nausea, a pharmacist can suggest dietary changes, or a number of products.

Vitamin B6 or antihistamines are often helpful for pregnancy women with mild to moderate nausea.

If the nausea and vomiting is triggered by gastrointestinal

distress, OTC reflux medications like Zantac or Pepcid can sometimes be effective.

It is advised that pregnant women avoid smoking cigarettes, as they could be harmful to their baby –pharmacists can suggest smoking deterrents, such as nicotine replacement therapy to a patient. There are many products that women cannot take while pregnant, as they will cause harm to her foetus.

If a woman who is pregnant has cold or flu, it is very important that pharmacists do not give cold remedies that contain alcohol, or the decongestants pseudoephedrine and phenylephrine, which can affect blood flow to the placenta.

Pharmacists can also suggest Folic acid for foetal health, as it helps prevent neural tube birth defects, which affect the brain and spinal cord.

Neural tube defects develop in the first 28 days after conception, before many women know they are pregnant.

It is also recommended that any woman who could get pregnant take 400 micrograms (mcg) of folic acid daily, starting before conception and continuing for the first 12 weeks of pregnancy.

Menopause

Menopause is the time in a woman’s life when menstruation stops and she can no longer conceive.

A woman is said to have experienced the menopause when she has had twelve consecutive months without a period. On average, the menopause occurs when a woman is 51 years of age, but this varies quite a bit.

The premenopausal, or perimenopausal, process usually begins in or around the early 40’s. Symptoms of this include hot flushes and night sweats, mood swings, vaginal dryness, diminished sexual desire, forgetfulness, trouble sleeping and urinary incontinence.

After a woman has experienced the menopause her body produces less of the female hormones oestrogen and progesterone. Symptoms of the menopausal transition can be very troubling for many women, with many doctors prescribing hormone therapy (HRT, HT, ERT, ET) to ease symptoms. Many different types of hormone therapies are available for a pharmacist to give to a patient. These include tablets, patches, gel, vaginal preparations and nasal sprays. A pharmacist should discuss the available options for a patient privately with them.

A pharmacist can also discuss with the patient some alternatives to hormone replacement therapy e.g. regular exercise, dietary changes, natural supplements like soy isoflavones and omega oils etc. They should also advise a patient see their doctor, if they are to make an informed decision about further treatment.

Urinary Tract Infections & Vaginal Dryness in Women

Urinary tract infections (UTIs) are among the most common infections affecting adult women. One-half of all women will experience at least one UTI in their lifetime. Recurrence of UTIs is common, with a reported rate of 25% within 6 months of the first occurrence.

Urinary tract infection (UTI) is the collective term used to describe infections involving any part of the urinary tract, which includes the kidneys, ureters, bladder and urethra. Infections of the bladder (cystitis) and urethra (urethritis) are known as lower UTIs and infections of the kidneys (pyelonephritis) or ureters are classed as upper UTIs.

Diagnosis of UTI is based primarily on signs and symptoms.

The incidence of UTIs in adult males under age 50 years is low.

Up to 40% of women develop a UTI at some point in their life, compared to 12% in men. In men, cystitis is often associated with infection and inflammation of the prostate gland (prostatitis). Anatomically, the female urethra is shorter and located closer to the anus than in males, which makes it easier for bacteria to reach the female urethra and bladder.

Adult women are 30 times more likely than men to develop a UTI, with almost half of them experiencing at least one episode during their lifetime and one-in-three women experiencing their first episode by the age of 24 years. UTIs are most commonly seen in sexually-active young women.

UTIs can be classified as ‘uncomplicated’ (sometimes referred to as a ‘simple’ UTI) or ‘complicated.’ Uncomplicated infections present most frequently in women without any structural or functional abnormality of the urinary tract, any history of renal disease, or other comorbidity (e.g. immunocompromised patients or those with diabetes), which may contribute to more serious outcomes. Complicated UTIs are associated with a condition or underlying disease that interferes with the patient’s immune mechanisms and increases the risk of acquiring infection.

Recurrent UTIs, defined as at least two UTIs in 6 months or three UTIs in 1 year, are a significant burden for the patient and result in high costs to the health system. The most commonly prescribed regimens are trimethoprimsulfamethoxazole (or trimethoprim alone), nitrofurantoin, cephalexin and the fluoroquinolones at a quarter of the usual daily dose for 6 months.

Symptoms may include:

• Pain or a burning sensation when passing urine

• Needing to urinate more often during the night

• Urine that looks cloudy

• Needing to urinate more urgently than usual

• Blood in the urine

Children with UTIs may also:

• Have a high temperature

• Appear generally unwell

• Wet the bed or themselves

• Be sick

When to Refer:

• Someone who has symptoms of a UTI for the first time

• A child has symptoms of a UTI

• A man with symptoms of a UTI

• Pregnant women with symptoms of a UTI

• Symptoms of a UTI after surgery

• Symptoms get worse or do not improve within 2 days

Those suffering with UTIs can be advised to take paracetamol up to four times a day to help reduce pain and a temperature. Children can take liquid paracetamol. They should also be advised to rest and drink fluids so that they can pass urine more regularly during the day.

It may also help for sufferers to avoid sexual intercourse until symptoms have passed.

Cranberry juice and capsules

Drinking cranberry juice may help to prevent UTIs. For those with recurring UTIs, higher strength cranberry capsules are recommended.

However, advise customers that they should not consume cranberry juice or cranberry capsules if they are taking warfarin.

Treat constipation promptly

Constipation (where it is difficult to pass stools) can increase the chances of developing a UTI.

Recommended treatments for constipation include:

• increasing the amount of fibre in the diet (20g to 30g of fibre a day)

• using a mild laxative on a short-term basis

• drinking plenty of fluids

Vaginal Dryness

Normally, the walls of the vagina stay lubricated with a thin layer of clear fluid. The hormone estrogen helps maintain that fluid and keeps the lining of your vagina healthy, thick, and elastic. A drop in estrogen levels reduces the amount of moisture available and can lead to vaginal dryness.

It is a common but treatable problem that many women experience at some point in their lives. It can be a problem at any age, but is a particular issue for women who are going through or have experienced the menopause. Sufferers will often feel embarrassed about seeking help but can be advised that there are a number of treatments that can help.

Symptoms

Some women only have symptoms of vaginal dryness at certain times, such as during sex, while others have them all the time.

Problems associated with having a dry vagina include:

• vaginal irritation, discomfort, itchiness or a burning sensation

• discomfort during sex

• a reduced sex drive

• difficulty getting aroused and reaching orgasm

• the surface of the vagina looks pale and thin

• narrowing or shortening of the vagina

• needing to pass urine more often than usual

• repeated urinary tract infections (UTIs)

Causes

Causes of a dry vagina include:

• the menopause - decreased levels of the hormone oestrogen during the menopause can cause persistent vaginal dryness (also known as vaginal atrophy or atrophic vaginitis)

• breastfeeding or childbirthoestrogen levels can temporarily decrease after giving birth and make the vagina feel drier than usual

• not being aroused before sex - if a woman doesn’t feel aroused before having sex, her vagina may not produce natural lubricant and sex may be uncomfortable

• some types of contraceptionthe combined contraceptive pill and contraceptive injection can occasionally cause vaginal dryness, although this is uncommon

• cancer treatmentradiotherapy to the pelvic area, hormonal cancer treatments, and sometimes chemotherapy can cause vaginal dryness

Vaginal dryness is also sometimes caused by an underlying condition such as diabetes or Sjögren’s syndrome, where the immune attacks the glands in the body that produce fluid.

Self-help

Sufferers of vaginal dryness can be advised that it’s worth trying selfhelp options first. It can help to:

• try using a lubricant or vaginal moisturiser – these can be bought without a prescription

• give yourself enough time to become aroused before having sex – read more about female arousal and get good sex tips

Treatments

The most common treatment for vaginal dryness due to low estrogen levels is topical estrogen therapy. These replace some of the hormone the body is no longer making. That helps relieve vaginal symptoms, but it doesn’t put as much estrogen in the bloodstream as the hormone therapy in pills.

Lubricants - liquids or gels that are applied to the vulva, vagina or the partner’s penis just before having sex to keep the vagina moist. They offer immediate but short-term relief from vaginal dryness.Several different brands of lubricant are available to buy from pharmacies without a prescription.

Vaginal moisturisers - creams that are applied inside the vagina to keep it moist. They may be better than lubricants if the dryness

isn’t just causing problems during sex, as they tend to have a longerlasting effect. They usually need to be applied every few days.

Vaginal oestrogen - a GP may prescribe vaginal oestrogen if the dryness is caused by the menopause. This works by increasing the level of oestrogen that declines during and after the menopause.

Vaginal oestrogen is available as pills that are placed in the vagina (pessaries), vaginal creams and vaginal rings. Oestrogen treatment can be more effective than lubricants and moisturisers for menopausal women, and it generally causes few side effects. However, it can take a few weeks to start working, so the patient may want to use a lubricant or moisturiser as well to begin with. Treatment usually needs to be continued indefinitely, as the dryness tends to return if treatment stops.

Hormone replacement therapy - HRT is a treatment that involves taking medication to replace the hormones that start to decline during the menopause.

It’s available on prescription from a GP either as tablets, a skin patch, an implant under the skin, or a gel that’s applied to the skin.

HRT has a wider effect on the body than vaginal oestrogen, so may be best if the person has other menopause symptoms, such as hot flushes. However, it also has more side effects.

Women's Health News

Fetal Alcohol Spectrum Disorders (FASD) Awareness Day

Recently, Ireland marked International Awareness day for Fetal Alcohol Spectrum Disorder (FASD) and the HSE took the opportunity to highlight the importance of supporting women to have an alcohol-free pregnancy.

FASD is a group of disorders caused by prenatal alcohol exposure and is associated with a range of lifelong physical, mental, educational, social, and behavioural difficulties. Prenatal alcohol exposure is therefore the leading preventable cause of neurodevelopmental disorder.

Alcohol at any stage of pregnancy, even small amounts, may affect a baby’s development and can have lifelong effects such as FASD.

Professor Maeve Eogan, Consultant Obstetrician and Gynaecologist, Rotunda Hospital says, “It is really important that we support women to have an alcohol-free pregnancy, and that the health service provides people with consistent advice about

alcohol use in pregnancy. While FASD is entirely preventable, if alcohol is avoided in pregnancy, we need to acknowledge that some women will need additional supports to abstain, and they should be supported to access these.”

Exactly how many people in Ireland are living with this condition is unknown but it is estimated that up to 600 babies with FASD are born each year. The predicted prevalence of FASD in Ireland is the third highest in the world and therefore, the message is that no amount of alcohol at any stage during pregnancy is safe for your baby.

The HSE provides some tips for not drinking during pregnancy:

It can be hard for some people to give up alcohol for the 9 months of their pregnancy.

Some may not want people to know about their pregnancy in the early stages and may feel under pressure to drink alcohol. They may also not realise they are pregnant for a few weeks, but they can reduce their baby’s risk of FASD by stopping drinking as soon as the pregnancy is confirmed.

Some tips to help women stop drinking alcohol during pregnancy include:

• Planning alcohol-free activities

• Planning ahead and avoiding triggers (people and places) which encourage drinking

• Asking partners, friends and family to support

• Finding new routines that don’t include alcohol

• Getting support a your GP, midwife and obstetrician.

More information and advice on not drinking alcohol during pregnancy is available on HSE.ie.

https://www2.hse.ie/pregnancybirth/keeping-well/food-drink/ alcohol/.

People with FASD experience lifelong challenges and need support with their physical health. They may struggle with learning, memory, attention, communication, emotional regulation, and social skills.

Women’s Health - Candidiasis

Vulvovaginal candidiasis: Diagnosis and Management

Written by Louise Delany –Antimicrobial Pharmacist, The National Maternity Hospital Dublin

• Immunosuppression.

• Genetic factors.

VVC is uncommon in postmenopausal women, unless they are taking oestrogen therapy. It is also uncommon in prepubertal girls.

Clinical Features

VVC typically presents with vulval itch and a non-offensive vaginal discharge.

Introduction

Candidiasis is a fungal infection caused by yeasts that belong to the genus Candida Candida yeasts are present in low numbers on healthy skin in moist areas and are part of the normal flora of the mucous membranes of the respiratory, gastrointestinal and female genital tracts. Overgrowth of Candida species can cause infections. There are over 20 Candida species that can cause such infections in humans, Candida albicans is the most common and causes 80-89% of vulvovaginal candidiasis (VVC) infections in women. Candida glabrata causes the majority of remaining VVC infections. Approximately 75% of women will experience at least one VVC infection in their lifetime and between 40 and 45% will have two or more infections. Infections can occur without any specific precipitating factor, however there are some risk factors which are known to predispose a woman to VVC infections. Known risk factors include;

• Poorly controlled diabetes mellitus.

• Use of broad-spectrum antibiotics. This is due to inhibition of normal bacterial flora, which allows for growth of Candida. VVC infections may occur up to 3 months after a course of antibiotics is taken.

• Increased oestrogen levels, especially during pregnancy (endogenous oestrogen) and with post-menopausal oestrogen therapy (exogenous oestrogen).

Acute infections

Other symptoms may include:

• Soreness or burning of the area

• Superficial dyspareunia

• Cyclical symptoms

Clinical signs may include:

• Erythema

• Fissuring

• Swelling/ oedema

• Vaginal discharge typically non-offensive and curdy but may be thick

• There may also be satellite lesions and excoriation marks

Acute vulvovaginal candidiasis in pregnancy

Clotrimazole 500mg pessary

Diagnosis

VVC diagnosis is based on typical features of the infection being present, supported by laboratory confirmation of Candida species from a vaginal sample. It is good practice to support a diagnosis with routine microscopy for those presenting to secondary care with symptoms. Recurrent VVC is defined as four or more symptomatic episodes over a 12-month period; at least two of these episodes should be confirmed by microscopyor culture. Clinical examination of the external genitalia is recommended in women presenting with symptoms

PV at night (can give for up to 7 consecutive nights if required)*

Clotrimazole 200mg pessary PV at night (can give for up to 7 consecutive nights if required)*

*Longer courses are recommended in pregnancy to achieve successful cure. Reviews have found that a four-day course will cure just over 50%, whereas a seven-day course cures over 90%.

Acute vulvovaginal candidiasis (not in pregnancy)

Fluconazole 150mg PO STAT (not for use in pregnancy)

Clotrimazole 500mg pessary PV STAT at night

Clotrimazole 200mg pessary

PV at night every 24 hours for 3 nights

Clotrimazole 10% internal vaginal cream 5g dose (one applicatorful to be inserted into the vagina at night)

Severe acute vulvovaginal candidiasis

Fluconazole 150mg PO on day 1 and day 4 (not for use in pregnancy)

Clotrimazole 500mg pessary PV at night on day 1 and day 4

Table 1: Acute Infections

Recurrent infections

Recurrent vulvovaginal candidiasis (pessary regime)

Induction

Clotrimazole 200mg pessary PV at night every 24 hours for 10-14 nights

Clotrimazole 500mg pessary PV at night every 24 hours for 7-14 nights

Followed by maintenance if required:

Clotrimazole 500mg pessary PV at night every week for 6 months

Recurrent vulvovaginal candidiasis (oral regime)

Induction

Fluconazole 150mg PO on day 1 and day 4 and day 7 (total 3 doses) (not for use in pregnancy)

Followed by maintenance if required:

Fluconazole 150mg PO weekly for up to 6 months

suggestive of acute VVC and examination should always be carried out for those presenting with recurrent VVC. Clinical examination should be used to exclude alternative or co-existing vulvovaginal pathologies.

A high vaginal swab should be carried out for microscopy and cultures should be carried out

for samples taken from women with recurrent VVC. Resistance to antifungals is rare, however sensitivity testing should be done for those with recurrent VVC.

Management

Women with a diagnosis of VVC, should be advised to avoid using local irritants such as perfumed soaps or wipes, however,

patients can be advised to use an emollient for personal hygiene as a soap substitute, as a moisturiser or as a barrier cream. Patients need to be aware that this is for use in the outer part of the genital area and not for internal use. For those with recurrent infections of VVC, clinicians should include a review of their daily hygiene routine to identify any potential

Table 2: Recurrent Infections

irritants for example washing hair in bath water or excessive cleaning. Medication causes should be considered for patients presenting with symptoms of VVC; women recently started on oestrogen therapy or those that have received a recent course of antibiotics.

Treatment

Treatment of VVC is based on whether it is a first presentation, a recurrent infection and whether the patient is pregnant at the time of infection. The tables below are based on the treatment recommendations as per British Association for Sexual Health and HIV national guideline for the management of vulvovaginal candidiasis (2019). It should be noted that intravaginal and topical treatment can damage latex condoms and diaphragms; extra precautions are advised. During pregnancy the use of an applicator is not advised, and the pessary should be inserted without using an applicator. Oral fluconazole can interact with medications and a medication history should be taken before prescribing this as a treatment option. Topical therapies can cause vulvovaginal irritation, and this should be considered if symptoms worsen or persist. Fluconazole should be avoided if the woman is pregnant, however breastfeeding can be continued if only a single dose of 150mg fluconazole is administered.

Funding for Assisted Human Reproduction Treatment

Minister for Health Stephen Donnelly has announced that fully publicly-funded assisted human reproduction (AHR) treatment commenced last month (September).

Eligible patients will be entitled to one full cycle of IVF (invitro fertilisation) or ICSI (Intracytoplasmic sperm injection) treatment, initially provided in HSE-approved private clinics of their choice ahead of the opening next year of the first public National Advanced AHR Centre.

The Minister has also set out details of eligibility criteria which sets parameters in respect of the ages of the intending parents, the female patient’s body mass index (BMI), the number of existing children and the number

of previous IVF cycles accessed. Patients with known clinical causes of infertility and patients where there is no known clinical cause will be eligible for treatment.

Given the complex regulatory and clinical issues still to be addressed in respect of certain categories of AHR treatment, public funding of a number of specific services is being commenced on a structured and phased basis.

Therefore, treatment involving the use of donated gametes (sperm and eggs) will not be available in

September for heterosexual or same-sex couples or single female patients. This treatment will become available as soon as possible.

Under the Model of Care for Fertility, people with fertility-related issues should be treated through the public health service at the lowest level of intervention necessary.

In the first instance, people will present to their GP for a consultation and if appropriate they will be referred to their local Regional Fertility Hub, which

provides a range of treatments and interventions for both males and females

From September, where IVF, ICSI or IUI is clinically indicated, eligible patients will be referred by the Reproductive Medical Consultant in the Regional Fertility Hub for publicly-funded treatment in a HSE-approved private clinic of their choice.

Female patients who meet the criteria will be eligible for treatment if they have been referred by their GP to a regional fertility hub before their 41st birthday.

The Only Way is Up for North Road Pharmacy

The team at North Road Pharmacy have focused in the last 2 years on achieving a healthy lifestyle through exercise, healthy eating and taking positives steps in self-care, whether that is taking vitamins and supplements, taking up a sport or seeking advice from the local GP if struggling with life in general. This has led patients and customers awareness to alternative ranges they currently

stock. The alternative route has been a key focus moving forward and the introduction of a Sports and wellbeing department has been instrumental in the growth of the other areas in the front of shop sales overall as proven from the positive feedback from customers which translated into strong growth in terms of sales in these particular areas.

North Road Pharmacy is are now recognised and has the reputation for taking care of all their customers and patients and continually strive to be the best in health care in the local pharmacy community.

Siobhan Taylor is the Owner and Managing Director of North Road Pharmacy. She told us, “As a team the togetherness and definition of team-work is defined and unanimously endorsed and proven on a daily basis by the team in North Road Pharmacy. Their flexibility and openness to change and the support of each other is unparalled. From the ordering procedures, the IT involved in inputting orders, the stock control is obviously made easier by the software we use however the time, effort and efficiency of everyone involved to successfully navigate these processes is phenomenal. On the occasions of sickness and holiday situations, all members of the team are confident in placing orders and picking up the loose ball.

“In the event of taking on new ranges or products the support behind all decisions regarding this is exceptional. For example, in the last couple of years we ventured into a different area that would be not be common in community pharmacy and introduced a Sports Department including many different sports accessories and equipment.”

Sea swimming has become a huge past-time and North Road Pharmacy are now stocking many Dry robes, Goggles etc. Siobhan adds, “All members got excited although dubious initially got behind this innovative direction and excitement in the store was palatable and as result ended more quite profitable and continues to grow monthly.”

Siobhan states that while the introduction of the new department was un-nerving - as something very different to what the team would’ve worked with before in pharmacy - the support they have received is what made the dream work.

She adds, “The team came together and organised the launch of this department which included well known Rugby International Rob Kearney to attend and perform the ribbon cutting ceremony, which caused a great stir in the community with queues of customers outside the store and as a team there was fantastic excitement. As can be imagined there was many young budding 6-Nation hopefuls getting Rugby balls autographed.

“There were many in-house meetings from the team in preparation for this event and launch and ensure everything would scan to lessen the time on the day and this in itself was quite time-consuming however was made simple by our EPOS software and ease of navigation which made life so much easier.

“Due to a restructure in my company and I now have 3 stores, the annual targets I set for each of the stores were realistic albeit ambitious, and I wasn’t disappointed as all stores were opened 11 years, 8 years and 5 years respectively. Through hard work and consistent perseverance it paid off both financially and beneficially to staff

Maria McClafferty, Pharmacy Channel Controller, Haleon with winners of the Haleon Self-Care Award Suzanne O’Reilly, Pharmacy Manager and Siobhan Taylor, Owner and Managing Director, North Road Pharmacy

North Road Pharmacy in Drogheda celebrated winning the Haleon Self-Care Award 2023.

Haleon, formerly part of GSK

morale, and if the financial targets weren’t achieved the growth and comradeship of the team is and was reward enough. The growth was 10%, 15% and 30% respectively and given the current climate after the exceptional area during Covid this was amazing and I am so proud of the team and of what they achieved.

“Initiatives, Promotions, and a broadening of our offering to our patients and customers was the key to this success. Personally, I invested in every member’s career and displayed the willingness and commitment to each person in terms of contributing to pension plans, bonuses and above all promotion opportunities within the company.

“With hand on heart, I believe the team across all stores are simply the best, and it is hard to nominate one or two in the bunch of amazing colleagues.

“The commitment and dedication that they give day in day out is phenomenal. We all have been through tough years recently and no one has escaped the fall out

in one way or the other. However, everyday each one of the team came into store with a smile and a positive remark for everyone regardless of age.

“The mantra I instilled into each member was “this is temporary and not permanent” and this was passed onto patients and customers alike and it some cases it helped their struggle in their life.

“The definition of a community is varied however our belief is it a group of people living together in a larger society. We are part of that environ and a pivotal part of it. We try and help each and everybody in this group. This circle of people is dependent on certain services and the community pharmacy being a vital component of this. Everyone at some stage of their lives have health concerns and the majority of times we are their first port of call. Distinguishing between some needing medication, a GP, a hospital or just a shoulder to cry on and a listening ear falls ultimately on our shoulders. We work on the coalface everyday and not taking way from other frontline workers

however it can be a touch and at time’s challenging. Ultimately, the majority of our day is taking care of others and the primarily the people walking in our door on a daily basis have an ailment of some description. We endeavour to make them feel better and hopefully return with a spring in their step.

“I believe if we have and continue to go the old cliché “the extra mile” in terms of customer service, delivery of medicines, services provided and giving what the customer wants and needs. The broad range of products which we now stock and are continually striving daily to be the best Pharmacy we can be. We work as a team and we play as a team, always with the best interest of patients and customer’s forefront in our mind.”

On winning the Award, Siobhan added, “I am delighted to accept the Haleon Self-Care Award on behalf of the whole team from North Road Pharmacy. Each and every member of the team work

diligently and with a shared goal of providing the best service and care for our customers and for the community.

“Self-Care and the promotion of self-care is something we feel very passionate about and so to receive this recognition is the best feeling.

“The entire night has been a fantastic celebration, we have had so much fun spending time with our team and with our wider colleagues but receiving this trophy just tops it all off.

“Our pharmacy is at the heart of the community, playing a critical role in the care and wellbeing of every individual and we can’t wait to bring this Award home and will be proud to show what we have achieved working together.”

Independent Community

Team shot from our Birthday celebrations. We ran a family fun day, hired Pauls Reptile Park and an ice cream truck. It was a great way to give back to the community and Thank them for their custom over the years.

Christmas Eve team photo.

McLernons Independent Community Pharmacy of the Year 2023

We launched our North Sports Health and Wellness section with the help of Rob Kearney.

Team Photo after a Make up Master Class event organised for The customers of Northroad. We had Local Make up Artist Sarah Jane in to give our customers guidance on make up application and ranges for their skin type

We launched our North Sports Health and Wellness section with the help of Rob Kearney

Team shot from our Birthday celebrations. We ran a family fun day, hired Pauls Reptile Park and an ice cream truck. It was a great way to give back to the community and Thank them for their custom over the years

McLernons Independent Community Pharmacy of the Year 2023

Team Photo after a Make up Master Class event organised for The customers of Northroad. We had Local Make up Artist Sarah Jane in to give our customers guidance on make up application and ranges for their skin type.

Christmas Eve team photo

Pharmacist of the Year Title for John

Awards

The Irish Pharmacy

As is the case every year, eight deserving finalists battled it out for the crown of Reckitt Community Pharmacist of the Year 2023. The title went to John O’Shaughnessy, of Woods CarePlus Pharmacy, Mullingar.

2023

John O`Shaughnessy has been a senior pharmacist for five years in Woods Pharmacy – a Keanes’ CarePlus store –on Mullingar’s main street. He is fully invested in the Keane group’s values in relation to the importance of patient wellbeing, and accordingly leaves no stone unturned to ensure that patients receive the best possible care. During the covid years, he introduced antigen testing, followed by covid vaccinations, showing courage at a time of great uncertainty.

John is totally selfless by nature, and puts others before himself, no matter if they are a patient or a staff member. He may be doing 100 jobs at once - but will drop them all to help anyone with anything, whether that be needing help with a prescription - or taking out the bins from the dispensary.

John is also an avid supporter of local charities, during the last year, he has reached out to local community groups and charities, supporting Diabetes

Ireland in conjunction with consultant endocrinologist Dr Shu Hoashi and Pediatrician Professor Michael O`Grady in providing advice on diabetes and medication management for the local diabetic community.

He also recently teamed with the local branch of the Order of Malta, providing health seminars and for their members.

Always conscious of the contribution of local charity

John O’Shaughnessy, Woods CarePlus Pharmacy, Mullingar –winner of the Reckitt Community Pharmacist of the Year Award with Adam Lee, Country Manager, Ireland with Reckitt

groups, John and his team have raised funds for both the Irish Kidney association and the Irish Asthma Society. A keen GAA man, he donated first aid bags to ten GAA and underage sporting clubs locally. Within the store, the St. Valentine’s “Go Red Cake Sale” raised over ¤400 for the Irish Kidney Association - one of the few days John`s hand did not wander into his beloved sweet drawer within the dispensary.

Owner of the pharmacy Robert Keane says, “Advocating for the expansion of services is something John has both championed and pioneered. John has always sought the more marginalized members of the community, in particular those who are homeless. Through listening and genuine empathy, he has often acted as a bridge for these patients accessing and contacting their GP, when they might otherwise not make the effort.

“The Woods store in Mullingar has a large cohort of homeless patients, and John O’Shaughnessy is for many of them a uniquely valuable and trusted point of contact. From a business perspective, John`s input cannot be underestimated. Woods Pharmacy is located in the center of Mullingar, and parking is limited: the opening hours are shorter than other pharmacies on the perimeter of town.

“Nonetheless, the shop’s business is thriving, showing growth and development. But what is not reflected in figures is culture, where John`s values of inclusion, professionalism and community shape how the team conduct themselves day in day out.”

Emerging from the covid pandemic has been tough for community pharmacies throughout Ireland. The provision of covid vaccinations against the backdrop of undersupply was difficult.

Recent shortages of medicines have been challenging. Yet John has always looked after his staff, and personally dealt with anxious customers both in person and over the phone.

The reduced availability of many healthcare services has understandably led to more anxious and demanding patients. Consequently John has sought to expand the range of pharmacy services to help patients, including blood pressure monitoring, emergency contraception, vaccinations, Otoscope screening, a pilot asthma control program, and, most recently, a Health Elevator Pilot, already described.

Ciaran Holton MPSI, recently completed his fifth year internship in 2022 and was tutored by John. He said of his mentor, “During our 5 years of college we were constantly reminded about “Patient centered care” by the academic professionals: we spent many hours completing care labs to become competent in practicing “patient centered care.” However, from my first day of placement, I could see the real expert on the topic was John O’Shaughnessy.

“He doesn’t see the men, women and children who come to Wood’s pharmacy as patients, clients or customers, but as unique individuals, always addressing them by their first names, getting to know a little about them, always checking up on them and asking what more he can do. It doesn’t matter how busy things are, he gives everyone the amount of time and effort they need. And it doesn’t just stop at helping people with their medicines. I once saw him help an elderly woman set up her new phone, because she didn’t know anyone else who could help.

“Having recently qualified as a pharmacist, I can definitely say that I would not have made it to the end without John. He ensured I was exposed to as much variety as possible throughout my placement, in order for me to complete my degree. He would stay back each evening to see how I was getting on, and to lend an ear when things were stressful. For many pharmacists this commitment can be an extra burden in a job that is already very intense, but not once did I feel I was an imposition. In fact he did everything to make

me feel welcome and showed a genuine interest in helping me qualify. Before proceeding into the Pre-Reg examination, while all my classmates were trying to cram last bits of information into their brains, I just said to myself

“Just pretend you’re John O’Shaughnessy for the next hour and everything will be fine.” And now I am a fully qualified pharmacist.”

On winning the title John stated, “To be the winner of the Reckitt Community Pharmacist of the Year is wonderful not only for me, but for my team. We have worked really, really hard to stay at the forefront of healthcare. Covid caused a whole knockdown across the health service and community pharmacy just got on with it and ploughed through it. We are vaccinating, delivering patient focused services and doing everything we can to ensure patients receive un-interrupted care but that also, they get the same type of care they were getting before Covid took place. Our team in particular are well trained for this.

“The work we have done in the last couple of years in particular has all been around patient care and for the healthcare profession as a whole. We are at the front line and we are happy to be at the front line. Pharmacists are the link between patients and doctors and we never closed our doors during Covid.

“The Irish Pharmacy Awards showcase an extremely high standard of excellence; they recognise the efforts of pharmacists and pharmacies nation-wide and they recognise that we have gone through a massive period of turmoil but collectively, we will et through it together. The standards these Awards ask of us are so high, they have become the standards that we hope to continually abide by.”

John O’Shaughnessy, Woods CarePlus Pharmacy, Mullingar – winner of the Reckitt Community Pharmacist of the Year Award with Adam Lee, Country Manager, Ireland with Reckitt and Awards compere Marty Whelan

Counting on Edel in the Pharmacy

Edel has had a considerable impact on her pharmacy team. She is familiar with all regular patients and customers and understands their needs and requirements.

As the pharmacy skincare expert Edel has taken on the promotion of events within the store, identifying brands for promotion and organising these events herself. Edel also liaises with suppliers to identify new products that may do

well and introduces them into the pharmacy as a trial. Edel has great communication skills and a warm, friendly demeanour that puts patients at ease and has an ability to listen actively and empathise with people.

The Irish Pharmacy

Awards 2023

Her positive attitude and willingness to help have contributed to a positive working environment within the Pharmacy. Pharmacists may grab many of the headlines, but alongside each is the remainder of the pharmacy team, all of whom play a critical role in the success of the pharmacy and the services it provides.

The Counter Assistant of the Year Award recognises excellence in knowledge and service to retail customers. Nominations for the category can be made through self-nomination, by colleagues or by pharmacy business owners.

Judges were looking to reward those who bring something

extra to the consumers experience of the pharmacy setting within a community.

Ian Middlehurst of Lannon Late Night Pharmacy told us, “Edel has had a considerable impact on our team. She is familiar with all our regular patients and customers and understands their needs and requirements.”

As the pharmacy skincare expert Edel has taken on the promotion of events within the store. Edel would identify brands that could be promoted and would organise and promote these events herself. She would co-ordinate with suppliers, set up displays and stands and advertise events in store and on the store social media channels.

Edel also liaises with suppliers to identify new products that may do well and introduces them into the Pharmacy as a trial. Edel would then promote these products on social media channels and in store.

Recent successful events Edel has organised and run include;

• Grinch and the Elf Christmas event for families.

• Ella and Joe. Edel Liaised with founder Charlene and arrange for her to visit the store to do a presentation and meet customers to answer any questions they had about her products.

• The pharmacy stocks

Dermalogica cosmetics and Edel would organise an event with gift promotions twice a year this would include her giving a live demonstration with the products to customers

Country Manager, Théa Pharma Ireland Diarmuid Gavin with winner of the Thea Pharma OTC Counter Assistant of the Year Award, Edel Cullen, Lannon Late Night Pharmacy, Sligo

I love what I do, I love my team and I love my customers. I have to say I put my heart and soul into everything I do for the betterment of our community and to be recognised with this Award is truly so rewarding”

• She also organised the Pharmacy stand for a recent Sligo show in aid of Sligo Cancer Support Centre

“We provide Pharmacy Services to a local Nursing Home. Edel came up with the idea for an event which she organised for the residents of that home over Christmas. The event was organised for the evening of 1/12/22 and advertised in the home to the residents’ families also.

“Edel organised goody bags for all the residents and arrived with a selection of fragrances and skincare samples.

“Edel made a presentation discussing skincare routines and gave the residents samples. The event was also attended by some resident’s families and the nursing team. The nursing home gave us very positive feedback on Edel’s event, something they hadn’t had before. It provided an opportunity for residents to try new products and receive advice on how to use them. The event was a great way to bring residents together for a fun and engaging activity.

“These events also help build our relationships with the nursing home team and their residents and make the local community aware of the products and services we provide.”

Ian continued, “Very recently the pharmacy joined a Pharmacy Group as a franchisee, whilst the ownership remained the

same. This has presented several challenges to the team including;

“Change of Software Systems – as part of the changeover we moved to McLernons software after 10 years with the previous supplier. Edel embraced this change and the benefits this would bring to her role and the business.

“Change of procedures – there has been a significant change in procedures that would affect the OTC part of the business more than the dispensary for example ordering is now done through the new software, monthly promotions are ordered separately, POS is ordered and changed regularly, SELs were introduced and maintained daily. Looking after our social medica locally Edel now also works with franchise head office to augment the social media posts they would use to personalise our social content and make us different to the other franchisees.

“Implementation of change – Edel has led the way implementing the new front of shop procedures such as for ordering, promotions, POS, and planograms. and as such has gone to other stores to train the teams and assist with their rollouts also.

“Edel has liaised closely with the franchise head office team to build a strong and positive working relationship.

“Edel has great communication skills and a warm, friendly demeanour that puts our patients

at ease and has an ability to listen actively and empathise with people. Edel has an ability to communicate effectively and has built trust with patients and colleagues.

“Her positive attitude and willingness to help have contributed to a positive working environment within the Pharmacy.

“Edel has always been willing to take on new challenges and is quick to adapt to any changes in our rapidly evolving profession. Edel approaches every task with enthusiasm and a positive attitude, leading our talented OTC team.

“She has demonstrated her ability to navigate the recent change for our company in joining a franchise. She has been implementing new ideas and procedures and transferring good practice across the group through training the teams and assisting teams in our other stores.

“Edel has also demonstrated leadership skills through the organisation of the events she runs for the store. Edel took the initiative to organise several successful skincare events as detailed.

“These events generate a significant uplift in sales and heavily promote the pharmacy positively in the community. Edels organisational skills and ability to motivate the team for these events were instrumental in making them a success.

“We are privileged to work with Edel, she makes a significant contribution to our company, and we were proud to nominate her for this award,” he said.

Edel told us after accepting her Award, “I am speechless and those who know me, know that I am rarely speechless. This Award means the world to me. I love what I do, I love my team and I love my customers. I have to say I put my heart and soul into everything I do for the betterment of our community and to be recognised with this Award is truly so rewarding.

“I was shocked t have been nominated but never in a million years did I think I would take home the title. I would urge anyone thinking of entering these Awards to go for it; me standing here with this trophy just goes to show what can be achieved.”

Edel Cullen, Lannon Late Night Pharmacy, Sligo

Country Manager, Théa Pharma Ireland Diarmuid Gavin with winner of the Thea Pharma OTC Counter Assistant of the Year Award, Edel Cullen, Lannon Late Night Pharmacy, Sligo and Awards Compere, Marty Whelan

Meaghers Rewarded for Excellence in Online Service

Meaghers Pharmacy is a wellknown Irish pharmacy chain with over 11 locations across the country. In addition to their physical stores, they also have an online store that offers a wide range of health and wellness products, including skincare, vitamins, supplements, beauty products, baby care, and more. The pharmacy team support various health needs such as immune support, energy, and joint health and lead the way in areas such as gut health, pain management, and specialised skincare, with a range of innovative products and knowledge that

support patient/customer care. Alongside beauty, lifestyle, and healthcare products, we also offer customers, access to our team of pharmacists, a prescription delivery service, and online sales of OTC medicines. We’re dedicated to providing the same personalised, excellent customer service to our online customers as we do to our in-store customers. Alongside beauty, lifestyle, and healthcare products, Meaghers Pharmacy also offer customers access to their team of pharmacists, a prescription delivery service, and online sales of OTC medicines. All pharmacy

The Irish Pharmacy

Awards

2023

teams are dedicated to providing the same personalised, excellent customer service to their online customers as they do to their instore customers.

The Advice Hub at Meaghers provides customers with access to expert advice surrounding pharmacy, health, and wellbeing. Here, customers can find in depth information surrounding some of the most frequently asked question across a range of topics such as menopause, pain management and gut health.

The SkinLab at Meaghers offers a new innovative service for customers seeking expert skincare

Adrian Curley, Commercial Lead ROI, Alliance Pharmaceuticals Ireland with Oonagh O’Hagan, Managing Director, Eimear McLaughlin, Ecommerce Manager, Andy Murphy and Darren Hardiman, Head of Operations, Marketing and Ecommerce, all from Meaghers Pharmacy Group with Awards Compere Marty Whelan

advice stocking professional, cosmeceutical skincare brands such as SkinCeuticals, Advanced Nutrition, Image Skincare and Murad Skincare. All brands are highly effective at treating various skin concerns and issues optimising skin health. The pharmacy team offer virtual skin consultations with their own SkinLab expert giving customers the opportunity to have a detailed professional consultation from the comfort of their own home.

Meaghers Pharmacy offer an online doctor consultation service, where customers can have a virtual consultation with a registered doctor. This service can be especially helpful for minor ailments or concerns that do not require an in-person visit to a doctor’s office. They have partnered with experts to provide additional services, such the LetsGetChecked at home testing service, Professor Suzanne Norris, a leading Hepatologist and Gastroenterologist, to provide liver screening services, Aoife Ni Eochaidh at International Pelvic Physiotherapy Management, providing services in the field of Men and Women’s Health & Continence. Their website also offers booking services for our vaccine clinics and blood pressure

In what was to be their first win of the night, Meaghers Pharmacy Group scooped the title of Alliance Online Retailer of the Year Award.

monitoring services, making it easy for customers to access these services.

Darren Hardiman, E-commerce and Marketing Director with Meaghers Pharmacy Group tells us, “We offer an omni-channel retail model, which allows our customers to browse and purchase products from our website, various social media platforms, and then pick up their items in-store or have them delivered to their doorstep. Through our social media channels, we provide customers with up to date, educational content with posts, videos, and infographics that provide useful information about products, services, and a range of topics. We host monthly lives and events such as Q&A sessions, product demonstrations, or webinars. These events allow us to engage directly with our customers and provide them with a more immersive educational experience.”

Meaghers Pharmacy’s online offering stands out from the rest through a continued commitment to innovation and customer service, Darren says. “We have invested heavily in technology to ensure that customers can easily and quickly navigate our website, finding the products they need, and completing their orders with ease. Our website is user-friendly and provides a seamless shopping experience for customers, with clear and concise product descriptions, helpful product images, and detailed information about each product.

“One of our standout offerings is our strong focus on personalisation. By personalising the shopping experience for our customers, we make them feel more valued and appreciated. Personalised recommendations, product suggestions and promotions have given greater customer satisfaction and loyalty.”

Meaghers Pharmacy offer a subscription service for customers who want to receive regular deliveries of their favourite health and beauty products. This offers customers a convenient, costeffective, and personalised way to shop for their favourite health and beauty products. The flexibility and personalised experience make it easy for customers to meet their unique needs while saving time and money.

He adds, “We aim to “surprise and delight” with every order we send out so we have invested in high quality environmentally conscious packaging and branding. We include free gifts

which are samples of our other brands in the range complimentary to the purchase and a Mars or “Meaghers” bar in every order to bring a smile to our customers’ faces. We work hard to bring a personal touch to our online customers. Our packaging that is eco-friendly and sustainable to appeal to customers who are environmentally conscious. We are committed to reducing its environmental impact by implementing sustainable practices such as reducing plastic packaging and promoting recycling.

“We have a hugely engaged online community, with millions of page impressions across our channels every week. We aim to educate on relevant topics – such as anxiety, sleep, pain management or how to support our immunity– and be part of key campaigns in Ireland and around the world, including Menopause Month. We achieve this through regular live Q&A sessions, Instagram and Facebook Lives, On-Site video content and product demonstrations to offer an immersive educational experience to our customers. We also believe in collaboration with other experts – our GP colleagues, dermatologists, and other professional leaders. Our goal is to be a trusted voice articulating messages in a professional and reassuring way.

“Now shipping to 58 different countries all around the world, we are keen to showcase home-grown Irish businesses abroad via our online presence. In line with our core company value of giving back to the community, we feel it is hugely important to support other Irish brands both at home and abroad. We are extremely proud of our Irish roots and a key strategy of our business is to champion and support Irish brands.

“As a pharmacy group and as the gatekeepers of the healthcare system, it has been of paramount importance that we navigate the ever-changing customer preferences and rapidly innovate to redesign customer experience journeys as is needed. We found we are uniquely placed in the digital space to offer people the extra information, guidance, and support to navigate a novel set of challenges, from keeping their families safe to helping with healthcare concerns like supporting their immune systems, coping with anxiety and children’s health. We have recently started using TikTok as a way to engage with our audience by educating and raising awareness about health-related topics and build our brand.

“We will continue to innovate and evolve as our customers need us to, we will continue to best

provide top class customer care and constantly improve upon our customer experience to reach those who need us.”

Darren adds, “Meaghers Pharmacy Group is a family business, and so to us it is really important that we serve our customers as best we can. We have a really strong relationship with our customers instore and so winning the Award for Alliance Online Retailer of the Year and gaining recognition for our online offering is really key for us as we continue to grow that side of the business.

“We are delighted and proud to win this Award. Despite being a relatively small team, we have an incredibly large team effort in everything we do and this effort is showcased day in and day out to make sure whatever services we carry out are successful and ultimately, benefit our customers.”

The team from Meaghers Pharmacy Group

Meaghers Continuing to Deliver Innovation

Awards

The Irish Pharmacy

Meaghers Pharmacy are continually evolving to deliver innovative services at the core of their community. The pharmacy team are continuously working on new ideas and services that they can bring to their pharmacies to improve the level of care which is provided to each and every one of their patients.

2023

Medication non-adherence is a widespread issue leading to reduced quality of life in patients, increased hospital admissions, premature deaths and increasing healthcare costs.

In 2022, Managing Director Oonagh O’Hagan and Superintendent Pharmacist, Elaine Lillis, wanted to highlight the key role pharmacists can play in tackling this issue and so began discussions to identify a new service that they could offer in the pharmacies to set about doing this.

Medication non-adherence is one of the largest problems facing healthcare today, with as many as 1 in 2 patients being non-adherent to their prescribed treatments. Patient non-adherence has a negative impact on the efficacy of treatments and patient outcomes and leads to unnecessary hospital admissions and healthcare costs.

Elaine told us, “Here in Meaghers, we see incidents of medication non-adherence among our own patients and so we really wanted to come up with a solution to help us firstly, get to the bottom of why

people may be non-adherent to their medication and secondly, provide them with the support to improve their compliance in order to achieve improved outcomes for our patients.

“Starting with our first cohort of patients – those with chronic illnesses on regular injectable medications, we partnered with HealthBeacon, an Irish medical adherence technology company, to design a service which included providing our patients with access to smart tools to help manage their injectable medication at home.

Elaine Lillis, Superintendent Pharmacist, Oonagh O’Hagan, Managing Director and Grace Grimes, Supervising Pharmacist, all from Meaghers Pharmacy Group with Barry Gray, Marketing Director, BOI Payment Acceptance

“Meaghers

Pharmacy became the first pharmacy group in Ireland to support their patient’s by giving them access to HealthBeacon’s technologies and their systematic adherence support. This technology had never been offered through community pharmacy before and had never been incorporated into a pharmacy service”

“Patients eligible for this service are identified on our PMR system. With their consent, our pharmacists enrol them on the programme. The pharmacist sits down with the patient and carries out a structured consultation including an adherence questionnaire which helps us to identify any barriers to the patient’s adherence to their medication. We use this opportunity to counsel and educate the patient, where necessary. After the consultation with the pharmacist, the patient is provided with a Smart Sharps Bin.

“The Smart Sharps Bin, developed by HealthBeacon, is a digitally connected sharps container. The unit tracks and logs all doses of the medication deposited within it by means of an infra-red (IR) sensor that triggers a camera when motion is detected. This data is recorded on a health care professional portal, which is then accessed by the patient’s pharmacist.

“The Smart Sharps Bin provides the patient with a visual reminder of the injection timepoint via the blue LEDs positioned above the display screen that light up on the day of injection. The date of the next injection is shown on the screen at the top of the unit.”

In addition, patients receive an SMS reminder on the day of injection as per their stated preferences at the point of enrolment.

Based on the doses of medication deposited in the Smart Sharps Bin, the patients’ Personal Adherence Score (PAS) is calculated and displayed on the units’ screen. After a successful, on-time used injection drop, patients are rewarded with a “Well done” message on the screen of the unit.

Elaine continues, “The pilot scheme gives our patients access to this tool to improve their adherence to their at home therapy regimens and to improve patient outcomes as a result, providing patients with a better quality of life. For the first time ever in a pharmacy service, the pharmacist has access to a real-time record so they can track the patient’s adherence to their medicine.

They can see when the patient is missing doses which helps our pharmacists intervene and support their patients. With this data as well as the information provided from by the patient in the adherence questionnaire, our pharmacists can address any barriers to adherence by educating the patient, discussing any concerns the patient may

have, dispelling any misconceptions they may have around their medication.”

The main objective in developing this service was to objectively measure the medication adherence levels of a particular cohort of patients and to create a service that Meaghers’ pharmacists could offer to tackle this widespread issue.

“As part of this initiative, we have designed an innovative service from start to finish, including service SOP, workflow diagrams, patient consent process, a structured consultation including an Adherence Questionnaire, User Guide and patient support material. We continue to refine these with insights and feedback from our team and with a quality improvement mindset. This service design can subsequently be used as a blue-print for the roll out of a national service across Irish pharmacies.”

Meaghers Pharmacy became the first pharmacy group in Ireland to support their patient’s by giving them access to HealthBeacon’s technologies and their systematic adherence support. This technology had never been offered through community pharmacy before and had never been incorporated into a pharmacy service.

Elaine adds, “For many of our patients, this is the first time they have felt they have been given an opportunity to have a real conversation about their medication habits and to discuss their concerns in a non-judgmental space. Some have held onto misconceptions about their medications for years, feeling too embarrassed to discuss these with the consultant at their annual/bi-annual appointments or with their pharmacists when they call to the pharmacy to collect their medication each month. This service has re-enforced the availability of the pharmacists in the community, the medication experts, to have these conversations with patients at any time. It has also given us, the pharmacists, the opportunity to educate our patients on the importance of medication and the potential impact of not being compliant with their prescribed regimen.

We also have a sustainability agenda at Meagher’s pharmacy and our partnership with Health Beacon has tied in perfectly with this. The Smart Sharps Bin disposes of the used pens

and injections, at no cost to the patient. The HealthBeacon unit is programmed to recognize when the inner sharps bin is almost full and has reached maximum capacity. At this point, a new sharps bin is sent automatically to the patient and once their own is full they are prompted to return this to HealthBeacon using their mailback service, which has been set up in partnership with An Post.

When the full sharps bin reaches the Health Beacon green labs, the plastic is recycled, and the Sharps Bins are cleaned and sterilised. These sharps bins are then reused, so as an additional benefit, this service is helping us drive the sustainability agenda as well as improving patient adherence.

Based on the results of this initiative, we are keen to roll out further services to support our patients with medication adherence across all patient cohorts.”

Speaking on behalf of the Group, Managing Director Oonagh O’Hagan said, “At Meaghers Pharmacy group we are always thriving to push forward and the

Irish Pharmacy Awards give us the opportunity to benchmark ourselves against the best in class.

“There was some really stiff competition within this category, from the entrants to the finalists and we are honoured to have been recognised but it’s amazing to have actually collect and win this Award as I believe it really shows the level of innovation within Meaghers Pharmacy Group.

“I must say this was a real team effort and a huge shout of thanks goes to Elaine Lillis, our Superintendent Pharmacist and her colleague Grace Grimes as they and their team came up with the idea, worked with stakeholders to implement the idea and launched the partnership with HealthBeacon to drive compliance in community pharmacy.”

Grace Grimes, Supervising Pharmacist and Elaine Lillis, Superintendent Pharmacist, Meaghers Pharmacy Group, winners of the BOI Payment Acceptance (BOIPA) Innovation & Service Development (Chain) Award with Barry Gray, Marketing Director, BOI Payment Acceptance

An Overview of Sezary Syndrome

Sezary syndrome (SS) is a rare and aggressive form of cutaneous T-cell lymphoma (CTCL), characterised by the triad of erythroderma, lymphadenopathy and presence of circulating neoplastic T-cells in the peripheral blood.

a male predominance. Initially the presentation with generalised itch and erythroderma may be nonspecific. In up to one-third of skin biopsies later confirmed as SS, the histologic picture may be nonspecific, making diagnosis difficult and consequently delayed. The exact cause of Sezary syndrome is unknown, and an inheritance pattern has not been determined. The condition occurs in people with no family history of the disorder and is not thought to be inherited in most cases.

Pathogenesis

features include generalized erythroderma, intractable pruritus, lymphadenopathy, and palmoplantar keratoderma. Pruritus is intense and even high doses of antihistamines cannot provide relief. In more advanced cases there may be alopecia, ectropion, onychodystrophy and palmar/plantar hyperkeratosis.

We spoke to Theresa Lowry Lehnen, PhD Clinical Nurse Specialist and Associate Lecturer South East Technological University to find out more about this rare disease.

Theresa explains, “Primary cutaneous lymphomas (PCL) are localised to the skin, without extracutaneous involvement at the time of initial diagnosis and are a subset of non-Hodgkin lymphoma (NHL). PCLs can originate from T or B lymphocytes and are called cutaneous T-cell lymphomas or cutaneous B-cell lymphomas.

“Cutaneous T-cell lymphoma is further categorised into two types: an indolent form that includes mycosis fungoides (MF), lymphomatoid papulosis, and anaplastic large T-cell primary cutaneous lymphoma; and an aggressive form that includes Sezary syndrome.

“Mycosis fungoides and Sezary syndrome are the most common forms of cutaneous T-cell lymphoma. Mycosis fungoides originates in the peripheral epidermotropic T-cells,

specifically the memory T-cells (CD45RO+), which express the T-cell receptor (TCR) and CD4+ immunophenotype. Mycosis fungoides has an incidence of around 6 cases per million per year in Europe and the United States, accounting for approximately 4% of all nonHodgkin lymphoma cases.”

Theresa adds that while there is evidence that Sezary syndrome is a distinct disorder from mycosis fungoides beyond merely leukemic presentation, there are patients with MF who develop significant Sezary syndrome at the time of progression. “It is hypothesised that Sezary syndrome can evolve gradually from mycosis fungoides or occur spontaneously,” she notes.

Sezary syndrome is a rare disease, with an annual incidence rate of 1/10,000,000, accounting for approximately 3% of all cases of CTCL. It typically presents in adults over 60 years of age, with

Theresa adds, “The exact pathogenesis of Sezary syndrome is not fully understood and involves complex interactions between neoplastic T-cells, immune dysregulation, and the microenvironment. Several molecular and cellular mechanisms contribute to the development and progression of the disease.

“The malignant T-cells in SS are typically CD4+ memory T-cells with a Th2 cytokine profile. Aberrant signalling pathways, including STAT3, NF-κB, and JAK/ STAT, play an important role in the survival and proliferation of neoplastic T-cells. The immune dysregulation in SS involves a complex interplay between neoplastic T-cells and the host immune system. The malignant T-cells evade immune surveillance and suppress the antitumor immune response through various mechanisms, including impaired antigen presentation, cytokine secretion, and recruitment of immunosuppressive cells.”

Sezary syndrome incurs significant morbidity and hallmark clinical

The cancer can spread to the lungs, liver, spleen, and bone marrow. People with Sezary syndrome are at a higher risk of developing other types of lymphoma or cancers. The disease can also lower the function of the immune system, increasing the risk of infections.

Diagnosis

Theresa told us, “Accurate and timely diagnosis of Sezary syndrome is crucial for appropriate treatment planning and improved patient outcomes. Early identification allows for the initiation of targeted therapies and the avoidance of unnecessary interventions. The condition can be a diagnostic challenge to clinicians as it can mimic benign skin disorders.

“General practitioners rarely see CTCL, and diagnostic delay can occur through misdiagnosis and because CTCL can initially respond to topical corticosteroids like more-common skin conditions. It is usually only on progression of the illness that a dermatology referral occurs, and some general dermatologists and histopathologists may also have little CTCL experience.”

She adds that a multidisciplinary team is needed for complete diagnosis and management,

An interview with Theresa Lowry Lehnen, RGN, RNP, PhD, Clinical Nurse Specialist and Associate Lecturer with South East Technological University

Cutaneous features of Sezary Syndrome

comprising a CTCL-experienced dermatologist, a dermato-and haemato-pathologist experienced in skin and lymphoma, respectively, and an oncologist experienced in delivering CTCLtailored treatments.

“The need for specialist nurses to support patients and liaise with nursing care closer to home is important. The diagnosis of Sezary syndrome requires a comprehensive evaluation involving various diagnostic modalities. SS should be differentiated from mycosis fungoides, psoriasis, pityriasis rubra pilaris, dermatitis, hypereosinophilic syndrome, and adult T-cell leukaemia. Primary skin disorders like scabies, and adverse drug reactions are also considered in the differential.”

A detailed patient medical history and physical examination is carried out. Tests include a full blood count with differential, Sezary blood cell count, HIV test and skin biopsy. More than one skin biopsy may be needed. Other tests that may be carried out include:

• Immunophenotyping using antibodies to identify cancer cells based on the types of antigens or markers on the surface of the cells.

Immunophenotyping is used to help diagnose specific types of lymphoma.

• Flow cytometry, a laboratory test that measures the number of cells in a sample, the percentage of live cells in a sample, and certain characteristics of the cells, such as size, shape, and the presence of tumour or other markers on the cell surface. The cells from a sample of a patient’s blood, bone marrow, or other tissue are stained with a fluorescent dye, placed in a fluid, and then passed one at a time through a beam of light. Test results are based on how

the cells that were stained with the fluorescent dye react to the beam of light. Flow cytometry is used to help diagnose and manage certain types of cancers, such as leukaemia and lymphoma.

• T-cell receptor (TCR) gene rearrangement test, in which cells in a sample of blood or bone marrow are checked to see if there are certain changes in the genes that make receptors on T cells. Testing for these gene changes can identify whether large numbers of T cells with a certain T-cell receptor are being made.

“After mycosis fungoides or Sezary syndrome has been diagnosed, further tests are necessary to determine if cancer cells have spread from the skin to other parts of the body,” Theresa adds. “Tests include, chest x-ray, CT scan, PET scan, bone marrow aspiration and biopsy, and lymph node biopsy. Excisional lymph node biopsy is preferred, and it can show reactive changes or dermatopathic changes or features suggestive of lymphoma. Secondary skin infections are common because of frequent scratching and compromised skin. Starting antibiotics and taking cultures to rule out methicillin-resistant Staphylococcus aureus may be indicated at diagnosis.”

Staging and Prognosis

The prognosis of patients with mycosis fungoides and Sezary syndrome is based on the TNMB staging system, which considers the extent of skin, lymph node and visceral organ involvement, and blood tumour burden. “The presence of lymphadenopathy and involvement of peripheral blood and viscera increase in likelihood with worsening cutaneous involvement and define poor prognostic groups,” she notes.

Stage I Mycosis Fungoides

Stage I is divided into stages IA and IB:

• Stage IA: Patches, papules and/ or plaques cover less than 10% of the skin surface.

• Stage IB: Patches, papules, and/or plaques cover 10% or more of the skin surface. There may be a low number of Sezary cells in the blood.

Stage II Mycosis Fungoides

Stage II is divided into stages IIA and IIB:

• Stage IIA: Patches, papules and/ or plaques cover any amount of skin surface. Lymph nodes are abnormal, but they are not cancerous.

• Stage IIB: One or more tumours that are 1 centimetre or larger are found on the skin.

Lymph nodes may be abnormal, but they are not cancerous. There may be a low number of Sezary cells in the blood.

Stage III Mycosis Fungoides

In stage III, 80% or more of the skin surface is reddened and may have patches, papules plaques, or tumours. Lymph nodes may be abnormal, but they are not cancerous. There may be a low number of Sezary cells in the blood.

Stage IV Mycosis Fungoides/ Sezary Syndrome

When there is a high number of Sezary cells in the blood, the disease is called Sezary syndrome. Stage IV is divided into stages IVA1, IVA2, and IVB depending on the presence of nodal and visceral involvement.

• Stage IVA1: Patches, papules, plaques, or tumours may cover any amount of the skin surface, and 80% or more of the skin surface may be reddened. The

lymph nodes may be abnormal, but they are not cancerous. There is a high number of Sezary cells in the blood.

• Stage IVA2: Patches, papules, plaques, or tumours may cover any amount of the skin surface, and 80% or more of the skin surface may be reddened. The lymph nodes are very abnormal, or cancer has formed in the lymph nodes. There may be a high number of Sezary cells in the blood.

• Stage IVB: Cancer has spread to other organs in the body, such as the spleen or liver. Patches, papules, plaques, or tumours may cover any amount of the skin surface, and 80% or more of the skin surface may be reddened. The lymph nodes may be abnormal or cancerous. There may be a high number of Sezary cells in the blood.

“For people with early-stage MF, the life span may be normal. Patients with stage IA disease have a median survival of 20 years or more.”

She adds, “Prognosis for Sezary syndrome is generally poor, with a median survival of 2 to 4 years, however, survival has improved with newer treatments. Prognosis can vary depending on age, disease stage, and response to therapy.”

Treatment Strategies

The management of Sezary syndrome requires a multimodal approach, including skin-directed therapies, systemic therapies, and supportive care measures. Skindirected therapies include topical corticosteroids, phototherapy, and electron beam radiation.

Theresa says, “Systemic treatments include interferonalpha, retinoids, histone deacetylase inhibitors, and novel immunotherapies targeting immune checkpoints, such

Erythroderma

Nail change

Plantar keratoderma

as PD-1 inhibitors. 7 Besides disease-directed treatment options, pruritis is a major concern in patients with Sezary syndrome.

“Various local and/or systemic options can be used to try and control the pruritis. Patients with Sezary syndrome are very susceptible to infections from poorly intact skin, colonization, indwelling catheters, and immunosuppression from therapy. Good skin care and avoidance of indwelling catheters are important for minimising these risks.

“Given the leukemic involvement in Sezary syndrome, the treatment is generally systemic. Specific treatment for individual patients is based on a variety of factors, including the patient’s general health and stage of disease.”

Treatments for SS include:

• Phototherapy: PUVA (ultraviolet-A light is directed onto the skin and the patient is given the drug psoralen); UVB (skin directed ultraviolet-B light);

NBUVB (skin directed narrow band ultraviolet-B light).

• Biologic or immunotherapy therapy used to stimulate a patient’s own immune system to fight the cancer.

• Retinoids, to slow certain types of cancer cells. Examples are Interferon alpha and Bexarotene.

• Extracorporeal photopheresis (ECP), a procedure used to expose the blood to ultraviolet light.

• Radiation therapy, using high energy X-rays or other types of radiation to kill cancer cells or prevent them from growing.

• Advanced disease treatment can involve chemotherapy, given either orally or through an intravenous infusion to stop the growth of rapidly dividing cancer cells. While the response may be quick, it can be short-lived and require maintenance therapy.

• Haematopoietic stem cell transplant.

Theresa concludes. “Sezary syndrome is generally an incurable condition, and the primary aims of treatment are symptom control and remission induction. While CTCL is currently deemed incurable, remission has been achieved for some following allogeneic stem cell transplant (ASCT). With new potential therapeutic options on the horizon, it is hoped that these agents will bring improved outcomes and a better quality of life for patients.

“Since the publication of the first WHO-EORTC classification in 2005, much progress has been made, and the 2018 update continues to be a useful guide for clinicians involved in the care of patients with cutaneous lymphomas. Genome-wide genetic studies have contributed to a better understanding of the molecular pathways involved in the pathogenesis of the different types of cutaneous lymphomas and resulted in the recognition of additional diagnostic and

National Shared Care Record

prognostic criteria and new potential therapeutic targets.

“Although genetic markers are becoming increasingly important, integration of histologic, immunophenotypic, genetic, and cutaneouslymphomas clinical data remain essential for an accurate diagnosis. In recent years, a multidisciplinary approach with collaboration among pathologists, dermatologists, haematologists, and radiation oncologists has been crucial for defining new entities and classifications and is the best guarantee for further progress in the diagnosis, treatment, and management of patients with a cutaneous lymphoma.

“More information, support, and the establishment of national and international patient CTCL advice and support groups is necessary for patients with Sezary syndrome and CTCL, who can feel isolated, especially when most people have never even heard of their disease.”

eHealth Standards and Shared Care Records has commenced procurement for a HSE National Shared Care Record. NSCR will aggregate existing digital health information from various sources and present it in a secure and structured way to clinicians, patients, and carers.

It will play a key role in achieving the Sláintecare vision of patient-centred, integrated care by joining up fragmented and siloed digital records.

Initial population of the National Shared Care Record (NSCR) will be from existing digital data available in HSE National Systems and will be aligned to HIQA, EU and International Patient Summary models. Over time the NSCR will be augmented from other data sources, such as GP records once the Health Information Bill is enacted, and expanded with additional categories and details of data beyond the patient summary information, such as lab and screening results and key clinical documents, enabling improved clinical decision-making and selfmanagement of healthcare.

One of the main challenges for the NSCR will be to extract, transform, and structure data from underlying source systems for display to clinicians and patients. Currently the approach to address data challenges is fragmented

as several eHealth work streams are running in parallel involving data quality, record linkage, data standardisation, clinical terminologies, interoperability standards, reference data and data structure modelling.

To reduce risk and deepen understanding of these challenges, as well as to develop further insights into potential tooling and standards, the NSCR Project Team embarked on an 8-week collaborative “Build to Learn” (B2L) project with IIS and A2IHIDs based on open standards using a collection of open-source components within existing controlled secure environments. The exercise was centred on deriving as much insight (to Learn) as possible to advantageously position the NSCR in preparation for a national deployment.

The NSCR B2L project resulted in the successful ingestion of almost 50,000 HealthLink Lab results (no associated demographic information was persisted or surfaced) into a Clinical Data

Repository(CDR) and surfacing them for viewing. The project achieved the following:

• CDR and basic Clinical Viewer deployed and configured.

• HSE data mapped to open standard.

• HealthLink data ingested into CDR.

• Development of technical components to measure content quality and thresholds.

From a clinical knowledge management perspective, the B2L team increased insights into creation of OpenEHR Archetypes (Lab Result) and modelling / development of Templates (specification that defines a tree of one or more Archetypes). Using open-source tooling for both the Clinical Data Repository and Viewer components provided useful information in terms of understanding the installation and configuration process.

Across the end-to-end B2L solution, significant insights have been gained in relation to utilisation of event-based architecture, provision of environments, deployment, and configuration of both a Clinical Data Repository and a Clinical Viewer, as well as a deepening understanding of development of Archetypes with supporting mapping activity. One of the positive aspects of the B2L project was the high level of collaborative working across the eHealth teams involved in the initiative. The intent was not to build a ‘shared record’ but to use the components in an active crossportfolio learning process to surface issues pertinent to the rollout of the NSCR. The insights gained from the B2L project are an important input to inform the Competitive Dialogue of the NCSR procurement currently underway.

If you would like to learn more about the National Shared Care Record or the NCSR B2L project, please contact eHealthStandards. SCRs@hse.ie.

DYNAMIC 100 NOMINATE TODAY

The Dynamic 100 is a network of the most influential professional in the Irish pharmacy industry who act as ambassadors and role models for their peers, colleagues and the rising stars of tomorrow within Community Pharmacy.

Dynamic

How to enter:

 Please submit 250-800 words, describing how you/they have achieved something special, gone above and beyond or behaved dynamically.

 We also require a high-resolution photograph of the entrant for print publication.

 Each entry must be within the pharmacy industry.

Pharmacists have continued to provide a first-class service in the face of adversity, with each pharmacy team displaying the highest levels of resilience, determination, and courage.

And now the time has come to reward that resilience. That determination. That courage… Nominations are sought from across the pharmacy profession in Ireland.

Email nomination(s) to aoife@ipn.ie or Kelly-jo@ipn.ie

An Overview of Liver Cancer in Ireland

Introduction: Primary liver cancer is among the top five causes of cancer related death worldwide. 905,700 people were diagnosed with liver cancer worldwide in 2020. 830,200 people died with liver cancer globally in the same year. There is estimated to be a 55% rise in the number of new diagnoses and deaths from liver cancer by 2040.¹

Written by: Michèle Bourke, Hepatocellular Carcinoma Advanced Nurse Practitioner, St. Vincent’s University Hospital, Elm Park, Dublin 4

October is Liver Cancer

Awareness month. Raising public awareness is vital in improving outcomes for patients with liver cancer. Not only because it is a major health problem itself, but it is also associated with liver disease and cirrhosis. Prevention and early detection of primary liver cancer through public health measures, surveillance programmes, education and health promotion are key in the battle against this disease.

Background

There are 2 main types of primary liver cancer, hepatocellular carcinoma (HCC) originating in hepatocytes, and cholangiocarcinoma (CCA) forming in the cells of the biliary tree. HCC is the most prominent type, accounting for approximately 90% of cases worldwide. HCC generally occurs on a background of liver cirrhosis, therefore the most common risk factor is chronic liver disease. This article will focus on HCC.

Liver cirrhosis is a chronic disease due to constant liver damage from a recurring insult e.g. excess fat in the liver, viral hepatitis, alcohol abuse, haemochromatosis, plus other aetiologies. Over time, as hepatocytes are in a constant state

of injury and repair, mutations develop in the cells leading to carcinogenesis and the formation of HCC. Patients with liver cirrhosis have a 1– 8% cumulative annual risk of developing HCC, therefore liver cirrhosis and HCC tend to be managed simultaneously by Hepatologists, in conjunction with Hepatopancreaticobiliary Surgeons, Interventional Radiologists, Oncologists and Specialist Nurses.

Diagnosis and Staging

HCC is one of the few cancers which can be diagnosed radiologically if the patient has liver cirrhosis, or chronic hepatitis B virus (HBV) in the absence of cirrhosis. The Liver Imaging Reporting and Data System (LIRADS) classification is widely used to guide non-invasive diagnosis of HCC. LI-RADS category LR-1 is considered a definitely benign lesion, whereas LR-5 is consistent with definite HCC.2 If a patient does not have cirrhosis or chronic HBV, or a LI-RADS classification of LR-M (definite or probable malignancy, not specific for HCC), a histopathological diagnosis is required.

Liver cancer can be staged with various systems. The staging of HCC and its treatment algorithm

differ from that of other cancers, as the background liver disease and level of liver function is a major determining factor in treatment selection. A patient may have a small cancer which would ordinarily be considered for curative resection in an organ without a synchronous pathology e.g. breast. However, when a patient has dual pathologies like HCC and liver cirrhosis, the level of liver dysfunction from the chronic liver disease will increase the mortality risk from interventions like surgery. Conservative management with a life prolonging treatment plan may become the clinical pathway of choice then, regardless of the small cancer size. There are validated scores available in the literature to assess the level of liver dysfunction and risk of mortality for patients with cirrhosis based on their clinical data. These include the Model for End Stage Liver Disease (MELD) score, which predicts the 3-month mortality risk for patients with liver cirrhosis. As well as, the Child Turcotte Pugh (CTP) score, which stratifies the severity of liver disease and predicts surgical mortality for patients with liver cirrhosis. For HCC management, the Barcelona Clinic Liver Cancer (BCLC) Staging Classification

is a widely accepted treatment algorithm which stages the cancer and guides clinicians to appropriate treatment modalities considering both HCC burden and extent of the background liver disease determined by the CTP score.3 The MELD, CTP and BCLC are internationally recognised and recommended for use in the management of HCC and can provide prognostic information for these patients.

Treatment

All patients with a new diagnosis of liver cancer should have their case discussed at a specialist liver cancer multidisciplinary team meeting (MDM) with an expert consensus decision made regarding recommended treatment.4, 5 The specialist liver cancer MDM in St Vincent’s University Hospital (SVUH) is an example of this. Treatment for HCC can be divided into 2 categories, those with curative intent and those which are life prolonging.

Surgical options include liver resection and liver transplantation. Surgical resection removes the part of the liver affected by the cancer. Factors affecting consideration for resection include tumour size, location, vascular invasion, presence of metastases and level of background liver function. Liver Transplant involves the removal of the patient’s native liver and replacing it with a new healthy donor liver. Strict criteria must be met before a patient is considered for a liver transplant. If deemed appropriate, they then undergo a period of assessment to ensure their suitability for this type of major surgery. Both surgical treatments are curative in nature, however liver transplantation is considered superior as it not only removes the existing liver cancer, but also the background liver cirrhosis which caused it, and is a continued risk factor for further HCC development.

Non-surgical options include thermal ablation (curative intent), transarterial chemoembolisation (TACE), selective internal radiation therapy (SIRT) and systemic therapy, all of which are non-

The National Cancer Registry of Ireland described a 300% increase in the number of liver cancer cases in Ireland in the last decade

curative in nature. Thermal ablation uses extreme temperature (heat or cold) to ablate the liver cancer and is used to treat lesions ≤3cm in size. TACE works by injecting chemotherapy directly into the blood supply feeding the HCC as well as blocking off the arterial blood supply to it. SIRT is similar to TACE, however radiation is injected into the liver this time, which damages the cancer cells internally. Systemic therapy is used for patients who have advanced liver cancer with preserved liver function. Immunotherapy (IV) and tyrosine kinase inhibitors (oral) are used for this type of treatment. For patients with deranged liver function and / or poor performance status, best supportive care and palliation is the treatment of choice regardless of the liver cancer burden.

SVUH is the only centre nationally equipped to offer the full array of approved treatment modalities here in Ireland.

Health promotion

The National Cancer Registry of Ireland described a 300% increase in the number of liver cancer cases in Ireland in the last decade.6 In 2018, they reported 285 new cases of primary liver cancer per year in Ireland, with 290 deaths from primary liver cancer here per year.7

While primary liver cancer is a major burden globally, awareness of liver cancer is limited in this country. When I ask members of the general public about liver cancer, they describe secondary liver cancer or metastases to the liver from another primary cancer originating elsewhere in the body. Their knowledge is lacking about primary liver cancer, its causes, surveillance options, treatments and outcomes. This liver cancer awareness month we hope to shine a light on liver disease and its associated cancer here in Ireland.

Primary prevention

While improvements in cancer care are always welcome, prevention is better than cure! Prevention of primary liver cancer requires awareness of the risk factors for its development, mainly chronic liver disease. Globally viral hepatitis is the leading cause of liver cirrhosis, however fatty liver and alcohol excess are the leading risk factors in the western world.

A fibroscan is a quick and easy, non-invasive test used to identify the presence of fat and inflammation or scarring in the liver. Liver specific blood tests

can be used to calculate scores to predict liver dysfunction. These tests, coupled with a comprehensive health history and physical assessment can make a diagnosis of liver disease and cirrhosis, prompting a surveillance protocol for liver cancer.

Viral Hepatitis

Strategies to tackle viral hepatitis associated HCC include vaccination against HBV. Universal vaccination programmes for newborn babies in Asia are associated with significant decreases in HCC incidence there. In Ireland, the HBV vaccine is now given to children as part of the 6 in 1 vaccine at 2, 4 and 6 months of age.

Additional strategies involve antiviral therapy for those with HBV and hepatitis C virus (HCV). Treatment for HBV will keep the virus under control. New treatments for HCV can eradicate the virus altogether. Both treatments aim to prevent the development of significant fibrosis or cirrhosis in the liver. Antiviral therapies have shown to significantly reduce HCC risk. However, patients who have already developed cirrhosis will have a persistent risk for HCC development.

Non-alcoholic fatty liver disease (NAFLD)

The Health Service Executive (HSE) recently reported that Ireland has one of the highest levels of obesity in Europe.8 Obesity is linked with many chronic illnesses including

NAFLD and liver cirrhosis. It is associated with a 1.5 – 4.5 times higher risk of HCC, contributing to nearly 10% of all HCC incidence worldwide. NAFLD is currently the fastest growing cause of HCC in liver transplant candidates and is the leading cause of HCC in the absence of liver cirrhosis.4

Weight loss and increased physical activity improves outcomes for patients with NAFLD, reducing the progression to cirrhosis.

Alcohol

Alcohol Action Ireland and the UCC School of Public Health attribute the number 1 cause of alcohol related deaths in Ireland to liver cancer and liver cirrhosis. The International Agency for Research on Cancer classify alcohol as a group 1 carcinogen. There is a proven link between alcohol and several types of cancer. While it is important to note that there is no safe level of alcohol consumption, low risk drinking guidelines are available recommending less than 11 standard drinks per week for women and 17 standard drinks per week for men. It is hoped that the Public Health (Alcohol) Act 2018 will help to reduce alcohol use and subsequent harms in Ireland.

Smoking

Smoking is associated with risk for many cancers, but specifically a 20%-86% increased risk for HCC.4 Quitting smoking can return this risk almost to baseline after 30 years of cessation. The HSE provide resources and programmes to assist in smoking cessation.

Surveillance

Once a diagnosis of liver cirrhosis has been made or a patient has chronic HBV in the absence of cirrhosis, regular surveillance for primary liver cancer is recommended the world over, in the form of an ultrasound liver every 6 months, to assess for the development of primary liver cancer.4, 5 Although the evidence is not strong for the use of tumour markers as part of the surveillance protocol, the measurement of alphafetoprotein (AFP) level in blood may assist in early detection of primary liver cancer.

Conclusion

Primary liver cancer rates are increasing in Ireland. HCC is the most common type of primary liver cancer and usually occurs on a background of liver cirrhosis. Surveillance for HCC should be offered to all patients who qualify for it. A specialist MDT should provide recommendations for management of anyone diagnosed with liver cancer. However, prevention is better than cure! Steps need to be taken in at risk groups to prevent the development of significant liver fibrosis, cirrhosis and primary liver cancer. If you would like any further information, the Irish Liver Foundation (www.liverfoundation. ie) and the Irish Cancer Society (www.cancer.ie) have excellent information pages dedicated to primary liver cancer.

References available on request

Topic Team Training – Cold and Flu

Following on from the September issue Continuing Professional Development on the Pharmacy Role in the Management of Cold and Flu, this 5-Minute Learning Module is designed to enhance the community pharmacy team understanding and ask further questions as to how you can support and advise patients.

Antihistamines: First-generation antihistamines such as brompheniramine and chlorpheniramine have been shown to provide some symptomatic relief. This involves a reduction in symptoms such as sneezing and nasal discharge, as well as a reducing the duration of symptoms.

The common cold and flu are generally self-limiting in healthy individuals and usually will resolve within two weeks. However, flu and complications of flu can lead to serious illness. In children, otitis media (middle ear infection) and respiratory complications including croup and bronchiolitis are most common.

After completing this module, you should recognise the signs and symptoms of both cold and flu sufferers and how they may present in the pharmacy, the treatments available, indications and suitability for patients and appropriate advice and counselling to be given for each.

Both the common cold and flu are contagious respiratory illnesses but are caused by different viruses; flu is caused by different influenza viruses and the common cold can be caused by coronaviruses, rhinoviruses, adenoviruses and parainfluenza viruses. The incidence of the common cold and flu is subject to seasonal variation, with a higher incidence in winter compared to summer. The common cold is the most common illness in the world, with an average of 6-8 episodes per year in children, decreasing to 2-4 episodes per year in adults. It can have a large economic burden due to absenteeism at work and school.

Symptoms of cold are usually limited to the upper respiratory tract (nose and throat) and flu symptoms generally affect more than just the upper respiratory tract, with symptoms of flu usually much more severe than those of a cold. Symptoms of a cold can

Consider:

include blocked or runny nose, sneezing, cough, sore throat and fever. Symptoms of flu can include fever, fatigue, body aches, headache, difficulty sleeping, loss of appetite, dry cough and nausea. Runny nose and sore throat are also possible, but less common than with the common cold.

The common cold generally has a gradual onset of symptoms, compared to the more sudden onset of flu symptoms, which usually appear within a few hours.

The diagnosis of common cold and flu is generally based on symptoms and physical examination. As these illnesses are usually self-limiting, symptoms can be examined by a physician and a diagnosis made without need for further diagnostic tools. Rapid influenza diagnostic tests (RIDTs) can be used to diagnose influenza by detecting antigens that stimulate an immune response. Molecular assays that detect genetic material of influenza can be used and are more accurate than RIDTs. Both tests take less than 20 minutes to perform.

OTC analgesic options including paracetamol and ibuprofen are useful in treating aches and pains, as well as lowering fever associated with the viral infection.

 Is the pharmacy team confident in informing pharmacy customers on the recommended treatment?

 Is the pharmacy team educated and knowledgeable on the dosage and contra-indications for all cold and flu medicines?

 Am I/my team familiar with the current lifestyle tips on dealing with the cold/flu such as drinking plenty of fluids and avoiding infecting others?

 Am I/my team aware of those at-risk of flu and who should be referred?

Decongestants: Decongestants have been shown to have clinical effectiveness in reducing symptoms of rhinorrhoea, nasal congestion and sneezing. Pseudoephedrine and Phenylephrine are two decongestants that are licensed for OTC use in those aged 12 years and older in Ireland. Xylometazoline is a decongestant that can be used topically to reduce nasal symptoms.

Cough medicines: Dextromethorphan is a non-opioid antitussive and does have efficacy in suppressing cough caused by upper respiratory tract infections. Expectorants and mucolytics have efficacy in treating productive cough caused by acute upper respiratory tract infections.

Non-pharmacological treatment: Daily administration of zinc has effectiveness in reducing the number of colds per year, particularly in children. Honey may be useful in treating nighttime cough in children but should not be used in children under 12 months due to the risk of infant botulism. Bulb suction with saline drops can be useful in relieving nasal symptoms in children. Vapour rub containing ingredients such as eucalyptus, camphor and levomenthol may provide symptomatic relief in children over 2 years old.

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

 The main routes of infection

 Recognising the specific symptoms of both cold and flu and how they differ

 Lifestyle and hygiene tips and advice on reducing infection

 Recognising which symptoms warrant urgent and non-urgent referral

 The recommendations for children and those aged under 6

Prevention is key in reducing the burden of cold and flu in society. Pharmacists are trusted healthcare professionals and therefore can reshape patient perceptions and reinforce the messaging around prevention of infection. Vaccination is an important preventative measure against influenza. Unfortunately, due to many different serotypes of the common cold, it is not possible to vaccinate against this illness. Simple measures including regular handwashing with soap, avoiding touching the face and cleaning surfaces that people regularly touch can help prevent spread of respiratory viruses.

Actions:

 Prior to recommending OTC products, pharmacists should ascertain whether self-treatment is appropriate

 Include POS with associated conditions relating to this category

 Ensure efficient sign posting and shop floor management with associated ailments linked for maximum cross aisle merchandising

 Ensure there is a discreet area in which staff can assist with advice and product selection

 Dedicated window displays will improve the shoppers experience and highlight the pharmacy as a centre for seasonal ailments

 Update the team’s knowledge of available remedies by type/cause, indications and doses to ensure appropriate product selection for each customer

 Train the team to meet all the above considerations

NEW

CO LD & F LU SY M PTO M S O N LY T R I P L E AC T IV E F O R M U L AT I O N

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution, Paracetamol 1000 mg, Guaifenesin 200 mg, Phenylephrine Hydrochloride 12.2 mg For the relief of symptoms of colds and flu and the pain and congestion of sinusitis, including aches and pains, headache, blocked nose and sore throat, chills, lowering of temperature, and to loosen stubborn mucus and provide relief from chesty coughs. Adults, the elderly and adolescents aged 16 years and over: One sachet every 4-6 hours as required to a maximum of 4 sachets (4 doses) in a 24-hour period. Do not give to children and adolescents under 16 years Not to be continued for over 3 days without consulting a doctor. Contraindications: Hypersensitivity to any of the ingredients, severe hepatic impairment, hyperthyroidism, hypertension, diabetes, cardiovascular disease, those taking tricyclic anti-depressants or beta-blockers or other antihypertensive agents, patients who are taking or have taken mono amine oxidase inhibitors within the last two weeks or those currently receiving other sympathomimetics, phaeochromocytoma, closed angle glaucoma, and porphyria Precautions: circulatory disorders, chronic alcoholism, urinary retention or prostatic hypertrophy, gilbert’s syndrome, concomitant treatment with flucloxacillin and medici nal products affecting hepatic function, glucose-6-phosphate dehydrogenase deficiency, haemolytic anaemia, glutathione deficiency, dehydration, chronic malnutrition, elderly, adults and adolescents weighing less than 50kg, may act as a cerebral stimulant. Use with paracetamol-containing products Do not take with alcohol. Pregnancy and lactation: Not to be taken during pregnancy or whilst breast feeding without medical advice. Side effects: Thrombocytopenia, agranulocytosis, anaphylaxis, severe cutaneous hypersensitivity, bronchospasm, hepatic dysfunction, acute pancreatitis, angioedema, angle glaucoma See SmPC for full list of side effects and f urther information. Product not subject to medical prescription. PA1186/021/003. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. Date of preparation: Feb 2023. SPC: https://www.medicines.ie/medicines/solpa-cold-flu-multi-relief-max-powder-for-oral-solution-35312/spc#tabs

Palliative Care Study Findings Released

Researchers at Trinity’s School of Medicine have investigated how patient and informal caregiver reciprocal support in specialist palliative care impacts on patient and caregiver decision making for care. Their findings indicate that both obligation to each other and feeling constrained by one another can limit patient and caregiver open disclosure in decision making. The study is published in the Journal of Pain and Symptom Management

• Caregivers who felt supported by the patient, by their own choice and obligation, were more likely to be invited into the decision-making process for care.

• Where the caregiver did not feel forced into caregiving and the patient did not feel inhibited by their reliance on the caregiver, open communication about the needs and preferences for care were far more likely.

added, “These findings highlight the importance for healthcare professionals to help the caregiver cope with loss of control and choice in a caregiving role. This includes increasing the level of support available to caregivers but also helping caregivers process and deal with loss of control and choice in a caregiver role.

The team’s previous research informed them that patient and caregiver can reciprocate in supporting one another. This current research now gives fresh insight into the area of decisionmaking in palliative care that had not previously been understood, and ties in with national palliative care week: September 10th to 16th 2023.

Palliative care is an interdisciplinary care approach focused on alleviating symptom distress for people living with life-limiting progressive conditions, and their families. Patients with advanced illness not only depend on healthcare professional support; they also rely heavily on family to take on caregiving roles. Family caregivers are often involved in the decision-making process for treatment and care.

Understanding how supportive behaviours between patients and informal (usually family) caregivers impacts on treatment decisionmaking is necessary to facilitate effective communication between patients and their caregivers, and in turn, optimise care outcomes for both the patient and caregiver.

Researchers now believe the impact of mutual obligation on patient and caregiver decision-making needs to be considered when designing interventions for patient care in palliative care settings.

The study involved in-depth qualitative interviews on the topic with patients with advanced

illness and their caregivers. All participants were recruited from a large regional specialist palliative care service in Ireland.

Key findings

• Although the patient and caregiver in palliative care can be mutually supportive, how they support one another can have negative connotations for both the patient and caregiver when faced with decisions about care.

• Mutual support between the patient and caregiver was underpinned by mutual obligation.

• For caregivers, obligation to the patient was explained by having little choice but to assume a caregiving role and feeling constrained in a caregiving role.

• For patients, obligation to their caregiver centred on feeling obliged to accept assistance from their caregiver and feeling constrained in a care recipient role.

• Caregivers who felt obliged to care reported difficulty in discussing the patient’s preferences for care with the patient as well as their own wishes for patient care.

• Some caregivers struggled to engage in conversations with the patient about treatment options.

• Caregivers who felt most obliged to care reported the most distress in their role, feeling burdened and under strain.

Dr Geraldine Foley, Assistant Professor in Occupational Therapy at Trinity, primary investigator and corresponding author of the study, said, “The findings from our study pinpoint key dimensions to the patient and caregiver relationship for decision-making in palliative care that we had not fully appreciated prior to conducting the study. We found that caregivers who felt obliged to care had difficulty communicating with the patient about the patient’s preferences, and that patients who felt obliged to accept assistance tended to minimise caregiver involvement in decision making. However, caregivers who assumed caregiving on their own accord and patients who did not feel constrained in care recipient role, were much more open in their communication with each another and trusting of one another.”

In considering the potential clinical impact of their findings, Dr Foley

“Supporting the patient should involve as appropriate open communication between the patient and caregiver because open communication between the patient and caregiver appears to have a positive outcome for the patient as well as the caregiver.”

You can read the full article at the following link: https://www. jpsmjournal.com/article/S08853924(23)00623-1/fulltext

The study was conducted in collaboration with Professor Karen Ryan, Consultant in Palliative Medicine and Clinical Professor at University College Dublin and St. Francis Hospice Dublin, and Dr Regina McQuillan, Consultant in Palliative Medicine at St. Francis Hospice Dublin and Beaumont Hospital Dublin.

The study was supported by a Trinity College Dublin Provost’s Project Award. PhD scholar funded by this award and co-author of the paper is Ms Rachel McCauley, Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin.

Dr Geraldine Foley, Assistant Professor in Occupational Therapy at Trinity

Tax-saving opportunities for Proprietary Directors and Business Owners

If you are a Proprietary Director (i.e. a director who owns or controls more than 15% of the shares in your company), you are obliged to file self-assessment tax returns by 31 October 2023 (or 15 November 2023 for ROS users) in respect of last year, even if all of your income is taxed under the PAYE system.

If your income includes non-PAYE income you must pay any balance of Income Tax , PRSI and USC outstanding from last year You will also need to consider paying Preliminar y Tax for the current year

If your income includes non-PAYE income you must pay any balance of Income Tax, PRSI and USC outstanding from last year. You will also need to consider paying Preliminary Tax for the current year.

You can reduce your 2022 total tax liability and you may even receive a refund from the revenue. This can be achieved by personally making a lump sum pension contribution by 31 October 2023 and also by this date electing to backdate the tax relief to 2022.

Your pension contributions are subject to age-related limits

S ar ah is a propr iet ar y dire c tor i e . a dire c tor who owns or cont 1 5% of the share s in her company. S he paid In come Ta x at the 4

Notes:

1. An earnings cap of ¤115,000 applies to contributions. Pension contributions made by you in 2022 must be deducted from the maximum tax-allowable contribution calculated based on these limits.

5% of the share s in her company. S he paid In come Ta x at the 4 0% r ate in 20 2 2 S he make s a p ension contr ibu tion of € 20,00 0 by 3 1 O c tob er 20 2 3 , which is wi thin the age -relate d limi t s allowe d W i th her return of in come for 20 2 2 she informs her lo cal t a x office by 3 1 O c tob er 20 2 3 of this payment an d of her de sire to backdate the t a x relief on this to 20 22 . S he is enti tle d to the following ref un d:

20 2 2 S he make s a p ension contr ibu tion of € 20,00 0 by 3 1 O c tob which is wi thin the age -relate d limi t s allowe d W i th her return 20 2 2 she informs her lo cal t a x office by 3 1 O c tob er 20 2 3 of this an d of her de sire to backdate the t a x relief on this to 20 22 . S he the following ref un d:

2. Age is age on your birthday in 2022.

3. Retirement benefits are subject to separate Revenue limits.

4. Reference throughout this document to ‘Tax’ refers to ‘Income Tax’

Note: If you use the Revenue Online Service (ROS)to both file your tax returns and pay your taxes you have until 15 November 2023 to file and pay for 2022.

Sarah is a proprietary director i.e. a director who owns or controls more than 15% of the shares in her company. She paid Income Tax at the 40% rate in 2022. She makes a pension contribution of ¤20,000 by 31 October 2023, which is within the age-related limits allowed. With her return of income for 2022 she informs her local tax office by 31 October 2023 of this payment and of her desire to backdate the tax relief on this to 2022. She is entitled to the following refund:

What type of pension plan?

What type of pension plan?

• If your company contr ibu te s to an o ccupational p ension scheme on your b ehal f you can make addi tional volunt ar y contr ibu tions ( AVC ’s) to your o ccupational p ension scheme (subje c t to scheme r ule s allowing same) to a G roup Addi tional Volunt ar y C ontr ibu tion ( AVC) arr angement or to a PRSA AVC plan in re sp e c t of your in come f rom yourcompany

What type of pension plan?

What type of pension plan?

• If your company contr ibu te s to an o ccupational p ension s b ehal f you can make addi tional volunt ar y contr ibu tions ( A o ccupational p ension scheme (subje c t to scheme r ule s all to a G roup Addi tional Volunt ar y C ontr ibu tion ( AVC) arr ange PRSA AVC plan in re sp e c t of your in come f rom yourcompa

• If your company contr ibu te s to a PRSA on your b ehal f, you can make contr ibu tions to that PRSA plan or another PRSA plan of your choice in re sp e c t of your in come f rom your company.

• If your company contributes to an occupational pension scheme on your behalf you can make additional voluntar y contributions (AVC s) to your occupational pension scheme (subject to scheme rules allowing same) to a Group Additional Voluntar y Contribution (AVC) arrangement or to a PRSA AVC plan in respect of your income from yourcompany

• If your company contr ibu te s to a PRSA on your b ehal f, you contr ibu tions to that PRSA plan or another PRSA plan of yo re sp e c t of your in come f rom your company.

• If your company contributes to an occupational pension scheme on your behalf you can make additional voluntary contributions (AVC’s) to your occupational pension scheme (subject to scheme rules allowing same), to a Group Additional Voluntary Contribution (AVC) arrangement or to a PRSA AVC plan in respect of your income from your company.

• If your company contributes to a PRSA on your behalf, you can make contributions to that PRSA plan or another PRSA plan of your choice in respect of your income from your company

• If your company doe s not contr ibu te to an O ccupational Pension arr angement or PRSA on your b ehal f, you can make contr ibu tions to a Per sonal Pension plan or a PRSA plan in re sp e c t of your in come f rom your company.

• If your company doe s not contr ibu te to an O ccupational P arr angement or PRSA on your b ehal f, you can make contr i Per sonal Pension plan or a PRSA plan in re sp e c t of your in your company.

• If your company does not contribute to an Occupational Pension arrangement or PRSA on your behalf you can make contributions to a Personal Pension plan or a PRSA plan in respect of your income from your company

• If your company contributes to a PRSA on your behalf, you can make contributions to that PRSA plan or another PRSA plan of your choice in respect of your income from your company.

• If your company does not contribute to an Occupational Pension arrangement or PRSA on your behalf, you can make contributions to a Personal Pension plan or a PRSA plan in respect of your income from your company.

Make the most of the tax-efficiency of pension contributions now – you may ne get such good value again!

you may never get such good value again!

Moore Wealth Management Limited trading as Moore Wealth Management is Regulated by the Central Bank of Ireland reg number 55195

Learning from Patient Safety Events

Educational videos of facilitated debriefs following patient safety events, co-designed and developed by RCSI with the HSE National Quality and Patient Safety Directorate, have been published in BMJ Open Quality.

Dr Siobhán McCarthy, Lecturer at the Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences

an event where groups discuss: what did we expect to happen; what actually happened; why was there a difference; and what have we learnt?

the Irish health services, using an in-person simulation-based programme co-designed and funded by the HSE National Quality and Patient Safety Directorate (NQPSD). Subsequently, RCSI and the HSE formed a research collaboration to assess the implementation and effect of AAR at a hospital site.

the skills required to facilitate AARs,” said Dr Siobhán McCarthy. “Effective AAR facilitation skills are important to support staff participating in AARs and to help identify learning and improvement actions.”

Suite of options

The access article, led by Dr Siobhán McCarthy, Lecturer at the Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, provides video resources designed to educate healthcare staff about a methodology known as After Action Review (AAR).

After Action Review is a nonhierarchical facilitated debrief of

The publication includes access to the online videos of simulated AARs and an associated case scenario of a patient safety event. These have the potential to be used widely to support social and near-to-real-time learning from patient safety and everyday events.

Awareness and skills

Since 2018, the RCSI Graduate School of Healthcare Management has trained up to 500 healthcare staff as AAR facilitators across

Arising from the collaboration, RCSI and the HSE have released a series of videos of simulated AARs to help spread and sustain AAR awareness and facilitation skills. The videos demonstrate the purposes of an AAR, the AAR process, and the skills required to facilitate an AAR effectively.

“By using digital technology and a university-health service partnership approach, we hope that this open-access educational resource will enhance awareness of AAR as a learning tool and of

New Research on Women’s Health

Lorraine Schwanberg, Assistant National Director for Incident Management at the HSE NQPSD, emphasised that “AAR forms part of a suite of incident response options as part of the HSE Incident Management Framework and we look forward to using this resource as part of the development of AAR across the health services.”

The videos were developed with funding from the Health Research Board Applied Partnership Award (APA-2019024) and includes co-funding from the Health Services Executive.

More than half of women in Ireland are worried about a female health issue, regardless of the stage of life they are in, according to a new survey. This relates to concerns around contraception, fertility and infertility, menstrual issues as well as perimenopause and menopause. The research was commissioned by Irish Life Health, one of Ireland’s leading health insurance providers. Irish Life Health today announced a new first of its kind female health GP consultation benefit dedicated to meeting the demand for more specialised health services for women

The survey, which was carried out amongst women aged 18+, revealed insights into perceptions of female healthcare in Ireland. Over half of respondents believe female healthcare is not well serviced in Ireland, while 38% are finding it difficult to get fast access to specialist female health expertise.

The research also revealed the main concerns among different age groups of women in Ireland, which found:

• four in ten 18-24-year-olds in Ireland are worried about menstruation issues

• four in ten 25-34-year-olds are worried about fertility issues

• almost half of 35-54-yearolds are worried about perimenopause or menopause

While the research shows there are significant levels of concern

about female health issues, the responses demonstrate confidence in taking action. 89% of women believe they know their body better than anyone, and more than 8 in 10 women are eager to understand more about their health.

The Female Health Consultation benefit by Irish Life Health is the first of its kind in Ireland, offering members access to GPs who specialise in female health, for support and advice in the areas of menstrual health, fertility, contraception, perimenopause and menopause, amongst others.

Dr Maire Finn, one of the specialist GPs delivering this service for Irish Life Health, comments, “These statistics are not surprising to me as a GP as every day in my practice I hear women’s concerns about their menstrual cycle, their fertility, menopause, and the impact these issues have on their

everyday lives. This research tells us that women feel they know their bodies but equally want to know more about health matters that relate specifically to them. It shows that there is work to be done to provide more specialised care in the area of women’s health. This new female health service that Irish Life Health is launching, is a timely and important step in providing the specialised care and information that all women need and want.”

In announcing the new benefit, Liz Rowen, Head of Marketing, Irish Life Health added, “Our research showed that women understand their own bodies, and they know when something isn’t right, but a large proportion of them don’t have the opportunity to talk to someone who really understands their individual concern. Our members will now have the opportunity to have their health concerns

heard through a dedicated and specialised female health service, which is available on all Irish Life Health hospital plans from the 1st of September.”

Other key findings from the research include:

• Only half of women (51%) feel like they truly understand their menstrual cycle

• 62% of women get their health information from family and friends, while 59% source their information through social media and online platforms

The new specialist female health GP consultation service will offer Irish Life Health members a GP consultation by phone or video, a recommended course of action and, if needed, an in-person appointment at one of Centric Health’s specialist female health clinics across Ireland.

Call for Judges:

OTC & Retail Pharmacy Product Awards 2024

As a judge for the OTC & Retail Pharmacy Product Awards 2024, you will play a crucial role in evaluating and selecting the most outstanding Over-the-Counter Pharmacy Products in Ireland. Your expertise and insights will help us identify products that have made significant contributions to the field, whether through technological advancements, patient care improvements, or other remarkable achievements.

Here are some key details about the judging process and requirements: Judging Process:

• The judging process will be conducted remotely.

• Finalists’ Products will be posted to each judge giving you the opportunity to try, test and evaluate.

• Each judge will be assigned specific product categories.

• Judges will review product submissions, provide scores, and offer constructive feedback.

Requirements:

• Pharmacists, Buyers and Owners.

• A commitment to fairness, impartiality, and confidentiality.

• Availability to review and evaluate product submissions during the judging period.

If you are interested in becoming a judge for the OTC & Retail Pharmacy Product Awards 2024, please email with your name, contact information to Aoife@ipn.ie

New Insights into Epilepsy

The largest genetic study of its kind, coordinated by the International League Against Epilepsy including scientists from FutureNeuro at RCSI University of Medicine and Health Sciences, has discovered specific changes in our DNA that increase the risk of developing epilepsy.

Professor Gianpiero Cavalleri, Professor of Human Genetics at RCSI School of Pharmacy and Biomolecular Science and Deputy Director of the SFI FutureNeuro Research Centre

epilepsy subtypes. This in turn will guide clinicians in selecting the most beneficial treatment strategies, minimising seizures,” said Professor Colin Doherty, Consultant Neurologist at St James’s Hospital, co-author and clinical investigator at the SFI FutureNeuro Centre.

Unprecedented collaboration

The research, published in Nature Genetics, greatly advances our knowledge of why epilepsy develops and may inform the development of new treatments for the condition.

Epilepsy, a common brain disorder of which there are many different types, is known to have genetic components and sometimes runs in families. In this new study, researchers compared the DNA from diverse groups of almost 30,000 people with epilepsy to the DNA of 52,500 people without epilepsy. The differences highlighted areas of our DNA that might be involved in the development of the disorder.

The researchers identified 26 distinct areas in our DNA that appear to be linked to epilepsy. This included 19 that are specific

to a particular form of epilepsy called Genetic Generalised Epilepsy (GGE). They were also able to point to 29 genes that are probably contributing to epilepsy within these DNA regions.

The scientists found that the genetic picture was quite different when comparing distinct types of epilepsy – in particular, when ‘focal’ and ‘generalised’ epilepsies were compared. The results also suggested that proteins that carry electrical impulse across the gaps between neurons in our brain make up some of the risk for generalised forms of epilepsy.

Quality of life

“Gaining a better understanding of the genetic underpinnings of epilepsy is key to developing new therapeutic options, and consequently a better quality of

life for the over 50 million people globally living with epilepsy,” said Professor Gianpiero Cavalleri, Professor of Human Genetics at RCSI School of Pharmacy and Biomolecular Science and Deputy Director of the Opens in new windowSFI FutureNeuro Research Centre.

“The discoveries we report on here could only be achieved through international collaboration, on a global scale. We are proud of how the global community of scientists working to better understand the genetics of the epilepsies have pooled resources and collaborated effectively, for the benefit of people impacted by the condition.”

The researchers also showed that many of the current medications for epilepsy work by targeting the same epilepsy risk genes that were highlighted in this study. However, based on their data, the researchers were able to propose some potentially effective alternative drugs. These will need to be clinically tested for use in epilepsy as they are normally used for other conditions, but they are known to target some of the other epilepsy risk genes uncovered.

“This identification of epilepsyassociated genetic changes will allow us to improve diagnosis and classification of different

Over 150 researchers based across Europe, Australia, Asia, South America and North America carried out the research. They worked together as part of the International League Against Epilepsy (ILAE) Consortium on Complex Epilepsies. The ILAE Consortium was formed by researchers in 2010, recognising that the complexity of genetic and environmental factors underlying epilepsy would require research across massive datasets, and therefore unprecedented collaboration on an international scale.

“Undertaking such a comprehensive study is a remarkable achievement that RCSI and FutureNeuro are proud to have played a leading role in. The challenge now is to translate the findings of this research to improve the lives of people with epilepsy,” concluded Professor Cavalleri.

“With this study, we have bookmarked parts of our genome that should be the major focus of future epilepsy research. It will form the basis for further work looking at the molecular pathways involved in seizure generation, neuronal dysfunction and altered brain activity,” said Professor Samuel Berkovic, University of Melbourne.

“This is a major milestone for the ILAE Consortium on Complex Epilepsies, demonstrating what can be achieved when scientists openly collaborate and share data from across the world. The outputs are wide-reaching and applicable to epilepsy patients globally,” said Professor Helen Cross, President of the International League Against Epilepsy.

Science Foundation Ireland (SFI) supported the work through its funding of the FutureNeuro Research Centre.

“This is a major milestone for the ILAE Consortium on Complex Epilepsies, demonstrating what can be achieved when scientists openly collaborate and share data from across the world. The outputs are wide-reaching and applicable to epilepsy patients globally”

Don’t get left in the dark

Since 1st September 2023, the EU has banned the sale of fluorescent lighting. This may directly affect your business. With a fully funded lighting upgrade from Energia, you can get your old fluorescent lighting replaced, while also reducing your lighting consumption by up to 80%. We’ll make it easy by managing the entire process from start to finish.

Find out more at energia.ie/lighting

The Unspoken Barriers to Treatment for Chronic Plaque Psoriasis

A.Wolinska1, M. Costa Blasco1, O. Mc Feely1, L. Murphy1, M. Andrawis1, P. Beatty1, C. Doyle1 and AM. Tobin1

1Department of Dermatology, Tallaght University Hospital, Dublin, Ireland.

Anna Wolinska

I can’t remember exactly when I first noticed the rash on my skin but I know it has been there for years. Within the Irish Traveller Community we have some cures but nothing could ever help me. I was eventually brought to the hospital when I was 15 years old and it was then I was told I had psoriasis. I had light treatment first which was good but it didn’t

take long for my rash to come back again. I am now 28 years old. It has had a huge impact on me growing up. I couldn’t wear the clothes that I liked or that my friends were wearing because my skin was so bad. If I tried to put on fake tan it would stick to my rash and everyone would look at me. It got to a point where I couldn’t go out. I stopped going to weddings because I couldn’t get dressed up. In the Traveller community, because I am not married, I am not allowed to go anywhere without someone from my family coming with me. It can be hard as all of my friends are married now and they can go out whenever they want.

I went back to the hospital a few years ago and I was given an injection for my skin. My rash went

away and my skin was perfect. I was so happy but then I couldn’t get anyone to go to the hospital with me and my parents wouldn’t let me go on my own. I missed a few appointments and I couldn’t get my treatment. It didn’t take long for my rash to come back again and it was worse than ever. I enjoyed going to the gym but when my skin got bad again I stopped and I put on weight. I didn’t go anywhere for a long time. Then my brother said he would bring me to my appointments. I felt scared and embarrassed explaining everything to the doctor in the hospital because it sounds silly to people who aren’t Travellers and I didn’t think they would understand. But they have been able to help me a lot - like when my pharmacy wouldn’t give me my injections the doctors were able to sort everything out for me or if I can’t get to an appointment I can call them instead. I hope that when my rash is gone I can start getting dressed up for weddings and things like that again. I hope I will meet someone and have a home of my own. I just want to finally have some independence.

National Youth Mental Health Office

Clinicians Comments

Research in dermatology that includes groups that have been historically marginalised is limited. The Traveller community represents 0.7% of the population in Ireland1. Previous studies have shown that this ethnic group has a significantly lower life expectancy than the general population, the reasons for which are multifactorial. Social inequalities are often stark compared with the rest of the population2,3. This patient’s viewpoint highlights the importance of recognising different cultural expectations and norms that can have an impact on a patient’s access to healthcare. As immigration rates continue to rise with significant population shifts in Europe over recent years4, we as dermatologists should be vigilant to ensure that we are well-informed and respectful of the social and cultural traditions of our patients. In doing so, we can foster a strong patient-doctor relationship with our most vulnerable patients and limit the potential for healthcare disparity across groups that have been historically marginalised. References available on request

Minister for Mental Health and Older People Mary Butler has announced the launch of the new National Youth Mental Health Office in the Health Service Executive (HSE). The new National Office will focus on delivering strengthened and more integrated supports for child and youth mental health care across Ireland.

This new HSE office will provide for co-ordinated input across service, legislative and policy developments for all child and youth mental area areas, from prevention and early intervention to the specialised Child and Adolescent Mental Health Service (CAMHS).

This is a very significant development, and it will improve leadership, operational oversight, and management of all service delivery and improvements. A new HSE National Clinical Lead for Youth Mental Health has already taken up post – Dr Amanda Burke - with a new Assistant National Director for Child and Youth Mental Health starting later this month. They will be supported by

additional and dedicated staff for the National Office.

Other priorities for the new National Office will include improved links to other care programmes such as primary care and disability services, as well as external agencies across the education, childcare and youth justice fields. It will also underpin current and planned initiatives arising from the recent Maskey and Mental Health Commission Reports on CAMHS as well as the forthcoming HSE audits on the current CAMHS Operational Guidelines and Service User experience. The Office will work closely with the Mental Health Commission.

A key focus of the new National Office for Youth Mental Health will be improved and centralised data collection and analysis to help inform new service responses for child and youth mental health. The government remains committed to developing all aspects of mental health, under our national mental health policies and the HSE Annual Service Plans. The overall budget for mental health has increased by nearly 20% during the term of this government to ¤1.2 billion this year. ¤137 million is being provided to CAMHS this year. In addition, more than ¤100 million has been provided to

community-based mental health organisations/NGOs this year, with a significant proportion of this dedicated to supporting child and young people.

Minister Butler said, “The new National Office is essential to tackling many acknowledged and evolving challenges facing youth mental health overall. Our specialist CAMHS service, in tandem with its Primary Care and NGO counterparts, have risen to unprecedented challenges in recent times, in light of increasing demand and case complexity, staffing vacancies, COVID-19 impacts and online safety issues to name but a few.”

DON’T WAIT UNTIL OSTEOPOROSIS STRIKES AGAIN

Rebuild bone before it breaks again—with Movymia®1

THE MEDICINES MANAGEMENT PROGRAMME RECOMMENDS

MOVYMIA® AS A BEST VALUE MEDICINE FOR TERIPARATIDE

RELIABLE: Movymia®’s quality, safety and efficacy is highly similar to its reference product1,3,*

EFFECTIVE: Anabolic MoA effectively rebuilds bone through the stimulation of osteoblasts1,4

AFFORDABLE: Allows more eligible patients to benefit due to its cost advantage5,6

RE-USABLE: One high quality reuseable pen for the entire treatment period1

MOVYMIA 20 MICROGRAMS/80 MICROLITERS SOLUTION FOR INJECTION

Each dose of 80 microliters contains 20 micrograms of teriparatide. One cartridge of 2.4 ml of solution contains 600 micrograms of teriparatide (corresponding to 250 micrograms per ml). Presentation: Glass cartridge. Indications: Movymia is indicated in adults. Treatment of osteoporosis in postmenopausal women and men at increased risk of fracture. In postmenopausal women, a significant reduction in the incidence of vertebral and non-vertebral fractures but not hip fractures has been demonstrated. Treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in women and men at increased risk for fracture. Dosage: The recommended dose is 20 micrograms administered once daily. Patients should receive calcium and vitamin D supplements if dietary intake is inadequate. The maximum total duration of treatment is 24 months. The 24 month course should not be repeated over a patient’s lifetime. Following cessation of teriparatide therapy, patients may be continued on other osteoporosis therapies. Teriparatide must not be used in severe renal impairment. Use with caution in moderate renal impairment and impaired hepatic function. Teriparatide should not be used in paediatric patients (less than 18 years), or young adults with open epiphyses. Method of administration: Movymia should be administered once daily by subcutaneous injection in the thigh or abdomen. It should be administered exclusively with the Movymia Pen reusable, multidose medicine delivery system and the injection needles which are listed as compatible in the instructions provided with the pen. The pen and injection needles are not included with Movymia. However, for treatment initiation a cartridge and pen pack should be used. Movymia must not be used with any other pen. Patients must be trained to use the proper injection techniques. Contraindications: Hypersensitivity to the active substance or excipients. Pregnancy and Breast-feeding Pre-existing hypercalcaemia, severe renal impairment, metabolic bone diseases other than primary osteoporosis or glucocorticoid-induced osteoporosis, unexplained elevations of alkaline phosphatase, prior external beam or implant radiation therapy to the skeleton, patients with skeletal malignancies or bone metastases. Warnings and precautions: In normocalcaemic patients, slight and transient elevations of serum calcium concentrations have been observed following teriparatide injection. Serum calcium concentrations reach a maximum between 4 and 6 hours and return to baseline by 16 to 24 hours after each dose of teriparatide. Therefore, if blood samples for serum calcium measurements are taken, this should be done at least 16 hours after the most recent teriparatide injection. Routine calcium monitoring during therapy is not required. Teriparatide may cause small increases in urinary calcium excretion, but the incidence of hypercalciuria did not differ from that in the placebo-treated patients in clinical trials. Teriparatide should be used with caution in patients with active or recent urolithiasis because of the potential to exacerbate this condition. In short-term clinical studies with teriparatide, isolated episodes of transient orthostatic hypotension were observed. Typically, an event began within 4 hours of dosing and spontaneously resolved within a few minutes to a few hours. When transient orthostatic hypotension occurred, it happened within the first several doses, was relieved by placing subjects in a reclining position, and did not preclude continued treatment. Caution should be exercised in patients with moderate renal impairment. Experience in the younger adult population, including premenopausal women, is limited. Treatment should only be initiated if the benefit clearly outweighs risks in this population. Women of childbearing potential should use effective methods of contraception during use of teriparatide. If pregnancy occurs, teriparatide should be discontinued. The recommended treatment time of 24 months should not be exceeded. Contains sodium. Interactions: Digoxin, digitalis. Fertility, pregnancy and lactation: Women of childbearing potential should use effective methods of contraception during use of teriparatide. If pregnancy occurs, Movymia should be discontinued. Movymia is contraindicated for use during pregnancy and breast-feeding. The effect of teriparatide on human foetal development has not been studied. The potential risk for humans is unknown. Driving and operation of machinery: Teriparatide has no or negligible influence on the ability to drive and use machines. Transient, orthostatic hypotension or dizziness was observed in some patients. These patients should refrain from driving or the use of machines until symptoms have subsided. Undesirable effects: Nausea, pain in limb, headache, dizziness. Refer to Summary of Product Characteristics for other adverse effects. Pack size: 1. Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance. Website: www.hpra.ie Marketing authorisation holder: STADA Arzneimittel AG, Stadastrasse 2-18, 61118 Bad Vilbel, German. Marketing authorisation number: EU/1/16/1161/001-003. Medicinal product subject toedical prescription. Date last revised: January 2022.

1. Movymia® SmPC. 2. Best Value Medicines https://www.hse.ie/eng/about/who/cspd/ncps/medicines-management/best-value-medicines/teriparatide/ Accessed February 2023.

3. Movymia® EPAR – public assessment report, available at: https://www.ema.europa.eu/documents/assessment-report/movymia-epar-public-assessment-report_en.pdf

4. Brixen KT et al. Basic Clin Pharmacol Toxicol. 200494(6):260–70. 5. Lyman GH et al. N Engl J Med. 2018378(21):2036–2044. 6. Janjigian YY et al. Future Oncol. 201814(23):2403–2414.* Forsteo®

Date prepared: March 2023. 2023/ADV/MOV/061H

¤25 MILLION INVESTMENT IN A NEW DIGITAL TRANSFORMATION PROGRAMME

Blackrock Health Group, which comprises of the Blackrock, Galway, Hermitage and Limerick Clinics, has announced a ¤25 million investment in a new digital transformation programme. The investment includes the introduction of the very latest in electronic health record systems, MEDITECH Expanse, and the introduction of Ireland’s first integrated digital engagement platform that will enable connectivity between patients, consultants and general practitioners (GPs).

These innovations will serve to connect patient data for the 325,000 patients it treats annually across its four clinics, enhance clinical care, improve patient safety all while reducing the administration burden and freeing up more time for clinicians to focus on patient care.

The digital transformation project will take three years to implement and will create 60 new jobs across the Blackrock Health group as a direct result of the investment. The partnership builds on the successful rollout of MEDITECH’s electronic health record in Galway Clinic in 2017, the first of its kind in Ireland.

The MEDITECH Expanse electronic health record system will help to guide clinical decision-making by offering a comprehensive view of a patient’s health history and will allow patients to attend any of the hospitals within the group with seamless access to their records. The system will also ensure that key information is available to their GP for any follow-up. Using the location agnostic solution, physicians, nurses, and other clinicians at Blackrock Health can use mobile devices to view patient records, place orders, and document care at any time.

CEO of Blackrock Health, Caroline Whelan said: “Improving patient care is always at the heart of the decisions that we make at Blackrock Health and that is why we are investing ¤25m to digitally transform the way we work across the Group, which in turn will enhance clinical care and patient safety for the 325,000 patients we treat annually. We are excited to embark on this three-year journey alongside our partners at MEDITECH which will enable staff across our four clinics to work in close collaboration and our patients to access one single health record, at any of our clinics.”

Mike McCann, Chief Information Officer, Blackrock Health said: “We introduced electronic health records at the Galway Clinic in 2017 and since then have seen great improvements in the way that we work day-to-day. Based on these results, the natural next step was to implement a group-wide rollout, as we continue to look at ways to integrate technology into healthcare. We look forward to bringing this technology to patients and staff.”

Gina Kerley, Executive Director, MEDITECH said: “For many years, the Galway Clinic has been a leader among Ireland’s healthcare organisations by leveraging technology to improve patient care. We are excited to build on this success and partner with Blackrock Health to provide all four clinics with the innumerable benefits of having a modern electronic health record.”

ACCORD HEALTHCARE

IRELAND LAUNCH ORGOVYX® (RELUGOLIX) 120 MG THE FIRST AND ONLY ORAL ANDROGEN DEPRIVATION THERAPY FOR PROSTATE CANCER

Accord Healthcare, one of Europe’s fastest growing pharmaceutical companies, is delighted to announce the launch of its latest oncology treatment, ORGOVYX® (relugolix) 120 mg which comes in pack size of 30 film-coated tablets. Relugolix is the first and only oral androgen deprivation therapy (ADT) for advanced hormone-sensitive prostate cancer. 1 in 3 injectable oncology medicines dispensed in Europe are from Accord.1

“Roughly 4,000 men are diagnosed with prostate cancer each year in

Ireland, which means 1 in 7 men will be diagnosed with prostate cancer during their lifetime.2 I am therefore delighted to announce our launch of Orgovyx® onto the Irish market, our 26th High Tech product. We are immensely proud of our ongoing investment in oncology and our drive to shape the future of cancer treatment”, said Padraic O’Brien, MD, Accord Healthcare Ireland.

“Our latest exciting partnership with Myovant, with ORGOVYX®, will enable us to bring a new ADT option to people in Ireland living with prostate cancer. Its oral formulation addresses some of the challenges with current injectables in terms of their in-hospital administration and risk of injection site reactions. We see the potential convenience of relugolix as the first needle-free ADT that can be taken at home, reducing the need for hospital visits which could in turn reduce the burden on both patients and healthcare providers” continued Mr O’Brien.

Relugolix was granted Marketing Authorisation by the European Medicines Agency on 29 April 2022.3 In May 2022, Accord was selected by Myovant Sciences to commercialise this product across Europe (European Economic Area, United Kingdom, Switzerland and Turkey).3

Please refer to the Summary of Product Characteristics (SPC) for further information. The SPC will be available at www.hpra.ie and for Healthcare Professionals at www.accord-healthcare.ie.

Orgovyx® will be available from both full-line wholesalers from launch. For further information contact Accord in Cork on 021-461 9040.

SAFER AND MORE EFFECTIVE BRAIN SURGERIES

After a surgical first, a Swiss company is getting closer to treating severe disorders with its unique electrode grid designed as a safe alternative to existing brain implants.

Under the guidance of neurosurgeon Prof. Nitin Tandon, a clinical study conducted at Memorial Hermann in Houston has marked the inaugural testing of Neurosoft Bioelectronics’ subdural electrodes as they were used for recording the human brain in the context of an epilepsy resective surgery. Two epileptic patients and one brain tumour patient have undergone a successful surgery, while detailed recordings were obtained in parallel from the surface of the brain. These results are very promising as the unique properties of these electrodes could allow for brain insertions in areas where no other implant can safely be inserted today, opening the door to treating indications such as severe tinnitus with no existing cure or validated treatment.

With the density of the electrode sites being 5 times higher and the entire device being 1000 times softer than standard electrodes, the usage of this new technology also holds the potential to address key challenges associated with invasive procedures, notably mitigating side effects such as brain compression, risks of hematomas, as well as scar tissue. Specifically for the first resective procedure, a sequence of sentences were echoed across the operating room, with the objective of capturing distinct brain activity within the auditory cortex. In addition, specific brain patterns recognized as interictal spikes were recorded within the hippocampus. These atypical neurological discharges also hold tremendous potential as they can help in localising regions of the brain implicated in epilepsy, improving the potential effectiveness of an epilepsy resection as a result.

Furthermore, the application of Neurosoft Bioelectronics’ electrodes presents the possibility of uncovering supplementary biomarkers which could significantly help in providing more effective and safer treatments of brain disorders for future patients. Invasive solutions presently employed for treating brain-related conditions pose substantial risks due to electrodes’ stiffness and thickness. Amidst these challenges, Neurosoft Bioelectronics’ soft and elastic electrodes present themselves as

a promising alternative to existing invasive solutions. The Neurosoft Bioelectronics team has also been studying how these electrodes could address indications like severe tinnitus.

Despite approximately 50 million patients worldwide and an estimated 3.5 million related suicide attempts, there is no effective treatment for severe tinnitus.

“The maturity of our technology has been underscored through its initial human testing. With each subsequent trial, we edge closer to obtaining FDA clearance for some of our initial indications, thereby progressing towards potentially aiding millions of individuals,” says Nicolas Vachicouras, CEO and Co-Founder of Neurosoft Bioelectronics.

Specifically for these first human interventions, “This milestone represents a great de-risking step for the company and is extremely important in bringing the concept of soft brain electrodes from academic laboratories to clinical applications,” says Prof. Lacour, Co-Founder of Neurosoft Bioelectronics and Director of the Neuro-X Institute at EPFL (Swiss Federal Institute of Technology in Lausanne). The study, led by Prof. Nitin Tandon, will continue to move forward in the coming months with additional electrode usage in up to 10 patients, potentially providing additional insights into potential applications of the technology.

“The preliminary findings of our study provide compelling validation for the trajectory of our technology, poised to enhance the safety and efficacy of brain surgery, while validating the ability to record specific information within the auditory cortex. Moving forward, we plan to widen our testing parameters and anchor our findings in a more comprehensive pool of data. Based on the first insights on the usability of our technology, applications for a wide range of treatments can be considered for development, among them tinnitus, deafness, traumatic brain injury and paralysis. In that regard, several other research projects leveraging our electrodes are currently ongoing both within our company, but also with partners at renowned Research Labs across the world,” says Nicolas Vachicouras.

VHI MAKES DERMATOLOGY SERVICES AVAILABLE TO CUSTOMERS IN PARTNERSHIP WITH ALLVIEW HEALTHCARE

Vhi has announced the launch of a new rapid access Dermatology service for the diagnosis and treatment of most dermatological conditions on an outpatient care basis.

Delivered in partnership with AllView Healthcare, Vhi’s Dermatology service provides end-to-end care for the diagnosis and treatment of medical dermatological conditions including common skin conditions such as acne, lesions, sun damage and melanoma - the most serious skin cancer.

With lengthy wait times for accessing dermatology services, Vhi’s new Dermatology service offers one of the fastest routes to medical dermatology treatment nationwide, with appointments available within ten days for Vhi members. Currently there are more 45,000 people awaiting a dermatology appointment in Ireland with 43% waiting for 6 months or more.1

By leveraging cutting-edge telehealth and digital technologies, Vhi Dermatology offers a new path to help meet the demand to treat serious skin conditions. Currently every year in Ireland, over 1,000 new cases of melanoma are diagnosed with non-melanoma skin cancer the most common cancer in Ireland. By 2045, it is projected that the number of cases of melanoma diagnosed among males will increase by 177% and among females will increase by 140%.2

New dermatology research commissioned by Vhi shows that 1 in 4 respondents are currently

concerned about the impact of sun damage on their skin. Serious skin conditions also appear to be having a negative impact on people’s health and wellbeing. Close to half (47%) of those surveyed reported that they suffered stress and anxiety as a direct result of having a skin condition.

Dr Rupert Barry, Consultant Dermatologist and Clinical Lead for Vhi Dermatology Services said, “Over recent years, there has been a growing incidence of skin cancer and other skin conditions with an increasing number of patients requiring end-to-end care from diagnosis to surgical excision. This trend is only set to accelerate. That is resulting in considerable wait times for patients looking to access dermatology services in Ireland with 1 in 4 having to wait a year or more for treatment.

“The launch of the Vhi Dermatology service will help give patients access to the care they need, when they need it. By cutting lengthy waiting times, we can rapidly diagnose patients with skin cancer who may be currently waiting for an appointment with a dermatologist and treat patients with skin conditions as quickly as possible.

“Tackling long wait lists and providing timely access to care will be pivotal to ensure the long-term health and wellbeing

of the population. By providing appointments to patients within days our service provides a faster and more effective approach to the management of skin conditions.”

Teledermatology appointments are available for Vhi members nationwide at AllView Healthcare Clinics and use specialist imaging equipment to record a series of high definition microscopic and macroscopic images of the skin complaint.

Following an initial appointment, AllView’s network of dermatology consultants deliver a diagnosis and treatment plan to manage conditions quickly and effectively. If surgery, biopsy or a face-toface appointment is subsequently required, the AllView Healthcare GP will explain this to the patient and give them the fast access option of attending the Vhi Dermatology Clinic at Vhi 360 Health Centre, in Carrickmines, County Dublin.

The Vhi Dermatology Service is one of a number of new services brought by Vhi to its members in recent times as it continues to innovate in the delivery of healthcare – specifically through the introduction of new facilities and services such as Vhi Women’s Health Clinic, Vhi Paediatric Clinic, Vhi Sports, Exercise and Musculoskeletal Medicine Clinic in Vhi 360 Health Centres, digital and

At the launch of the new dermatology service at the Vhi 360 Health Centre in Carrickmines were (from left): Michele Tait, chief operating officer, Vhi Health and Wellbeing; Dr Rupert Barry, consultant dermatologist and clinical lead for dermatology, Vhi 360 Health Centre Carrickmines; Edina O’Driscoll, head of operations, Vhi 360 Health Centre Carrickmines; and Eoin O’Reilly, chief executive, AllView Healthcare. Photograph: Leon Farrell / Photocall Ireland

Clinical Profiles

tele-health services, Vhi Hospital@ Home, Vhi Health Screening, Vhi Midwife Support Service and Vhi’s National Clinical Call Centre.

For more information on Vhi’s Dermatology services, please visit: https://www1.vhi.ie/360health/ dermatology

XWAVE TECHNOLOGIES AND QURE.AI ANNOUNCE STRATEGIC COLLABORATION

Qure.ai, a leading provider of medical artificial intelligence (AI) solutions and xWave Technologies, which has developed a cloudbased Clinical Decision Support (CDS) system for radiology referrals, have today announced a strategic partnership.

The collaboration will focus on enhancing market access, product co-development and integration in order to identify opportunities to deliver advanced healthcare solutions globally that address critical healthcare challenges.

Darren Stephens, Senior VicePresident & Commercial Head UK and Europe, Qure.ai, said, “Together, Qure and xWave can create patient-centric efficiencies in the radiology pathway. By dovetailing clinical decision support with AI in imaging, clinicians will be further supported. Patients will gain quicker results and imaging departments will see reduced demand for unnecessary diagnostic appointments.

This will help to slow the growth of waiting lists, particularly in the NHS. Ordering the right test, first time, along with the efficiency gains of AI, will provide hospitals with powerful support when looking ahead to winter healthcare pressures.”

xWave Technologies, an Irish health technology company, is headquartered at NovaUCD in Dublin.

Mitchell O’Gorman, Chief Executive Officer, xWave Technologies, said, “When we started xWave in 2020, one of the first organisations that we reached out to was Qure.ai. We were struck by the brilliance of its AI technology, the impact it was already delivering across the world and the clear fit between its offering and ours.

The xWave team is now looking forward to working closely with Qure.ai to co-develop innovative diagnostic solutions that aim to solve global health problems at scale.”

Qure.ai, headquartered in India with offices in London and New York, is one of the world’s most deployed medical AI companies, present in over 70 countries having grown in scale and size over seven years. Its certified medical imaging AI solutions for neurocritical trauma or stroke CTs; musculoskeletal x-ray fracture detection; and chest x-ray/CT for detection of lung

cancer, TB or heart failure are used in collaboration with over 25 NHS Trusts and Health Boards in the UK.

xWave’s Clinical Decision Support (CDS) system has been developed in partnership with the European Society of Radiology (iGuide) and the Royal College of Radiologists (iRefer). The CDS system expertly guides clinical referrers to order the best test for patients, ensuring patients get an early diagnosis, tackles radiology waiting lists and reduces clinician burnout.

JANSSEN MARKS FIRST APPROVAL WORLDWIDE FOR AKEEGA® (NIRAPARIB AND ABIRATERONE ACETATE DUAL ACTION TABLET) WITH EC AUTHORISATION FOR THE TREATMENT OF PATIENTS WITH METASTATIC CASTRATION RESISTANT PROSTATE CANCER WITH BRCA1/2 MUTATIONS

The Janssen Pharmaceutical Companies of Johnson & Johnson have announced that the European Commission (EC) has granted marketing authorisation for AKEEGA® (niraparib and abiraterone acetate [AA]), in the form of a dual action tablet (DAT), given with prednisone or prednisolone, for the treatment of adults with metastatic castrationresistant prostate cancer (mCRPC) and BRCA1/2 mutations (germline and/or somatic) in whom chemotherapy is not clinically indicated.2

Prostate cancer is one of the most common cancers in men in Ireland with about 3,940 men diagnosed each year.4 Despite treatment advances, mCRPC remains an incurable, deadly disease.5,6 BRCA1/2 gene mutations have been identified in approximately 10-15 percent of mCRPC patients7,8 and are more likely to cause aggressive disease, poor outcomes, and a shorter survival time.9,10,11,12 Professor Ray McDermott, Consultant Medical Oncologist, St Vincent’s University Hospital, Dublin said, “Metastatic castrationresistant prostate cancer remains a lethal disease, with high unmet needs in terms of treatment options, particularly for patients with BRCA1/2 gene mutations. The development of innovative therapies is vital to provide patients with new treatment options. The dual action tablet of niraparib with abiraterone acetate is a promising first line targeted treatment option for men with mCRPC and BRCA1/2 mutations. With BRCA testing now publicly available in Ireland, I hope this medicine will reach the right patients at the right time when available here.”

The EC authorisation, which also marks the first worldwide approval for AKEEGA®, is based on results of the randomised, double-blind, placebo controlled, Phase 3 MAGNITUDE study (NCT03748641).13 The trial assessed whether the addition of niraparib to AAP improved outcomes in those with untreated mCRPC, with or without alterations in homologous recombination repair (HRR) associated genes (which are involved in the repair of damaged DNA), including BRCA1/2.1,13 A total of 423 patients with HRR gene alterations were enrolled, 225 (53.2 percent) of whom had BRCA mutations, making it the largest cohort of BRCA1/2-positive patients with first line mCRPC in any clinical study to date.14

Dr Thorsten Giesecke, General Manager, Commercial Business, Janssen Sciences Ireland UC, said: “Janssen’s legacy in innovation and the development of treatments for prostate cancer spans more than a decade. We remain committed to harnessing the power of science to bring solutions to patients at every stage of their cancer journey. The MAGNITUDE trial was prospectively designed as a precision medicine study to identify the specific population of patients who would most benefit from niraparib with AAP, and potentially increase the likelihood of treatment success. This

Pictured (l-r) at NovaUCD in Dublin are, Darren Stephens, Senior Vice-President and Commercial Head UK and Europe, Qure.ai and Mitchell O’Gorman, CEO, xWave Technologies. (Credit: Paul Sharp, SHARPPIX).

approval marks an exciting step in the right direction, changing the outlook for patients with mCRPC for the better.”

The primary endpoint for MAGNITUDE was radiographic progression-free survival (rPFS), as analysed by blinded central review.1,13 Niraparib plus AAP significantly improved rPFS in all HRR-positive patients (Hazard Ratio [HR] 0.73; 95 percent Confidence Interval [CI], 0.56 to 0.96; p=0.022).3 This improvement was most pronounced in patients with BRCA1/2 gene mutations, where a statistically significant 47 percent risk reduction was observed for rPFS.3 With additional median follow-up at 24.8 months in the BRCA subgroup, rPFS by central review demonstrated a consistent and clinically meaningful treatment effect favouring niraparib plus AAP, with a median rPFS of 19.5 months compared with 10.9 months for placebo plus AAP.1 Additionally, there was a trend towards improved overall survival (OS) with niraparib plus AAP, strong improvement in time to symptomatic progression (TSP) and clinically meaningful improvement in time-to-initiation of cytotoxic chemotherapy (TCC).1

The observed safety profile of the combination of niraparib and AAP was consistent with the known safety profile of each agent.3

Of the patients with HRR gene alterations, 67 percent experienced Grade 3/4 adverse events (AEs) in the combination arm versus 46.4 percent in the control arm.15 The most common grade 3 AEs were anaemia (28.3 percent versus 7.6 percent) and hypertension (14.6 percent versus 12.3 percent) with niraparib and AAP versus placebo and AAP, respectively.15The combination of niraparib and AAP also maintained overall quality of life in comparison with placebo and AAP.3,15

Niraparib is a highly selective poly adenosine diphosphateribose polymerase (PARP) inhibitor.13 Together with AA plus prednisone, the combination DAT regimen targets two oncogenic drivers in patients with mCRPC, namely alterations in the androgen receptor axis and in BRCA1/2.13,16,17 This is the first DAT formulation available in the European Union for patients with mCRPC with BRCA mutations.2 Europe is the first region to approve AKEEGA® (niraparib and abiraterone acetate DAT), for the treatment of patients with BRCA-positive mCRPC, globally.

In February 2023, Janssen submitted a New Drug Application (NDA) to the U.S. Food and Drug

Administration (FDA) seeking approval of this niraparib-based combination for the treatment of patients with BRCA-positive mCRPC.18

ABBVIE CELEBRATE EIGHTH COMMUNITY INITIATIVE

AbbVie, a global biopharmaceutical company which employs approximately 80 people at its company offices in south-west Dublin, celebrated its eighth annual community volunteering initiative recently.

The day-long effort in support of children’s charity Barnardos involved company employees creating 300 activity packs for children going from Early Years Services (aged four-to-five years old) to ‘Big’ School and two different Wellbeing Packs for older children aged eight-to-eleven.

The AbbVie employee activity forms part of the company’s signature Week of Possibilities community volunteering programme. It seeks to empower employees to volunteer whilst at work and personally undertake activities that improve the communities in which AbbVie people work and live.

Barnardos will make 150 Early Years Packs available to children aged four to five who are about to go to school for the first time. Included are pencils, a copybook, eraser, and a whiteboard with markers. Also included are fun items such as stampers, stickers, colouring sheets and additional arts and crafts supplies.

Grow Your Own House

A special feature of the packs is an environmental and sciencefocused activity that allows children to grow their own ‘Sprout House’. AbbVie volunteers cut colourful sponges into size for children to assemble and grow cress from seed. Instructions on how to build their house and grow seeds are also included, alongside helpful pictures.

Two different Wellbeing Packs were assembled for older children accessing services supported by Barnardos. These contain books about how to manage their feelings, educational jigsaws and much, much more. The biopharmaceutical company organised the project in partnership with Volunteer Ireland. The packs will be distributed to Barnardos Services both local to AbbVie’s office in Dublin and across Ireland.

AbbVie is committed to leveraging its science and business expertise to positively influence education in the communities where it is based. All around Ireland, and across the world, it actively engages with schools, colleges, industry, and charity partners to achieve this ambition.

AbbVie believes in making a strong commitment to local communities. Commenting on the project, AbbVie’s General Manager Andres Rodrigo said:

“We are an Irish organisation that works closely with doctors to harness the power of innovation

and science to improve people’s lives. We do that through the provision of medicines that improve outcomes and advance standards of care. Barnardos is a particularly appropriate community partner for AbbVie given the charity was founded by a Dublin-born doctor. The work they undertake on behalf of disadvantaged children in Ireland is outstanding.”

Barnardos CEO Suzanne Connolly said: “Barnardos is delighted to have the support of AbbVie and employee volunteers in creating the Early Years and Wellbeing Packs. These packs will support Barnardos’ programmes which focus on the importance of children’s heart, body and mind, through an holistic approach to education and wellbeing. A huge thank you to the AbbVie team for this donation.”

The event was coordinated by Volunteer Ireland, whose CEO Nina Arwitz joined with AbbVie employees as they created the packs. She said: “The Week of Possibilities demonstrates what’s possible when corporate volunteers come together to work on projects which provide real value in the community. We are delighted to continue our long running partnership with AbbVie supporting their employees to volunteer and make a difference in their communities.”

AbbVie volunteers are pictured with Halina McNabb during the company’s Week of Possibilities initiative