IPN 2023 September

September 2023 Volume 15  Issue 9 PHARMACYNEWSIRELAND.COM

THE INDEPENDENT VOICE OF PHARMACY

FOR HEALTHCARE PROFESSIONAL USE ONLY

ANTI-REFLUX

In this issue: NEWS:

Have you tried nutrition first?

NICE recommends trialling a thickened formula before medication*†1

Overwhelming Support shown for Pharmacy Page 4

MEDICINES: Prescription Medicine in Ireland ‘Revolutionised’ Page 8

SMA Anti-Reflux ®

The only anti-reflux formula that offers easily digestible starch and 100% whey, partially hydrolysed protein to help manage reflux and regurgitation2-6

REPORT:

A thickened formula shown to significantly LEADING nutrition reduce the number of daily regurgitation babyresearch **6 For over episodes 100 years

Scan here to learn more about SMA® Anti-Reflux

An Overview of Medicine Shortages Page 10

FEATURE: Risk Factors for Crohn’s Disease Page 16

CPD: *For the management of frequent regurgitation with marked distress in formula fed infants, following parental reassurance and advice, NICE recommends trialling a thickened formula1. †Alginate therapy **p<0.0001, compared to a standard formula

References: 1. NICE (2015). Gastro-oesophageal reflux disease in children and young people. Available at https://www.nice.org.uk/guidance/ng1. Accessed: August 2023. 2. Billeaud C, Guillet J, Sandler B. Gastric emptying in infants with or without gastro-oesophageal reflux according to the type of milk. Eur J Clin Nutr. 1990 Aug;44(8):577-83. PMID: 2209513. 3. SMA® Anti-Reflux datacard (2022). Available at www.smahcp.co.uk 4. Aptamil Anti-Reflux and Cow & Gate Anti-Reflux datacards. Available at https://www.nutricia.co.uk/hcp/products.html Accessed July 2023. 5. Hipp Organic anti-reflux datacard. Available at www.hipp.co.uk/ healthcare-professionals/. Accessed July 2023. 6. Indrio F, Riezzo G, Giordano P, Ficarella M, Miolla MP, Martini S, Corvaglia L, Francavilla R. Effect of a Partially Hydrolysed Whey Infant Formula Supplemented with Starch and Lactobacillus reuteri DSM 17938 on Regurgitation and Gastric Motility. Nutrients. 2017 Oct 28;9(11):1181. doi: 10.3390/nu9111181. PMID: 29143799; PMCID: PMC5707653.

IMPORTANT NOTICE: We believe that breastfeeding is the ideal nutritional start for babies as breast milk provides a balanced diet and protection against illness for a baby. We fully support the World Health Organization’s recommendation of exclusive breastfeeding for the first six months of life followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to two years of age. We also recognise that breastfeeding may not be an option due to certain medical conditions. Parents should only feed Infant formula for special medical purposes under supervision of a healthcare professional after full consideration of all feeding options, including breastfeeding. Continued use must be assessed by the healthcare professional in relation to the baby’s progress bearing in mind any social and financial implications for the family. Infant formula should always be prepared, used and stored as instructed on the label in order to avoid risks to a baby’s health. This product must be used under medical supervision. SMA® Anti-Reflux is a special formula intended for the dietary management of bottle-fed babies when significant reflux (regurgitation) is a problem. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 12 months of age. If the baby’s reflux does not improve within 2 weeks of starting SMA® Anti-Reflux, or if the baby fails to thrive, the family doctor should be consulted.

SMA® Nutrition UK & Ireland | ®Reg. Trademark of Société des Produits Nestlé S.A

This Publication is for Healthcare Professionals Only

ZRI975_D_08_23 | DENWHS016-2

Management of Cold & Flu Page 39

AWARDS: A Winning Team Page 44

TEAM TRAINING: Cough Page 58

IPN is proud to Launch The People’s Pharmacist 2023 The Search is Now On

Nominating is Easy Email or call Kelly Jo Eastwood on: kelly-jo@ipn.ie / 00353 87 737 6308 OR Aoife Hunter on: aoife@ipn.ie 00353 (87) 337 9258 Closing Date for Nominations: Wednesday, 20th September, 2023

In association with

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Contents

Foreword

Page 5: Investing in Pharmacy must be a ‘Priority’

Readers will notice on the facing page that we have launched our search for The People’s Pharmacist 2023.

Irish Pharmacy News is delighted to announce the search is on to find The People’s Pharmacist for 2023, in association with Panadol; giving the Irish public the opportunity to nominate and vote for, their local pharmacist who has gone above and beyond.

Page 6: New Pharmacy Podcast Page 8: Revolutionising prescription medicines

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Page 12: Unregulated Melanotan 2 deemed ‘not safe’

We will hear stories of compassion and dedication which go above and beyond – resulting in a shortlisting of six of the most deserving finalists. Full details on how to enter are listed in the accompanying advert or get in touch with myself via email at Kelly-jo@ipn.ie for further details.

Page 14: Acknowledging World Heart Day Page 22: Opioid Prescribing Updates Page 28: Preventing Cervical Cancer in children and teenagers

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MANAGING DIRECTOR Natalie Maginnis n-maginnis@btconnect.com

ADVERTISING EXECUTIVE Esther Elliott-Coulter: 00353 (87) 062 2025 Esther@ipn.ie

CONTRIBUTORS

Theresa Lowry-Lehnen Adam Esa Dr Cormac F Mullins Ciara O’Connor Professor Fergal Malone Professor Donal Brennan Professor William Gallagher Damien O’Brien Rebecca Conway Michele O’Brien | Martina Phelan

DESIGN DIRECTOR Ian Stoddart Design PHARMACYNEWSIRELAND.COM @Irish_PharmNews IrishPharmacyNews

In other news on page 8, a sister company of one of Ireland’s most trusted pharmacy chains, Pure Pharmacy, has announced the launch of its DNA testing service, that will analyse patients’ genes and identify variants that may affect their reaction to commonly prescribed medications. Available now in Pure Pharmacy stores nationwide, the revolutionary new service will make it easier for GPs to select appropriate medications and dosages for their patients.

Whist on page 43, we reveal that 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.

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

EDITORIAL/ EVENTS & MARKETING EXECUTIVE Aoife Hunter: aoife@ipn.ie

Elsewhere in this issue, we detail the overwhelming public support for plans to allow pharmacists to prescribe medicines for minor ailments, according to new research by Behaviour & Attitudes (B & A). The Minister for Health Stephen Donnelly has recently appointed an Expert Taskforce to make recommendations to support the expansion of pharmacist roles, including independent prescribing, measures which this research indicates would be welcomed by the vast majority of patients.

The Pharmacy Index 2023 was researched by B&A on behalf of the Irish Pharmacy Union. It found that almost half of the adult population (48% or nearly 1.9 million adults) now visit the pharmacy over a typical week. Read more about this on page 4.

Page 35: Establishing a National Cancer Mission Hub PUBLISHER: IPN Communications Ireland Ltd. Clifton House, Fitzwilliam Street Lower, Dublin 2 00353 (01) 6690562

The People’s Pharmacist Award seeks nominations from across the country, giving patients the opportunity to recognise and salute their local pharmacist. Through this Award, we are enabling the public to have a voice in recognising the unwavering support and spirit that makes pharmacists the backbone of our health service in every community across Ireland.

He says, “The evidence we hope to generate through innovative, data-driven approaches will improve the quality of healthcare to benefit population health.”

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

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

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

I hope you enjoy the issue.

Regulars CPD: COLD & FLU

P39

FEATURE: FOOT CARE

P54

TEAM TRAINING: COUGH

P58

FEATURE: OSTEOPOROSIS

P60

CLINICAL PR:

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PHARMACYNEWSIRELAND.COM

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News

‘Overwhelming’ Support for Pharmacy There is overwhelming public support for plans to allow pharmacists to prescribe medicines for minor ailments, according to new research by Behaviour & Attitudes (B & A). The Minister for Health Stephen Donnelly has recently appointed an Expert Taskforce to make recommendations to support the expansion of pharmacist roles, including independent prescribing, measures which this latest research indicate would be welcomed by the vast majority of patients.

The Pharmacy Index 2023 was researched by B&A on behalf of the Irish Pharmacy Union.

It found that almost half of the adult population (48% or nearly 1.9 million adults) now visit the pharmacy over a typical week.

With 98% of people stating they value the advice pharmacists provide, it also found that nine in ten adults agree that the role of pharmacists is becoming increasingly important.

Amongst the key findings was close to universal support for community pharmacies increasing the range of services they provide.

This includes: • 96% in favour of pharmacists being able to prescribe treatments for minor ailments such as back pain, migraine and indigestion;

• 94% in favour of pharmacists being able to repeat certain prescriptions without recourse to a GP; and • 96% in favour of pharmacists offering a new medicine service to improve adherence to new medicines.

Commenting on the findings Kathy Maher Chair of the IPU’s Pharmacy Contractors said, “There is huge potential for pharmacies to expand the range of healthcare services they provide. As the new Expert Taskforce commences its work it is heartening to see that patients across the country want to avail of these new services.”

“Supporting the sector to provide enhanced healthcare services would deliver a revolution in community care.”

“The pharmacy profession wants to do more for its patients, and it is clear patients would support this. However, achieving this potential will also require addressing the chronic underfunding of pharmacy services. When a pharmacy dispenses a medication on behalf of the state today, they are receiving a lower payment than they did in 2009 but facing much higher costs. This is creating huge pressure on our pharmacy network, which must be addressed before expansions can be realised.

Concluding Ms Maher said “We look forward to engaging with the Expert Taskforce and hope that the recommendations lead to the most ambitious possible expansion of services.”

Pharmacy makes the Top 100 Community pharmacy stores across Ireland are hitting the high notes, with no fewer than being shortlisted in the 2023 Retail Excellence Top 100 Stores Award.

Those who have made the list include four Adrian Dunne pharmacies; Adrian Dunne Pharmacy Arklow, Adrian Dunne Pharmacy Ashbourne, Adrian Dunne Pharmacy Ashford, Adrian Dunne Pharmacy Trim; two Brennans Pharmacy in Buncrana and Creeslough; Cunningham’s Pharmacy in Athlone; Gannon’s Life Pharmacy, Limerick; Hickey’s Pharmacy, Drogheda, Laura Armstrong Life Pharmacy, Arklow; four McCabes pharmacies in Clarehall, Kimmage Rod, Newcastle and Tallaght; McCauley’s Pharmacy in Mahon Point; two Mulligans pharmacies in Gladtsone and Tramore and Reens Life Pharmacy, Millstreet, Cork

Established in 1997 to promote best practice and encourage high standards in the Irish retail industry, the selection process involved stores being visited by a mystery shopper, with those

Four Adrian Dunne Pharmacies have made it to the Top 100 Stores with Retailer Excellence including; e four Adrian Dunne pharmacies; Adrian Dunne Pharmacy Arklow, Adrian Dunne Pharmacy Ashbourne, Adrian Dunne Pharmacy Ashford, Adrian Dunne Pharmacy

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exceeding service and standards criteria making it to the Top100.

These stores will progress into Phase 2 for the Store of the Year Award 2023. The Awards evening take place in November, 2023.

Newborn Screening Programme The Health Information and Quality Authority (HIQA) has published the protocol for its health technology assessment (HTA) of the addition of spinal muscular atrophy (SMA) to the National Newborn Bloodspot Screening Programme. The protocol describes the evidence synthesis approach that HIQA will use to complete this work.

In January 2023, the National Screening Advisory Committee (NSAC) requested that HIQA undertake an assessment of including SMA in the National Newborn Bloodspot Screening Programme. This programme provides newborn bloodspot screening (the ‘heel prick test’) within the first 72 to 120 hours of life and currently screens for nine conditions.

SMA is a rare, genetic condition which causes irreversible damage to the nerves that control movement; this leads to muscle wasting and weakness.

The severity of SMA and the age at which symptoms present vary, with some forms historically resulting in death in early childhood. In recent years, new treatments have become available for SMA with the potential to significantly improve outcomes through earlier diagnosis and treatment.

Dr Máirín Ryan, HIQA’s Deputy CEO and Director of Health Technology Assessment said, “The National Newborn Bloodspot Screening Programme is a successful and important public health initiative that screens infants for rare, but serious conditions to enable early intervention. Screening programmes can offer considerable benefits. They can identify conditions before symptoms begin, enabling earlier access to treatment.”

Dr Ryan continued, “A decision to screen for a condition should always be considered carefully and be based on the best available evidence. Our assessment of screening for SMA will examine how accurate the available screening tests are, the current diagnostic and treatment pathway for children with SMA and if there are any significant ethical, resource or organisational challenges which would impact adding this test to the screening programme.”

News Skin Cancer Awareness A mum of six has bravely revealed the realities of skin cancer treatment in a bid to encourage people to take adequate precautions in the sun.

Deirdre Bonass (56) from Wexford is one of 13,000 people diagnosed with skin cancer in Ireland every year.

She is currently in recovery from treatment for basal cell carcinoma (BCC) skin cancer and wants to encourage anyone heading on holidays or out in the Irish sun to follow the Sun Smart Code.

Deirdre is also highlighting the cost of sun cream as an issue for families and urging Government to follow the Irish Cancer Society’s position on making it more affordable.

Dr Blaithin Moriarty, Consultant Dermatologist at St. Vincent’s Hospital and Associate Professor, UCD School of Medicine, said, “Skin cancer is the most frequently diagnosed cancer in Ireland and skin cancer rates trebled between 1995 and 2020. Certain types of skin cancer are predicted to at least double between 2020 and 2040. While the majority of skin cancers, when caught at an early stage are not life threatening, treatment is frequently unpleasant, distressing and disfiguring. 90% of skin cancers are induced by UV light and are, as such, preventable.”

Kevin O’Hagan, Cancer Prevention Manager at the Irish Cancer Society, added,“Nearly nine out of every 10 cases of skin cancer are caused

by UV rays from the sun or sunbeds. Sun safety is vital and that means protecting your skin, wherever you are, home or abroad. In the midst of record temperatures across Europe, in many typical holiday destinations for Irish tourists, we are particularly emphasising the need to follow the Sun Smart Code stay in the shade at peak times and stay hydrated.

“In our pre-budget submission, we at the Irish Cancer Society would absolutely echo her personal calls for Government to take action and ensure sun cream is more affordable and to ensure protecting your skin is not out of reach for struggling families in the middle of a cost-of-living crisis. Through cases like Deirdre’s, you can see exactly why Government action on this is urgently required.”

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Budget 2024 for Pharmacy Investing in Community Pharmacies Must be a Priority Budget 2024 should be used as an opportunity to address the underfunding of Ireland’s community pharmacy sector, to prepare it for future growth. This was the central message of the Irish Pharmacy Union’s (IPU) Pre-Budget Submission that was delivered to Government recently. With Minister Donnelly seeking recommendations on the future expansion of Ireland’s pharmacy services the IPU has said it is essential that the upcoming Budget ensures the sector’s long-term viability.

Tom Murray, Pharmacist

Outlining the key recommendations of the IPU’s Pre-Budget Submission Tom Murray IPU Honorary Treasurer said, “Research from Fitzgerald Power has revealed the stark and concerning fact that right now one in 10 of Ireland’s pharmacies is lossmaking. This is the result of years of underfunding and needs to be addressed to facilitate the sector’s expansion. For each medicine a pharmacy dispenses on behalf of the state, the state is paying pharmacies 24% less today than in 2009. This is clearly not feasible in the context of soaring costs.”

The central recommendation of the IPU in Budget 2024 is to restore funding to the sector via a new flat rate dispensing fee of ¤6.50. “This would represent an increase of just 50 cents on the rates that pertained in 2009.

This modest increase would be transformational for the sector and allow the levels of investment required to expand pharmacy services nationwide.”

Mr Murray says there is huge potential for the sector to alleviate problems across the health sector. “An expert group has been convened to make recommendations on how to expand pharmacy services. At a time when GPs are consistently

raising concerns about their capacity, utilising the pharmacy sector to the maximum would provide a huge boost to community care.

“Investment should be provided for a Minor Ailment Scheme that would allow pharmacies to dispense medications for a defined list of self-limiting conditions directly to medical card patients. Similarly, the new scheme that provides free contraception to women, which is due to be expanded next month, should be available direct from pharmacies. Both measures would reduce wait times for patients and free up precious GP time.”

“Pharmacists are the only healthcare profession yet to receive restoration to pay

cuts administered during the pandemic,” said Mr Murray. “Next year will mark 15 years since the first cuts and while all other professions have had increased funding pharmacies are left to continue to grapple with the current cost conditions with no increased state investment. The profession must be treated equally and to prevent future chasms the link to public sector pay should also be restored.”

Concluding, Mr Murray said that Budget 2024 represents a unique opportunity. “We have a profession that is ready and waiting to do more. We have a state with a very clearly defined need to expand community-based care. The large budget surpluses predicted should mean there is no logical reason not to invest in pharmacy and expand pharmacy care.”

Date for your Diary The Irish Pharmacy Union National Pharmacy Conference takes place this year on Saturday, 21st October in Johnstown House Estate in Enfield, Co. Meath.

This event, plays a vital role in supporting pharmacists with CPD, covering a range of clinical and business topics.

This is the first face to face conference since 2019 and will also mark the start of the celebrations of the 50th Anniversary of the IPU. The event will provide support to the pharmacy profession through an extensive programme of events, education sessions and ‘The Great Debate’.

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Pharmacist and owner of Milltown totalhealth Pharmacy Sheena Mitchell, The Irish Podcast launched in March of this year.

News

6 from totalhealth and Haven pharmacies around Ireland have featured on The armacists macy Podcast to have conversa�ons giving clarity around key topics specialising in health, ‘DUMP’ Pharmacy Podcast Launches in Ireland and disease management.

As Ireland’s largest group of independent community es, Haven and totalhealth Pharmacists areofpassionate about empowering pa�ents with the Medicines Hosted

by Pharmacist and owner Milltown totalhealth Pharmacy Sheena e and resources theyIrish needPharmacy to supportPodcast their health.

Mitchell, The launched in March of this year.

Following a successful DUMP Campaign in Waterford in May, the HSE/South East Community Healthcare is asking the public to avail of a free service to dispose of unused medication over the next few weeks in Co. Wexford.

owner of enced Podcaster herself, Sheena is Pharmacist a naturalandwhen Milltown totalhealth Pharmacy ng Pharmacists from the group onSheena their Mitchell different areas of The podcast features high quality health informa�on, o you in a casual, chaty manner which makes for easy The aim of the podcast is to share a wealth of knowledge teners. This podcast benefits pa�ents, their families and hcare providers by highligh�ng health and wellness management. As Ireland’s largest n in a holis�c and encouraging way. group of independent community

The free ‘Dispose of Unused Medicines Properly’ (DUMP) Campaign will enable anyone to bring unused or out of date medicines to a designated “DUMP” site at the HSE’s Vaccinations Centre on the St. John’s Hospital campus in Enniscorthy.

pharmacies, Haven and totalhealth Pharmacists are passionate about covered are relevant to a wide demographic in terms of age, gender, or ac�vity level. Post empowering patients with the The topics covered are relevant knowledge and resources they the relevance of self- care has come to the fore and pa�ents are huge ininterest in Among unused and out of date to a showing wide demographic terms need to support their health. medicines brought to the facility of age, gender, or activity ually tailored approach to managing their health and wellbeing.

Topics covered solevel. far when recently operated at the An experienced Podcaster Post pandemic the relevance of Vaccination Centre herself, Sheena is a natural when selfcare has come to the fore TI preven�on and treatment, signs and symptoms of stress and how to manage it and the Waterford were some 32,800 tablets/pills. interviewing Pharmacists from the and patients are showing huge on their in different areas of interest inaan individually tailored e of high-quality sleep. With moregroup episodes the pipeline covering wide variety of expertise. The podcast features approach to managing their health Explaining why people should ated topics, this is the one to watch. now on Spo�fy, and Apple podcasts or wherever take this opportunity to safely highAvailable quality health information, wellbeing.

Topics covered brought to you in a casual, chatty so far include UTI prevention and dispose of unwanted medicines, ur podcasts. manner which makes for easy treatment, signs and symptoms HSE Pharmacist Fiona Maher listening. The aim of the podcast of stress and how to manage it says, “The HSE urges people to Expert pharmacists from is to share a wealth of knowledge and the importance of high-quality take this opportunity to get rid of totalhealth and Haven pharmacies with all listeners. This podcast sleep. With more episodes in the out of date or unused medicines. around Ireland have featured on benefits patients, their families pipeline covering a wide variety Medication can pose a real The Irish Pharmacy Podcast to and even healthcare providers by of health-related topics, this is hazard in the home, particularly have conversations giving clarity highlighting health and wellness the one to watch. Available now to children or other vulnerable around key topics specialising information in a holistic and on Spotify, Apple podcasts or people. Clearing out your in health, wellness, and disease encouraging way. wherever you get your podcasts. medicine cabinet is something that should be done on a regular basis. Check all the dates and remove anything that is out of date or no longer required.

Medicines have an expiry date for the same reason food does An international team of scientists led in Trinity College by Professor John O’Leary, and out of date medicines could Consultant Histopathology, School of Medicine, and Professor Doug Brooks at the do more harm than good.”

Breakthrough in Men’s Health

University of South Australia (UniSA) has made a landmark breakthrough which will assist pathologists when visualising prostate cancer in patient tissue samples.

The team has identified three new biomarkers which will allow pathologists to determine which patients require immediate, radical treatment compared to those who need close monitoring.

With more than one million men diagnosed with prostate cancer worldwide each year, the research breakthrough is significant.

Prostate cancer incidence in Ireland is currently the highest in Europe (GLOBOCAN, 2020).

The number of deaths from prostate cancer was 554 per year, during the period 20162018. This represents 20.2 deaths per 100,000 of the population, attributing to 12% of male cancer deaths (NCRI, 2021).

The UniSA-based team has collaborated with the Australian company Envision Sciences

on the technology to improve patient management and treatment outcomes.

Speaking on the discovery, Professor John O’Leary said, “This discovery made with colleagues from the University of South Australia, University of Adelaide, Royal Melbourne Institute of Technology, and the Prostate Cancer Research Consortium (PCRC) - the biobank for which is maintained and curated by colleagues at UCD - marks an important breakthrough in prostate cancer diagnostics and prognostics and offers for the first time a precision medicine approach in prostate cancer diagnostics allowing pathologists to a). define the entire extent of the prostate cancer in a specimen; b). establish whether it is indolent

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or aggressive disease and define the risk of disease recurrence and metastasis and c). define the metabolic profile of the tumour to decide whether it is using sugar or lipid metabolism, which also defines outcome of the disease.”

Professor Doug Brooks (UniSA), also said, “It is anticipated this will lead to long-term improvements in the way prostate cancer is diagnosed and graded.

“The biomarkers are remarkably sensitive and specific in accurately visualising the progress of the cancer and confirming its grade.

This discovery has led to the commercial development of a test designed to determine how advanced and aggressive the cancer is and whether immediate treatment is needed.”

“It’s important that medicines are disposed of correctly.

Disposing of medicines in the rubbish bin means that they could be accessed by children or pets. Flushing medicine down the sink or toilet means that medicine residues can enter the environment and even small amounts of medicines can affect freshwater ecosystems.”

“Also, older people or someone with an ongoing illness can often have large amounts of medicine at home. Whatever the reason, the HSE/South East Community Healthcare urges householders to take this opportunity to dispose of these unwanted medicines (prescription or overthe-counter) safely.

Future of pharmacIE Friday, 20th October 1pm - 4pm RCSI, 123 St Stephen

Connect with future pharmacists at APPEL's exclusive careers event. Book your ticket now!

TICKETS

8

News

Revolutionising Prescription Medicine in Ireland A sister company of one of Ireland’s most trusted pharmacy chains, Pure Pharmacy, has announced the launch of its DNA testing service, that will analyse patients’ genes and identify variants that may affect their reaction to commonly prescribed medications. Available now in Pure Pharmacy stores nationwide, the revolutionary new service will make it easier for GPs to select appropriate medications and dosages for their patients, and as a result, improve medical care.

Dave Beggs, Founder of GeneCheck and Pure Pharmacy

beneficial for those who are on multiple medications or already know they are suffering from side effects from medications.

Speaking on the innovative testing service, GeneCheck founder and CEO of Pure Pharmacy, David Beggs comments,“GeneCheck testing reduces the ‘trial and error’ approach to prescriptions, avoids some of the risks of serious side effects, leads to more personalised treatment and

The tests, which have been developed and refined in the US and Europe over the last few decades were not widely available, until now. GeneCheck will allow people in Ireland to access such testing through their nearest Pure Pharmacy store.

relevant genetic variants, drawing attention to any medicines that need special attention. The analysis will be provided by email to patients within two weeks and explained in preliminary detail by one of GeneCheck’s’ healthcare specialists.

Patients can expect a non-invasive procedure, with a simple saliva sample taken by the pharmacist, and sent confidentially and anonymously to one of Europe’s leading pharmacogenomics (PGx) laboratories. The sample is then analysed by Polymerase Chain Reaction (PCR) to identify any

Once patients have their results, they can consent to have the report shared with their doctor, with whom they can discuss any proposed alterations to their prescriptions. The report will be relevant when their doctors are considering entirely new prescription and will be particularly

ultimately saves patients and GPs both time and money.

“As a pharmacist, I’ve regularly seen patients who felt their prescribed medication didn’t agree with them and I wanted to find a solution. Ireland deserves to have access to world-leading healthcare technologies that offer the best quality of life possible – that’s why we founded GeneCheck.”

David, who is also a current 2023 EY Entrepreneur of the Year Finalist, continues, “We believe Pure Pharmacy will be the first pharmacy in the country to offer this service in-store, with hopes to work in partnership with some of the country’s leading healthcare providers in the near future.”

Pharmacy Engagement in TB Three priority actions to engage pharmacies more effectively in identifying people with tuberculosis, especially in high-burden settings, are proposed in a paper published recently in BMJ Global Health.

The authors include FIP CEO Catherine Duggan and FIP’s lead for practice development and transformation Gonçalo Sousa Pinto. The three actions are: o Granting access to clear and concise pharmacy-specific guidance for the management of people presenting with cough. o Establishing structured

mechanisms for pharmacies to support people with presumptive TB, for example regarding screening. o Embracing digital technologies to improve the linkage between pharmacies and TB programmes and surveillance.

The paper also includes an infographic to support

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pharmacists in managing cough and other TB-presumptive symptoms in the pharmacy.

“To date, there is little specific guidance or practical tools available on TB management for pharmacists, co-designed with pharmacy professionals or societies. To address this gap, we set about creating a simple,

easy-to-understand and evidencebased infographic to use as an educational tool,” the authors write. The number of people with TB that are not reported is growing globally, up from 2.1 million in 2019 to 4.1 million in 2021. Often being the first point of access to care, community pharmacies are strategically positioned to identify these people, the authors add.

The end of erectile problems?

Touch wood.

Sidena. Your new firm favourite.

Sidena 50mg Tablets are now available over the counter in a 4 and 8 pack.

ABBREVIATED PRESCRIBING INFORMATION Product Name: Sidena 50 mg Tablets.

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

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

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

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

Contraindications: Hypersensitivity to sildenafil or any of the excipients. Concomitant with ritonavir, nitric oxide donors or nitrates in any form, guanylate cyclase stimulators e.g. riociguat. In patients that sexual activity is inadvisable (e.g. severe cardiovascular disorders such as a recent (6 months) acute myocardial infarction (AMI) or stroke, unstable angina or severe cardiac failure). Refer these patients to a doctor. Patients with loss of vision in one eye due to NAION. Known hereditary degenerative retinal disorders. Severe hepatic impairment.

Hypotension. Anatomical deformation of the penis. 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 sildenafil. Most, but not all, of these patients had pre-existing cardiovascular risk factors. Sildenafil has vasodilator properties, resulting in mild and transient decreases in blood pressure. Caution: Patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). Advise patients that in case of priapism, prolonged erections (longer than 4 hours) or sudden visual defect, they should stop taking sildenafil and consult a physician immediately. Administer to patients with bleeding disorders or active peptic ulceration only after careful benefit-risk assessment, as there is no safety information available.

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

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

Marketing Authorisation Holder: Rowex Ltd, Bantry, Co. Cork. Marketing Authorisation Number: PA 0711/170/002. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417 E-mail: rowex@rowa-pharma.ie Adverse events should be reported. Reporting forms and information can be found on the Legal Category: Not subject to medical prescription.

HPRA website (www.hpra.ie) or by emailing Rowex pv@rowa-pharma.ie Date of Preparation: Aug 2022 Date of preparation: (10-22) CCF: 25156

Supply status: Supply through pharmacies only.

10

News

Medication Shortages in Ireland Medications shortages is a wide spread issue affecting pharmacy in Ireland today. Moreso, due to the interconnectedness of the medication supply chain, this has unravelled a complex web of challenges. In recent times, Ireland has witnessed a concerning rise in medication shortages. At present, according to the HPRA list of medication shortages, there is over 300 known shortages. This has resulted in increased pressures on pharmacies, healthcare systems and of course, patient access to medications. Being a superintendent pharmacist over a chain of pharmacies and having a specialist interest in medication wholesaling, I can categorically confirm this strain. The availability of essential medication is fundamental for healthcare, as it ensures that patients receive timely and effective treatment. A number of factors has led to the emergence of a complex web that unfortunately, has far reaching implications for public health.

Written by Adam Esa MPSI MPHARM MBA aesa@localpharmacy.ie the interconnectedness of medication supply chain, this could be an unintended consequence of politics.

In order to understand the reasons for medication shortages in Ireland, it is important to understand the root causes.

One such cause is that of global supply chain disruptions.

Many medications and active pharmaceutical ingredients are manufactured overseas, making Ireland vulnerable to disturbances.

Factors relating to political, economic, social, technological and environmental issues can all impact the availability of crucial medication. One such crises includes export bans and restrictions. During time of emergencies, many countries implement export bans or restrictions on critical medications to ensure domestic availability.

Whilst, these measures are intended to safeguard local populations, for smaller countries such as Ireland, this can disrupt the medication supply chain and so availability to our own demographic. Export bans come about due to a variety of reasons.

Domestic supply priority is one of these which governments implement where demand is greater than supply. International relations also factor into export restrictions and so some countries may use bans as part of broader policy objectives.

Whilst this may not directly impact Ireland, again due to

Active pharmaceutical ingredients are the key components which make medications effective.

Contributory factors which lead to shortages include capacity constraints. As pharmaceutical manufacturing facilities have a limited capacity for production, if a demand for certain medication increase suddenly, then the existing capacity might not be sufficient to meet the increased demand. Most recently, this has been the case with Ozempic which has become popular for treating weight loss.

Consequently, as there has been a huge demand for Ozempic for the treatment of weight loss, this has caused an stock issue in the production being enough to meet both diabetic and weight loss demand. Hence, prescribers may switch to alternative medication which then causes a domino effect of stock issues.

Addressing medication shortages requires a coordinated effort involving the government, pharmaceutical companies, healthcare providers and patient advocacy groups. Whilst largely, it is out of our hands, pharmacies can improve their own current situation through diversifying their suppliers and building relationships with alternate wholesalers. Smaller, independent wholesalers often have the benefit of being flexible and innovative in accessing medications which can prove quite difficult to get.

This is just one small improvement method. Communication and transparency between all relevant stakeholders will allow for us to communicate to patients and prescribers regarding medication availabilities. Medication shortages

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is a challenging issue that requires multifaceted approach to resolve.

By implementing strategies and working collaboratively though, then Ireland can take significant steps to ensuring a more stable and reliable medication supply for the public.

60% Affected by Shortages 60% of Ireland’s population has been impacted by medicine shortages in the last year, with almost half of the country’s population deeply concerned by the deteriorating situation, new research has found.

It comes as the number of medicines out-of-stock in Ireland has reached a new record high of 289 as the scale of the shortages of vital medicines continues to worsen for Irish patients.

The latest Medicines Shortages Index shows that in the past four weeks alone, the number of medicines unavailable across the State jumped by almost 50, the largest single monthly increase recorded. Medicine shortages have increased by 50% in just six months and 65% in 12 months.

Among the medicines out-of-stock include low dose packs of Aspirin 75mg, which is dispensed around 4 million times per year in Ireland.

Others out of stock include medicines to treat blood pressure, high cholesterol, common

antibiotics, medicines for depression, anxiety and insomnia together with a number of eye drops and topical creams.

Separately, a survey of 1,200 people on their experiences of medicine shortages, conducted

by Amárach Research and commissioned by Azure Pharmaceuticals, reveals for the first time the impact medicine shortages are having on the public.

It found that three out of five patients have experienced medicine shortages, with over half being told on more than one occasion by a pharmacist in the last 12 months that the medicine they were seeking was not in stock.

56% of Irish adults said they were aware of the medicine shortages crisis that Ireland has faced over the past year, with 48% of the population reporting a high level of concern about the scarcity of various medicines.

Out of the patients who encountered medicine supply issues at a pharmacy, 44% had difficulties obtaining prescription medicine, 24% faced issues with over-the-counter (OTC) medicine, and 31% encountered shortages for both types of medications.

The cohort most worried by the lack of availability of medicines are females in the age category of 35-44, according to the research findings.

DON’T LET PAIN HOLD YOU BACK

ESSENTIAL INFORMATION *To verify contact verify@perrigo.com 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 14

12

News

Pharmacy Advice on ‘Unsafe’ Products Community pharmacists and their teams are being urged to remind the public that the unregulated substance Melanotan 2 is not safe for use and may cause serious, long-term damage to health.

HPRA Director of Compliance Grainne Power good to be true, it is likely that they are. Serious side effects of taking Melanotan 2 include the development of new moles, darkening of existing moles and freckles, potential loss of vision, muscle tremors, stroke and anaphylaxis.” Ms Power said.

Consumers should be aware that Melanotan 2 is not authorised by the HPRA or any medicines regulator to treat any condition.

Despite how it may be presented, it is not a cosmetic product. The HPRA advises anyone using Melanotan 2 to stop using it immediately and to contact medical professionals regarding potential health concerns.

Often described as a self-tanning aid, the product is also referred to as Melanotan, Melanotan II or MT2. It is commonly sold as an injectable powder or in the form of drops and nasal sprays.

The Health Products Regulatory Authority (HPRA) is also concerned that products containing Melanotan 2 are increasingly being targeted towards young people by using bright colours, flavours, and branding. The HPRA will take action against individuals using social media and e-commerce to advertise and supply Melanotan 2 containing products, including the removal of content and accounts, and prosecution activity when there is significant risk to public health. In this regard, the HPRA continues to engage with e-commerce and social media

platforms with the goal of limiting the sale and promotion of these untested products.

According to Grainne Power, Director of Compliance with the HPRA, this substance continues to be advertised for cosmetic purposes online despite known side effects. To protect the public, the HPRA works to remove these advertisements with a focus on stemming the supply of Melanotan 2. It is also important to raise awareness and inform people of the dangers of using this product.

“A substance like Melanotan 2 poses a threat to someone’s health. There is no safety data to support its use, with no guarantees as to its quality, safety or effectiveness. If products advertised online seem too

Ms. Power continued, “As it is intended to be inhaled or injected, it cannot be classified as a cosmetic because it results in an action within your body. We urge consumers to carefully consider and question both what they are seeing online and the motivation of the individuals who profit from the sale and promotion of this substance. There are no legitimate suppliers of Melanotan 2 and those that do so illegally do not have your best interests or your health in mind. Taking this product simply puts your health at risk.”

The HPRA has noted a marked increase in activity on social media illegally advertising the sale and promotion of Melanotan 2 products. Between July 2022 and June 2023, the HPRA has removed over 500 social media or e-commerce listings relating to Melanotan 2. This is a noticeable escalation in activity when compared to a combined total of less than 500 listings removed across the previous two years.

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.

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.

PHARMACYNEWSIRELAND.COM

Acting ‘FAST’ Campaign From Kerry to Wexford, Sligo to Carlow, Limerick to Louth, and throughout many more counties in Ireland, the pubic were busy this July highlighting the Irish Heart Foundation’s stroke awareness campaign and making a difference in their community.

First responders, local businesses, hospital staff, libraries, and leisure centres and gyms were amongst the many who responded to the call to host a local #actFAST event in their community to share information on the key signs of stroke and the importance of time in getting to hospital quickly when someone suspects they or someone else may be having a stroke.

The Irish Heart Foundation launched the 2023 F.A.S.T. campaign in February following the release of figures from the National Stroke Audit in January that showed that only 58% of stroke patients were getting to the hospital within the recommended 4.5 hours from symptom onset to receiving specialised clotbusting treatment. Further IPSOS research by the Irish Heart Foundation revealed that the amount of people who recognised the vital F.A.S.T signs was declining, with just one in 10 knowing what F.A.S.T. stood for.

Coffee mornings, shopping centre desks, county fairs, library displays, and even an underwater scuba photo shoot were just some of the ways in which community event holders decided to mark their #actFAST awareness drive, many posting their events on social media with #actFAST. Irish Heart Foundation F.A.S.T Campaign Project Manager, Pauline O’Shea commented, “It has been phenomenal to see the uptake of our ‘Host and Share’ #actFAST request in communities all over Ireland. We thank every group who held an event up and down the country.

Each person’s effort will no doubt save the lives of many stroke patients in Ireland in the future.

Two million brain cells die every minute during stroke. The faster people can get to hospital for specialised clot-bursting treatment the more of the patient can be saved.

For pharmacists only

Helping patients forget the itchy rash of chicken pox...

– Piriton delivers effective relief for a range of allergies and allergic skin conditions. It now also can be used to relieve the itchy rash of chicken pox - helping little ones get back to being themselves again.

chlorphenamine maleate

Product Information Piriton 4mg Tablets (Chlorphenamine maleate). Indications: Symptomatic control of allergic conditions. Also, for symptomatic relief of itch associated with chicken pox. Dosage and method of administration: Minimum dosing interval 4 hours. Adults and children 12 years and over: 1 tablet every 4 - 6 hours (maximum of 6 tablets in 24 hours). Elderly: 1 tablet every 4 - 6 hours (maximum of 3 tablets in 24 hours). Children 6 - 12 years: 0.1mg/kg or 1/2 a tablet every 4 - 6 hours (maximum of 6 half tablets in 24 hours). Children under 6 years: Not recommended. Do not use for more than 2 weeks without consulting a doctor. Contraindications: Hypersensitivity to ingredients. Pre-coma states. Patients who have been on MAOI therapy within previous 14 days. Precautions: May act as cerebral stimulant in children and adults, with children and elderly more likely to experience the neurological anticholinergic effects and paradoxical excitation. Use with caution in patients with severe renal or hepatic impairment, epilepsy, severe hypertension and cardiovascular disease, raised intra-ocular pressure, prostatic hypertrophy, bronchitis, thyrotoxicosis, bronchiectasis and bronchial asthma. May cause drowsiness, dizziness, blurred vision and psychomotor impairment which may seriously affect ability to drive and operate machinery. Avoid alcohol and seek advice before using concurrently with sedative drugs. Avoid in elderly with confusion. Should not be used with other antihistamine containing products. Contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine. Side effects: Sedation, somnolence, disturbance in attention, abnormal coordination, dizziness, headache, blurred vision, nausea, dry mouth, vomiting, abdominal pain, diarrhoea, dyspepsia, fatigue, chest tightness, blood dyscrasias, hepatitis including jaundice, allergic reactions including anaphylaxis, angioedema, anorexia. Legal category: Pharmacy Only. Product Authorisation Number: PA 0678/080/001. Marketing Authorisation Holder: Haleon Ireland Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. Full product information is available in the SPC. Additional information is available upon request. Text prepared: June 2023.

Trade marks are owned by or licensed to the Haleon group of companies. PM-IE-PIRI-23-00005

14

News

Celebrating World Heart Day Every year, over 17 million people die from heart disease. As a way to fight this, the World Heart Federation created World Heart Day. It’s an event held every year on September 29. the global pediatric and adult congenital cardiac community gathered in Washington, D.C., at the 8th World Congress of Pediatric Cardiology and Cardiac Surgery. Ahead of this meeting, the community has issued an urgent call to action for all governments, all health and development agencies, and the world research and academic community to protect and promote the health of all people with pediatric and congenital heart diseases.

The World Heart Federation stated, “Accelerating progress to address the burden of pediatric and congenital heart disease globally is in line with the 2030 Global Agenda for Sustainable Development (SDG3). We believe that the existing gross inequity in the health status of people with pediatric and congenital heart disease, particularly in LMICs, is politically, socially, and economically unacceptable, and is therefore of concern to all countries. Long-term investment into the lifelong well-being of children should be a guiding value for investments in health and a key priority.

World Heart Day is observed and celebrated annually on September 29, with the aim of increasing awareness of cardiovascular diseases and how to control them to negate their global impact.

The international holiday was established by the World Heart Federation in collaboration with the World Health Organization.

The president of the World Heart Federation from 1997 to 1999, Antoni Bayés de Luna, had conceived this idea. The first celebration of the annual event took place on September 24, 2000, and, until 2011, World Heart Day was observed on the last Sunday in September.

Cardiovascular diseases (CVD) are the most common cause of death globally. An estimated 17 million people die from CVD every year.

Coronary heart disease or strokes were the major causes of these deaths. A common misconception about CVD is that it impacts more people in developed countries who are more reliant on technology and

lead sedentary lifestyles. But more than 80% of the deaths occur in middle-income and low-income countries. Fortunately, the main causes of cardiovascular disease are modifiable factors, which include lack of exercise, smoking, and a poor diet. Economic systems of countries are also majorly impacted by cardiovascular diseases — the cost of treatment is high and failure to treat the diseases timeously results in loss of productivity and long absences from work.

More than 90 countries take part in this international observance every year. As a result, World Heart Day has proven to be an effective means for disseminating information about CVD. The high level of involvement from governments and organizations is most important for developing countries, which are heavily affected by these diseases.

In other news from the World Heart Federation, on 27 August 2023,

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“We hereby call upon the global community in general, and every responsible government, for an effective policy response supported by adequate financial investment to address the needs of all with pediatric and congenital heart diseases. To this end, we recommend to governments, multilateral organizations (the World Health Organization, the United Nations Children’s Fund, the World Bank and others), funders, professional societies, research and teaching institutions, civil society, and the private sector, the following key actions”: Increase Capacity 2030 Goal: The timely diagnosis treatment and lifelong care of pediatric and congenital heart disease will be integrated into all health system strengthening and surgical scale up plans.

• Domestic and global investments to increase capacity for pediatric and congenital cardiac care at secondary and tertiary hospitals.

• Harness private sector capacity and innovations in areas

of digital, primary care and diagnostics, task shifting if available.

• Support of local referral networks by ministries of health and regional academic institutions to improve early diagnosis, surveillance, and lifelong care of heart disease, and to develop diagnostic and treatment guidelines for low resource settings.

• Universities, NGOs (Non Governmental Organizations) and teaching hospitals should invest in multi year partnerships focusing on leadership, infrastructure development and training to increase the technical capacity and financial sustainability of local hospitals.

Build the Cardiac Workforce 2030 Goal: Health professionals will be able to recognize the basic signs and symptoms of congenital and rheumatic heart disease Accredited pediatric cardiac training programs will be available in all countries Ministries of health, finance, and education, and regional professional bodies collaboration to: • Evaluate workforce needs in pediatric and congenital cardiac care.

• Develop accredited pediatric and congenital cardiac training and education centers and programs that include developing the technical and leadership capacity of specialist pediatric cardiac nurses, physicians, pharmacists, perfusionists, and respiratory therapists, and others.

• Develop pediatric and congenital cardiac workforce strengthening plans with appropriate recruitment and incentivization to minimize attrition, promote career satisfaction and skills retention in the nursing and pediatric cardiac care professions.

• Support the careers of existing pediatric and congenital cardiac care professionals and build mentorship programs and viable career path options for the next generation.

Strengthen your body’s shield HIGH in 10 vitamins & minerals each contributing to the normal function of the immune system while supporting your mind and body.

With added Vitamin A for Immunity* With added Vitamin D for Bone Health** Karl Henry Fitness Expert, Radio & TV Broadcaster, Author and Columnist

Immunity support

ENERGY RELEASE

Pharmacy only brand To place an order, contact your Clonmel Healthcare Area Representative or call our freephone order line on 1800 262626 *www2.hse.ie/conditions/vitamins-and-minerals/vitamin-a **www2.hse.ie/conditions/vitamins-and-minerals/vitamin-d

Mental performance

Suitable for Adults over 18 years. Food supplements are not intended to be a substitute for a balanced and varied diet and / or a healthy lifestyle.

Always read the label. Distributed in Ireland by Clonmel Healthcare Ltd. www.clonmelhealthcare.ie | 2023/ADV/PHA/154H

16

Crohn’s Disease

Overview and Risk Factors for Crohn’s Disease Crohn’s disease (CD) is a chronic idiopathic inflammatory bowel disease, with a complex aetiology involving genetic, environmental, and immunological factors. It is characterised by recurring episodes of inflammation, ulcerations, and strictures, leading to a wide range of symptoms and complications.

An interview with Theresa Lowry Lehnen, RGN, RNP, PhD, Clinical Nurse Specialist and Associate Lecturer with South East Technological University

Over 40,000 people in Ireland are living with inflammatory bowel disease (IBD). Of these approximately 20,000 people are affected by colitis and Crohn’s Disease. Crohn’s disease can affect people of any age but usually starts between the ages of 15 and 35, while a second smaller peak can occur from the ages of 50s to 70s. CD affects men and women equally, with a slight female predominance in adult onset Crohn’s disease. Incidence and prevalence are higher in high income countries and in urban areas, with a high incidence in Northern Europeans and among the Ashkenazi Jewish population.

IBD is complex and costly, and its increasing prevalence places a greater stress on health care systems.

We spoke with Theresa Lowry Lehnen, Clinical Nurse Practitioner and Associate Lecturer South East Technological University to find out more about the diagnosis, management and outlook for this condition.

or extra intestinal manifestations (EIMs) which can affect the skin, joints, eyes, liver, blood vessels, and kidneys. Arthritis is the most common EIM affecting up to 25% of patients with CD. There is no cure and most patients experience bouts of remissions and relapse at unpredictable times.

“In Crohn’s disease, the inflammation extends through the entire thickness of the bowel wall from the mucosa to the serosa.

The disease runs a relapsing and remitting course. With multiple relapses, it can progress from an initially mild or moderate inflammatory condition to a severe penetrating and stricturing disease. CD has a significant impact on the quality of life of affected individuals, necessitating early diagnosis and appropriate management strategies.”

Theresa told us, “Crohn’s disease can affect any part of the gastrointestinal tract. 50% of patients have terminal ileum and colon involvement, while 30% have small-bowel only involvement, and 20% of cases are isolated to the colon. In addition, 25% of patients experience perianal complications including fissures and fistula. Less frequently (<10%), patients present with isolated perianal complaints, upper gastrointestinal disease,

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Pathophysiology The pathophysiology of Crohn’s disease is multifactorial in nature, involving genetic predisposition, infectious, immunological, environmental, and dietary factors.

Theresa adds, “A major role is played by alterations at the level of immunity and inflammation. Innate immunity is involved in terms of defects in the mucous barrier (MUT2 and FUT2 genes) while adaptive immunity relies on a TH1 lymphocytic response and TREG cells mediated by cytokines like TNF-α, IL-12, IL-34 and IL-23. The increased migration to the sites of inflammation is also determined by a reshaping of the extracellular matrix through the action of metalloproteins MMP-1 and MMP-3 and the overexpression of adhesions molecules such as MAcCAM-1 and integrin α4β4.

“The characteristic transmural inflammation can include the entire GI tract from mouth to the perianal

area; although it most frequently involves the terminal ileum and right colon. The initial lesion starts out as an infiltrate around an intestinal crypt. This leads on to ulceration first in the superficial mucosa and then the deeper layers.

“As the inflammation progresses, non-caseating granulomas form involving all layers of the intestinal wall. It can develop into the classic cobblestone mucosal appearances and skip lesions along the length of the intestine sparing areas with normal mucosa. As the flare of Crohn settles, scarring replaces the inflamed areas of the intestines. Granuloma formation is very common in Crohn’s disease but absence does not exclude the diagnosis. Ongoing inflammation and scarring can lead to bowel obstruction and stricture formation. Crohn’s disease is also associated with enterovesical, enteroenteral, enterocutaneous, and enterovaginal fistulas.”

YOUR ALL-IN-ONE With all the benefits you expect from an adalimumab biosimilar, and more Patient friendly:

Citrate-free and concentrated formula with a 50% lower injectable volume* to reduce pain following injection1,2

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40 mg

40 mg

The new adalimumab biosimilar from CLONMEL HEALTHCARE1

THE MEDICINES MANAGEMENT PROGRAMME RECOMMENDS HUKYNDRA AS A BEST VALUE BIOLOGICAL MEDICINE FOR ADALIMUMAB3 ABBREVIATED PRESCRIBING INFORMATION. Hukyndra 40 mg solution for injection in pre-filled syringe. One 0.4 ml single dose pre-filled syringe contains 40 mg adalimumab. Hukyndra 40 mg solution for injection in pre-filled pen. One 0.4 ml single dose pre-filled pen contains 40 mg adalimumab. Indications: 1) Rheumatoid arthritis 2) Juvenile idiopathic arthritis 3) Axial spondyloarthritis 4) Psoriatic arthritis 5) Psoriasis 6) Paediatric plaque psoriasis 7) Hidradenitis suppurativa (HS) 8) Crohn’s disease 9) Paediatric Crohn’s disease 10) Ulcerative colitis 11) Paediatric ulcerative colitis 12) Uveitis 13) Paediatric uveitis. Dosage: Refer to Summary of Product Characteristics. Method of administration: Hukyndra is administered by subcutaneous injection. Full instructions for use are provided in the package leaflet. Hukyndra is only available as 40 mg pre-filled syringe and 40 mg pre-filled pen. Thus, it is not possible to administer Hukyndra to patients that require less than a full 40 mg dose. If an alternate dose is required, other adalimumab products offering such an option should be used. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Active tuberculosis or other severe infections such as sepsis, and opportunistic infections. Moderate to severe heart failure (NYHA class III/IV). Warnings and precautions: Infections (Serious infections, Tuberculosis, Other opportunistic infections), Hepatitis B reactivation, Neurological events, Allergic reactions, Immunosuppression, Malignancies and lymphoproliferative disorders, Haematologic reactions, Vaccinations, Congestive heart failure, Autoimmune processes, Concurrent administration of biologic DMARDS or TNF-antagonists, Surgery, Small bowel obstruction, Elderly and Paediatric population. Interactions: Refer to Summary of Product Characteristics. Fertility, pregnancy and lactation: Women of childbearing potential should consider the use of adequate contraception to prevent pregnancy and continue its use for at least five months after the last Hukyndra treatment. Hukyndra should only be used during pregnancy if clearly needed. Hukyndra can be used during breast-feeding. Driving and operation of machinery: Hukyndra may have a minor influence on the ability to drive and use machines. Vertigo and visual impairment may occur following administration of Hukyndra. Undesirable effects: Very common: Respiratory tract infections (including lower and upper respiratory tract infection, pneumonia, sinusitis, pharyngitis, nasopharyngitis and pneumonia herpes viral), Leukopenia (including neutropenia and agranulocytosis), Anaemia, Lipids increased, Headache, Abdominal pain, Nausea and vomiting, Elevated liver enzymes, Rash (including exfoliative rash), Musculoskeletal pain, Injection site reaction (including injection site erythema). A copy of the SmPC is available upon request or go to www.clonmelhealthcare.ie . Pack size: Hukyndra 40 mg solution for injection in pre-filled syringe - 2 pre-filled syringes + 2 alcohol pads, Hukyndra 40 mg solution for injection in pre-filled pen - 2 pre-filled pens + 2 alcohol pads. Marketing authorisation holder: STADA Arzneimittel AG, Stadastrasse 2-18, 61118 Bad Vilbel, Germany. Marketing authorisation numbers: EU/1/21/1589/002, EU/1/21/1589/005. Distributed by Clonmel Healthcare Ltd. Medicinal product subject to medical prescription.

Date last revised: December 2021. 2023/ADV/HUK/130H. Date of Preparation: May 2023. *When compared with Humira®. For example, 0.4 mL instead of 0.8 mL for a Hukyndra® 40 mg dose. **STADA founded Bioceuticals Arzneimittel AG in 2000. 1. Hukyndra® SmPC (Jan. 2022).

2. Nash P et al. Rheumatol Ther 2016;3:257–270. 3. Best-value biological medicines https://www.hse.ie/eng/about/who/cspd/ncps/medicines-management/best-value-medicines/best-valuebiological-medicines/

http://biosimilars.stada

ĂďƐĞŶĐĞ ĚŽĞƐ ŶŽƚ ĞdžĐůƵĚĞ ƚŚĞ ĚŝĂŐŶŽƐŝƐ͘ KŶŐŽŝŶŐ ŝŶĨůĂŵŵĂƚŝŽŶ ĂŶĚ ƐĐĂƌƌŝŶŐ ĐĂŶ ůĞĂĚ ƚŽ ďŽǁĞů ŽďƐƚƌƵĐƚŝŽŶ ĂŶĚ ƐƚƌŝĐƚƵƌĞ ĨŽƌŵĂƚŝŽŶ͘ ƌŽŚŶ’s ĚŝƐĞĂƐĞ ŝƐ ĂůƐŽ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ĞŶƚĞƌŽǀĞƐŝĐĂů͕ 18 Crohn’s Disease ĞŶƚĞƌŽĞŶƚĞƌĂů͕ ĞŶƚĞƌŽĐƵƚĂŶĞŽƵƐ͕ ĂŶĚ ĞŶƚĞƌŽǀĂŐŝŶĂů ĨŝƐƚƵůĂƐ͘ ϯ͕ϰ WĂƚŚŽƉŚLJƐŝŽůŽŐLJ ϰ

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EŽƚ ĨƵůůLJ ƵŶĚĞƌƐƚŽŽĚ /ŵŵƵŶŽďŝŽůŽŐLJ͗ ŝŵƉĂŝƌĞĚ ŝŶƚĞƐƚŝŶĂů ďĂƌƌŝĞƌ ĨƵŶĐƚŝŽŶ ĂŶĚ ĚLJƐƌĞŐƵůĂƚŝŽŶ ŽĨ ƚŚĞ ŝŶŶĂƚĞ ĂŶĚ ĂĚĂƉƚĂƚŝǀĞ ŝŵŵƵŶĞ ƐLJƐƚĞŵ ƌĞƐƉŽŶƐĞƐ͕ ǁŝƚŚ ĂŶ ĂůƚĞƌĂƚŝŽŶ ŽĨ ŐƵƚ ŵŝĐƌŽďŝŽƚĂ o ĞĨŝĐŝĞŶƚ ŵƵĐƵƐ ďŝŽĨŝůŵ ďĂƌƌŝĞƌ͗ ĚĞĐƌĞĂƐĞĚ ĞdžƉƌĞƐƐŝŽŶ ŽĨ ŵƵĐŝŶ ƐĞĐƌĞƚŝŽŶ ŐĞŶĞƐ ;Dh ϭ͕ Dh ϭϵ ĂŶĚ Wd' ZϰͿ ŝŶ ƚŚĞ ƚĞƌŵŝŶĂů ŝůĞƵŵ ŝŶ ƉĂƚŝĞŶƚƐ ǁŝƚŚ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ o WĞƌŵĞĂďŝůŝƚLJ ĐŚĂŶŐĞƐ ŝŶ ƚŚĞ ŝŶƚĞƐƚŝŶĂů ĞƉŝƚŚĞůŝƵŵ͗ ĂůƚĞƌĞĚ ĞdžƉƌĞƐƐŝŽŶ ŽĨ ƚŝŐŚƚ ũƵŶĐƚŝŽŶ ƉƌŽƚĞŝŶƐ ;ĐůĂƵĚŝŶͿ o WĂŶĞƚŚ ĐĞůů ĚLJƐĨƵŶĐƚŝŽŶ o /ŵƉĂŝƌĞĚ ĂƵƚŽƉŚĂŐLJ ŽĨ ŝŶǀĂƐŝǀĞ ŵŝĐƌŽďĞƐ o /ŵďĂůĂŶĐĞ ŽĨ ĞĨĨĞĐƚŽƌ d ĐĞůůƐ ĂŶĚ ŶĂƚƵƌĂůůLJ ƌĞŐƵůĂƚŽƌLJ d ĐĞůůƐ o ZĞĐƌƵŝƚŵĞŶƚ ĂŶĚ ĞƌƌĂƚŝĐ ƌĞƚĞŶƚŝŽŶ ŽĨ ůĞƵŬŽĐLJƚĞƐ LJƐďŝŽƐŝƐ͗ o ŽŶƚŝŶƵŽƵƐ ĂůƚĞƌĂƚŝŽŶƐ ŝŶ ŝŶƚĞƐƚŝŶĂů ŵŝĐƌŽďŝŽƚĂ ƌĞƐƵůƚŝŶŐ ŝŶ ĐůƵƐƚĞƌŝŶŐ ĂŶĚ ƌĞĚƵĐĞĚ ĚŝǀĞƌƐŝƚLJ ŝŶ &ŝƌŵŝĐƵƚĞƐ ĂŶĚ ĂĐƚĞƌŽŝĚĞƚĞƐ ƉŚLJůĂ o ZĞĚƵĐƚŝŽŶ ŝŶ &ĂĞĐĂůŝďĂĐƚĞƌŝƵŵ ƉƌĂƵƐŶŶŝƚnjŝŝ ǁĂƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ĂŶ ŝŶĐƌĞĂƐĞĚ ƌĞĐƵƌƌĞŶĐĞ ŽĨ ŝůĞĂů ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ ŝŶ ƚŚĞ ƉŽƐƚŽƉĞƌĂƚŝǀĞ ƐĞƚƚŝŶŐ 'ĞŶĞƚŝĐ ƌŝƐŬ ĨĂĐƚŽƌƐ͗ o /ŶĐƌĞĂƐĞĚ ƌŝƐŬ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ĨĂŵŝůLJ ŚŝƐƚŽƌLJ o ŽŶĐŽƌĚĂŶĐĞ ŝŶ ŵŽŶŽnjLJŐŽƚŝĐ ƚǁŝŶƐ ŝƐ ϮϬ Ͳ ϱϬй ĐŽŵƉĂƌĞĚ ǁŝƚŚ ϭϬй ŝŶ ĚŝnjLJŐŽƚŝĐ ƚǁŝŶƐ o tŝĚĞ ŐĞŶŽŵĞ ĂƐƐŽĐŝĂƚŝŽŶ ƐƚƵĚŝĞƐ ŝĚĞŶƚŝĨŝĞĚ ϮϬϬ ůŽĐŝ ĂƐƐŽĐŝĂƚĞĚ ƚŽ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ͖ ŚŽǁĞǀĞƌ͕ ƚŚĞLJ ĐŽŶƚƌŝďƵƚĞ ŽŶůLJ Ă ŵŽĚĞƐƚ ƌĞůĂƚŝǀĞ ƌŝƐŬ ŝŶĐƌĞĂƐĞ o EK Ϯ͕ d'ϭϲ>ϭ͕ />ϮϯZ ŐĞŶĞ ǀĂƌŝĂŶƚƐ ĂƌĞ ƌĞƐƉŽŶƐŝďůĞ ĨŽƌ ƐŽŵĞ ŽĨ ƚŚĞ ŚĞƌŝƚĂďůĞ ƌŝƐŬ

ŶǀŝƌŽŶŵĞŶƚĂů ƌŝƐŬ ĨĂĐƚŽƌƐ͗ o ŝŐĂƌĞƚƚĞ ƐŵŽŬŝŶŐ ĚŽƵďůĞƐ ƚŚĞ ƌŝƐŬ ŽĨ ĚĞǀĞůŽƉŝŶŐ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ o ZĞĚƵĐĞĚ ĨŝďƌĞ ĚŝĞƚĂƌLJ ŝŶƚĂŬĞ o ŶƚŝďŝŽƚŝĐ ƚŚĞƌĂƉLJ ĚƵƌŝŶŐ ĐŚŝůĚŚŽŽĚ ŝŶĐƌĞĂƐĞƐ ƚŚĞ ƌŝƐŬ ŽĨ ĚĞǀĞůŽƉŝŶŐ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ o KƚŚĞƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝŶĐůƵĚŝŶŐ ŶŽŶƐƚĞƌŽŝĚĂů ĂŶƚŝͲŝŶĨůĂŵŵĂƚŽƌLJ ĚƌƵŐƐ͕ ŽƌĂů ĐŽŶƚƌĂĐĞƉƚŝǀĞƐ ĂŶĚ ĂƐƉŝƌŝŶ ƌĞĂƐƚĨĞĞĚŝŶŐ ĂƉƉĞĂƌƐ ƚŽ ďĞ Ă ƉƌŽƚĞĐƚŝǀĞ ĨĂĐƚŽƌ ĂŐĂŝŶƐƚ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ

Risk Factors Environmental factors can include smoking, antibiotics, nonsteroidal anti-inflammatory drugs and reduced fibre diet. Theresa notes that while the role these factors play is not fully known, they can act as triggers to initiate a harmful immune response in the GI tract.

“Smoking is the most notable risk factor for developing Crohn’s disease, aside from family history and ethnic background. Smokers are twice as likely to develop Crohn’s compared to nonsmokers, and those who smoke usually experience more severe symptoms compared to those with the condition who do not smoke,” she says.

“While there is no evidence that diet plays a role in Crohn’s disease, certain types of food and drink have been associated with worsening symptoms including milk, dairy products, alcohol, processed, spicy and fatty foods.

There is no diet or eating plan that will work for everyone with Crohn’s disease and dietary recommendations must be tailored

“The goal of medication management is to control the inflammation and induce a clinical remission with pharmacological therapy, however, most patients will eventually require surgery. Surgery is not curative, and patients still require ongoing therapy even after surgery for disease recurrence” individually. Some research suggests that a Mediterranean style diet is associated with an improved quality of life and reduced disease activity in Crohn’s disease. Some probiotics have also demonstrated small benefits. Although flares are often associated with stressful events, there is no evidence to prove that stress causes or contributes to Crohn’s disease.”

There are 3 main phenotypes of CD: inflammatory, stricturing, and penetrating. Presenting symptoms are variable and some patients may have symptoms for years before a diagnosis of Crohn’s disease is made. Patients with inflammatory disease often present

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with abdominal pain and diarrhoea, and may develop more systemic symptoms including weight loss, low-grade fevers, and fatigue.

Patients with stricturing disease may develop bowel obstructions while those with penetrating CD can develop fistula or abscesses.

When an abscess is present, in addition to abdominal pain, patients can have systemic symptoms such as fever and chills and may also present with signs of acute peritonitis.

“The diagnosis of Crohn’s disease can be quite challenging given that presenting symptoms can be insidious and nonspecific,” she says. “A detailed patient medical history and physical examination

is carried out. Blood tests can highlight the presence of anaemia (B12 or iron deficiency) or liver disease. Special serology such as normal anti-neutrophil cytoplasmic antibodies (ANCA) and raised anti-saccharomyces cerevisiae antibodies (ASCA) can distinguish Crohn’s disease from ulcerative colitis. C-reactive protein (CRP) or erythrocyte sedimentary rate (ESR) can reflect the severity of the inflammation. Stool tests to rule out infections include culture and sensitivities, ovum and parasites, clostridium difficile toxins, and leukocyte count. Stools for calprotectin can detect active Crohn’s disease and are also used for monitoring the illness.

Plain x-rays are ordered if bowel obstruction is suspected. The perineum should be examined in all patients, and may reveal skin tags, ulcers, fistulas, scarring, and abscess. Frank perforation is rare but can be a presentation of Crohn’s disease.

“Symptoms that require further investigation include weight loss, bloody diarrhoea, iron deficiency, and night-time awakenings.

19 A significant family history of IBD, unexplained elevations in the C-reactive protein level, sedimentation rates, or other acute phase reactants such as ferritin and platelets, or low B12 should prompt further investigation.”

Treatment and Management

as budesonide, and has also been known to cause mental health problems in an estimated 5% of people.”

The diagnosis, treatment and management of Crohn’s disease requires a multi-professional Sulfasalazine belongs to a team approach. Patient education group of medicines called regarding their illness is very aminosalicylates, known to reduce important. There are several inflammation inside the colon. medications available to treat According to Theresa, there is no Theresa explains, “Sulfasalazine Crohn’s disease, however, there is single test that can be used to can be used as an alternative no cure. The mainstay of treatment confirm or disprove a diagnosis of ^LJŵƉƚŽŵƐ ƚŚĂƚ ƌĞƋƵŝƌĞ ĨƵƌƚŚĞƌ is ŝŶǀĞƐƚŝŐĂƚŝŽŶ ŝŶĐůƵĚĞ ǁĞŝŐŚƚ to ůŽƐƐ͕ ďůŽŽĚLJ ĚŝĂƌƌŚŽĞĂ͕ steroids to treat mild cases ŝƌŽŶ medical therapy with the goal of Crohn’s disease. of Crohn’s disease. achieving clinical, endoscopicĨĂŵŝůLJ and ĚĞĨŝĐŝĞŶĐLJ͕ ĂŶĚ ŶŝŐŚƚͲƚŝŵĞ ĂǁĂŬĞŶŝŶŐƐ͘ ƐŝŐŶŝĨŝĐĂŶƚ ŚŝƐƚŽƌLJ ŽĨ / ͕ Common ƵŶĞdžƉůĂŝŶĞĚ “The diagnosis is made based side effects include headache, histologic remission, demonstrated ĞůĞǀĂƚŝŽŶƐ ŝŶ ƚŚĞ ͲƌĞĂĐƚŝǀĞ ƉƌŽƚĞŝŶ ůĞǀĞů͕ ƐĞĚŝŵĞŶƚĂƚŝŽŶ ƌĂƚĞƐ͕ Žƌ ŽƚŚĞƌ ĂĐƵƚĞ ƉŚĂƐĞ ƌĞĂĐƚĂŶƚƐ on symptoms, endoscopic and nausea, abdominal pain and by mucosal healing. Treatment diarrhoea. Immunosuppressants radiologic findings. (Colonoscopy, ϭ is chosen based on the disease ƐƵĐŚ ĂƐ ĨĞƌƌŝƚŝŶ ĂŶĚ ƉůĂƚĞůĞƚƐ͕ Žƌ ůŽǁ ϭϮ ƐŚŽƵůĚ ƉƌŽŵƉƚ ĨƵƌƚŚĞƌ ŝŶǀĞƐƚŝŐĂƚŝŽŶ͘ are used in maintenance therapy Biopsy, SBE, CT, MRI, Wireless stage, severity and location. and in combination with steroids

Capsule Endoscopy). Pathology Dietician input and nutritional when a person has a relapse of can also be confirmatory. supplementation are highly dŚĞƌĞ ŝƐ ŶŽ ƐŝŶŐůĞ ƚĞƐƚ ƚŚĂƚ ĐĂŶ ďĞ ƵƐĞĚ ƚŽ ĐŽŶĨŝƌŵ Žƌ ĚŝƐƉƌŽǀĞ Ă ĚŝĂŐŶŽƐŝƐ ŽĨ ƌŽŚŶΖƐ ĚŝƐĞĂƐĞ͘ symptoms. Immunosuppressants recommended before and during Endoscopy with histological used for treating Crohn’s disease the treatment of Crohn disease. evaluation remains the gold dŚĞ ĚŝĂŐŶŽƐŝƐ ŝƐ ŵĂĚĞ ďĂƐĞĚ ŽŶ ƐLJŵƉƚŽŵƐ͕ ĞŶĚŽƐĐŽƉŝĐ ĂŶĚ ƌĂĚŝŽůŽŐŝĐ ĨŝŶĚŝŶŐƐ͘ ; ŽůŽŶŽƐĐŽƉLJ͕ include methotrexate, azathioprine, standard for diagnosing CD. ϭ͕ϱ͕ϳ Theresa says, “Steroids are ŝŽƉƐLJ͕ ^ ͕ d͕ DZ/͕ tŝƌĞůĞƐƐ ĂƉƐƵůĞ ŶĚŽƐĐŽƉLJͿ͘ WĂƚŚŽůŽŐLJ ĐĂŶ ĂůƐŽ ďĞ ĐŽŶĨŝƌŵĂƚŽƌLJ͘ tacrolimus and mercaptopurine.

However, advanced imaging used to induce remission but Side effects of azathioprine techniques, such as magnetic ŶĚŽƐĐŽƉLJ ǁŝƚŚ ŚŝƐƚŽůŽŐŝĐĂů ĞǀĂůƵĂƚŝŽŶ ƌĞŵĂŝŶƐ ƚŚĞ ŐŽůĚ ƐƚĂŶĚĂƌĚ ĨŽƌ ĚŝĂŐŶŽƐŝŶŐ ͘ are not an effective maintenance include increased vulnerability to resonance enterography (MRE) agent.

Steroids are usually only ,ŽǁĞǀĞƌ͕ ĂĚǀĂŶĐĞĚ ŝŵĂŐŝŶŐ ƚĞĐŚŶŝƋƵĞƐ͕ ƐƵĐŚ ĂƐ ŵĂŐŶĞƚŝĐ ƌĞƐŽŶĂŶĐĞ ĞŶƚĞƌŽŐƌĂƉŚLJ ;DZ Ϳ infection, bleeding and bruising. and computed tomography used to treat the active disease Less common side effects include enterography (CTE), have emerged ĂŶĚ ĐŽŵƉƵƚĞĚ ƚŽŵŽŐƌĂƉŚLJ ĞŶƚĞƌŽŐƌĂƉŚLJ ; d Ϳ͕ use ŚĂǀĞ ĂƐ ǀĂůƵĂďůĞ ƚŽŽůƐ ĨŽƌ because their long-term is ĞŵĞƌŐĞĚ headaches, shortness of breath, as valuable tools for evaluating associated with a range of adverse dizziness, nausea and vomiting. ĞǀĂůƵĂƚŝŶŐ ĚŝƐĞĂƐĞ ĞdžƚĞŶƚ ĂŶĚ ĐŽŵƉůŝĐĂƚŝŽŶƐ͘ ŝŽŵĂƌŬĞƌƐ͕ ƐƵĐŚ ĂƐ ĨĂĞĐĂů ĐĂůƉƌŽƚĞĐƚŝŶ ĂŶĚ Ͳ disease extent and complications. side effects. Budesonide and ϭ͕ϱ originally Biomarkers, such as faecal “Mercaptopurine ƌĞĂĐƚŝǀĞ ƉƌŽƚĞŝŶ͕ ĂŝĚ ŝŶ ĚŝƐĞĂƐĞ ŵŽŶŝƚŽƌŝŶŐ ĂŶĚ ƉƌĞĚŝĐƚŝŶŐ ĚŝƐĞĂƐĞ ĂĐƚŝǀŝƚLJ͘ prednisolone are two steroids that calprotectin and C-reactive protein, are often used to treat Crohn’s developed to treat leukaemia in disease monitoring and aid has since proved effective in the disease. Budesonide is usually the predicting disease activity.” treatment of Crohn’s disease. first choice of steroid prescribed ŽŵƉůŝĐĂƚŝŽŶƐ Given in tablet form, its side to help control the symptoms of Complications ƌŽŚŶ’s ĚŝƐĞĂƐĞ ŝƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ĞdžƚƌĂŝŶƚĞƐƚŝŶĂů ŵĂŶŝĨĞƐƚĂƚŝŽŶƐ ŝŶĐůƵĚŝŶŐ ĞƉŝƐĐůĞƌŝƚŝƐ͕ ƵǀĞŝƚŝƐ͕ effects are not as severe as those Crohn’s disease. associated with other forms of Crohn’s diseaseĂƉŚƚŚŽƵƐ is associatedƵůĐĞƌƐ͕ ůŝǀĞƌ ƐƚĞĂƚŽƐŝƐ͕ ŐĂůůƐƚŽŶĞƐ͕ ĐŚŽůĂŶŐŝƚŝƐ͕ ƐƚŽŵĂƚŝƚŝƐ͕ ƉƌŝŵĂƌLJ ƐĐůĞƌŽƐŝŶŐ “Taken on a short-term basis of chemotherapy treatment. Common with extraintestinal manifestations less than 12 weeks budesonide side effects include nausea and ĐŚŽůĂŶŐŝƚŝƐ͕ ŶĞƉŚƌŽůŝƚŚŝĂƐŝƐ͕ ŚLJĚƌŽŶĞƉŚƌŽƐŝƐ͕ ƵƌŝŶĂƌLJ ƚƌĂĐƚ ŝŶĨĞĐƚŝŽŶƐ͕ ĂƌƚŚƌŝƚŝƐ ;ƐĂĐƌĂů ƐƉŝŶĞ͕ including episcleritis, uveitis, may cause acne, oedema of the vomiting while less common side stomatitis, aphthous ulcers, liver ŬŶĞĞ͕ ĂŶŬůĞƐ͕ ŚŝƉƐ͕ ǁƌŝƐƚ͕ ĞůďŽǁƐͿ͕ ĂŶŬLJůŽƐŝŶŐ ƐƉŽŶĚLJůŝƚŝƐ͕ ĞƌLJƚŚĞŵĂ ŶŽĚŽƐƵŵ͕ ĂŶĚ ƉLJŽĚĞƌŵĂ face, hands, arms, feet and legs, effects include loss of appetite, steatosis, gallstones, cholangitis, mood changes, insomnia and fatigue, breathlessness ŐĂŶŐƌĞŶŽƐƵŵ͘ dŚƌŽŵďŽĞŵďŽůŝĐ ĚŝƐĞĂƐĞ ĐĂŶ ďĞ Ă ĐŽŵƉůŝĐĂƚŝŽŶ ŽĨ ƌŽŚŶ ĚŝƐĞĂƐĞ͕ and ĂŶĚ ŵĂLJ primary sclerosing cholangitis, indigestion. If taken for more weakness caused by anaemia. nephrolithiasis, hydronephrosis, ƉƌĞƐĞŶƚ ǁŝƚŚ ĚĞĞƉ ǀĞŝŶ ƚŚƌŽŵďŽƐŝƐ͕ ǁŝƚŚ ƌŽŚŶΖƐ than 12ƐƚƌŽŬĞ͕ weeks, Žƌ ƉƵůŵŽŶĂƌLJ budesonide may ĞŵďŽůŝƐŵ͘ Effective WĂƚŝĞŶƚƐ contraception if sexually urinary tract infections, arthritis cause osteoporosis, increased active is important while taking ϭ͕ϰ ĚŝƐĞĂƐĞ ŚĂǀĞ ĂŶ ŝŶĐƌĞĂƐĞĚ ƌŝƐŬ ĨŽƌ ĐŽůŽƌĞĐƚĂů ĐĂŶĐĞƌ͘

(sacral spine, knee, ankles, vulnerability to infection, mercaptopurine, as it temporarily hips, wrist, elbows), ankylosing cataracts, muscle cramps and affects both ova and sperm and can spondylitis, erythema nodosum, stiffness, and vitamin D and increase the risk of birth defects. and pyoderma gangrenosum. ŝĨĨĞƌĞŶƚŝĂů calcium supplements will be “Biological therapies are a new Thromboembolic disease can be required to help protect against KƚŚĞƌ ĐŽŶĚŝƚŝŽŶƐ ĐĂŶ ŵŝŵŝĐ ƚŚĞ ƐLJŵƉƚŽŵƐ ŽĨ ĂŶĚ ŝƚ ŝƐ ŝŵƉŽƌƚĂŶƚ ƚŽ ƌƵůĞ ŽƵƚ ŝŶĨĞĐƚŝŽŶ ĂŶĚ type of medication created using a complication of Crohn disease, the effects of osteoporosis. Due naturally occurring biological and may present with deep vein ŽƚŚĞƌ ĐĂƵƐĞƐ ĞǀĞŶ ǁŚĞŶ ƉĂƚŝĞŶƚƐ ǁŝƚŚ ŬŶŽǁŶ ĂƌĞ ŚĂǀŝŶŐ ĨůĂƌĞͲƵƉƐ͘ WĂƚŝĞŶƚƐ ǁŝƚŚ ĚŝĂƌƌŚŽĞĂ to increased vulnerability to substances, such as antibodies thrombosis, stroke, or pulmonary infections, close contact with ƐŚŽƵůĚ ďĞ ĂƐƐĞƐƐĞĚ ĨŽƌ ŝŶĨĞĐƚŝŽŶ͕ / ͕ ĂŶĚ ŝŶ ĐĞƌƚĂŝŶ ĐĂƐĞƐ ĐŽĞůŝĂĐ ĚŝƐĞĂƐĞ͘ KƚŚĞƌ ĐŽŶĚŝƚŝŽŶƐ and enzymes. Two main biological embolism.

Patients with Crohn’s people who are known to have therapies are infliximab and ϭ /ƚ ŝƐ disease haveƉƌĞƐĞŶƚ an increased infections, particularly those ĚŝƐĞĂƐĞ͕ with ƚŚĂƚ ŵĂLJ ůŝŬĞ risk for ŝŶĐůƵĚĞ ĂƉƉĞŶĚŝĐŝƚŝƐ͕ ĞŚĐĞƚ ĂŶĚ hůĐĞƌĂƚŝǀĞ ŽůŝƚŝƐ͘ adalimumab.

Infliximab is usually colorectal cancer. chickenpox, measles and shingles important not to confuse inflammatory disease (IBD) like only Crohn’s disease in orsevere ulcerative recommended should bebowel avoided.

Both Crohn’s Disease and cases of Crohn’s disease that ĐŽůŝƚŝƐ ǁŝƚŚ ŝƌƌŝƚĂďůĞ ;/ ^Ϳ͘ / ^ inŝƐ Ă ĚŝƐŽƌĚĞƌ ĂĨĨĞĐƚƐ to ƚŚĞ ŵƵƐĐůĞ Ulcerative Colitis (UC) are ďŽǁĞů ƐLJŶĚƌŽŵĞ “Prednisolone is used cases haveƚŚĂƚ not responded steroid and inflammatory bowel diseases where budesonide proves immunosuppressant treatments, ĐŽŶƚƌĂĐƚŝŽŶƐ ŽĨ ƚŚĞ ďŽǁĞů ĂŶĚ ŝƐ ŶŽƚ ĐŚĂƌĂĐƚĞƌŝƐĞĚ ďLJ ŝŶƚĞƐƚŝŶĂů ŝŶĨůĂŵŵĂƚŝŽŶ͕ ŶŽƌ ŝƐ ŝƚ Ă (IBDs), but there are some ineffective. It has the same type of and where the person is unsuitable ϴ Both Crohn’s Disease and Ulcerative Colitis (UC) are inflammatory bowel ĐŚƌŽŶŝĐ ĚŝƐĞĂƐĞ͘ short and long-term side effects for surgery. key differences, see table below.

ĚŝƐĞĂƐĞƐ ;/ ƐͿ͕ ďƵƚ ƚŚĞƌĞ ĂƌĞ ƐŽŵĞ ŬĞLJ ĚŝĨĨĞƌĞŶĐĞƐ͘ ϴ Crohn’s Disease hůĐĞƌĂƚŝǀĞ ŽůŝƚŝƐ /ŶĨůĂŵŵĂƚŝŽŶ ŵĂLJ ĚĞǀĞůŽƉ ĂŶLJǁŚĞƌĞ ŝŶ ƚŚĞ '/ ƚƌĂĐƚ ĨƌŽŵ ƚŚĞ ŵŽƵƚŚ ƚŽ ƚŚĞ ĂŶƵƐ DŽƐƚ ĐŽŵŵŽŶůLJ ŽĐĐƵƌƐ Ăƚ ƚŚĞ ĞŶĚ ŽĨ ƚŚĞ ƐŵĂůů ŝŶƚĞƐƚŝŶĞ DĂLJ ĂƉƉĞĂƌ ŝŶ ƉĂƚĐŚĞƐ DĂLJ ĞdžƚĞŶĚ ƚŚƌŽƵŐŚ ĞŶƚŝƌĞ ƚŚŝĐŬŶĞƐƐ ŽĨ ďŽǁĞů ǁĂůů ďŽƵƚ ϲϳй ŽĨ ƉĞŽƉůĞ ŝŶ ƌĞŵŝƐƐŝŽŶ ǁŝůů ŚĂǀĞ Ăƚ ůĞĂƐƚ ϭ ƌĞůĂƉƐĞ ŽǀĞƌ ƚŚĞ ŶĞdžƚ ϱ LJĞĂƌƐ

>ŝŵŝƚĞĚ ƚŽ ƚŚĞ ůĂƌŐĞ ŝŶƚĞƐƚŝŶĞ ;ĐŽůŽŶ ĂŶĚ ƌĞĐƚƵŵͿ KĐĐƵƌƐ ŝŶ ƚŚĞ ƌĞĐƚƵŵ ĂŶĚ ĐŽůŽŶ͕ ŝŶǀŽůǀŝŶŐ Ă ƉĂƌƚ Žƌ ƚŚĞ ĞŶƚŝƌĞ ĐŽůŽŶ ƉƉĞĂƌƐ ŝŶ Ă ĐŽŶƚŝŶƵŽƵƐ ƉĂƚƚĞƌŶ /ŶĨůĂŵŵĂƚŝŽŶ ŽĐĐƵƌƐ ŝŶ ŝŶŶĞƌŵŽƐƚ ůŝŶŝŶŐ ŽĨ ƚŚĞ ŝŶƚĞƐƚŝŶĞ ďŽƵƚ ϯϬй ŽĨ ƉĞŽƉůĞ ŝŶ ƌĞŵŝƐƐŝŽŶ ǁŝůů ĞdžƉĞƌŝĞŶĐĞ Ă ƌĞůĂƉƐĞ ŝŶ ƚŚĞ ŶĞdžƚ LJĞĂƌ

“Infliximab works by targeting the tumour necrosis factor (TNF) antibodies that are responsible for much of the inflammation associated with Crohn’s disease.

Given by intravenous infusion, around one in four people has an allergic reaction to infliximab and experiences symptoms such as joint and muscle pain, itchy skin, high temperature, rash, swelling of the hands and/or lips, problems swallowing and headaches.

Symptoms range from mild to severe and usually develop in the first two hours after the infusion has finished.

“Adalimumab works in a similar way to infliximab by targeting TNF antibodies. It is given by injection and most people will need to have an injection every two weeks.

Like infliximab, adalimumab increases vulnerability to infection, and those taking it should avoid contact with people with chickenpox or shingles and always report any symptoms of a possible infection to their GP. Adalimumab can cause reactivation of the hepatitis B virus and may not be suitable for people who were previously infected. Common side effects of adalimumab include pain, swelling, redness and itching at the site of the injection, headache, and abdominal pain, nausea, vomiting, skin rash, muscle, joint and bone pain and respiratory tract infections, such as colds and pneumonia.”

Theresa told us that the goal of medication management is to control the inflammation and induce a clinical remission with pharmacological therapy, however, most patients will eventually require surgery. Surgery is not curative, and patients still require ongoing therapy even after surgery for disease recurrence.

“Some people report complementary and alternative medicines (CAM) (including fish oils and probiotics) helpful in controlling certain symptoms of Crohn’s disease, however, there is little scientific data to support their effectiveness. Although many types of CAM are generally safe, issues of purity, contamination with toxic metals, lacing with prescription drugs, and the side effects of some traditional herbal remedies must be considered.

Large well-designed RCTs are needed to validate specific CAM therapies, before they can be incorporated into evidence based medical treatments” she concluded.

PHARMACYNEWSIRELAND.COM

20

News

Upskilling with Online CPD RCSI University of Medicine and Health Sciences has created a new suite of online CPD short courses for healthcare practitioners looking to upskill and advance their careers. scheduling is flexible for healthcare professionals with competing commitments. Each course includes regular learning checks to reinforce knowledge acquisition and measure progression through the content. On successful completion, course participants receive RCSI certification and associated CPD points.

The short CPD courses currently offered by RCSI Online include: • AI & Medical Imaging • Cybersecurity • Digital Health Technologies • Foundations of Digital Health • Person-Centred Digital Healthcare The short continuous professional development (CPD) courses are provided via RCSI’s digital learning platform, RCSI Online, and are available to those working in healthcare and allied healthcare roles anywhere in the world.

Running over five-week terms, the

courses are delivered by experts on topics ranging from healthcare strategy and finance to cyber security in healthcare.

The content is delivered entirely online with 1.5 hour weekly webinars accompanied by selfpaced activities, ensuring that

• Introduction to Healthcare Strategy • Finance for Healthcare • Personalised Medicine.

Speaking about the new course offerings, Sara McDonnell, Executive Director of the RCSI

Graduate School of Healthcare Management, said: “We are delighted to introduce our new suite of short CPD healthcare courses, specifically designed to meet the current professional development needs of those working in healthcare and allied healthcare, helping them to further their careers today and prepare for the ever-evolving healthcare landscape of tomorrow.

“The new courses will allow participants to access a transformative RCSI educational experience that is locationand time-independent. We are developing a growing portfolio of topics relevant to the current and anticipated needs of healthcare professions, with content delivered by subject-matter experts with industry and sectoral experience and expertise.”

To learn more about the short courses available on RCSI Online, visit https://www.rcsi.com/online/ courses/short-courses.

Best in Class for Ostomy and Urology United Drug – Irelands leading provider of Ostomy and Urology Products and services to the Pharmacy sector The Ostomy & Urology Care team at United Drug are committed to providing the best-in-class service and support, enabling you to give your Ostomy & Urology Customers confidence and peace of mind that they are receiving the best possible care through your pharmacy.

United Drug continues to invest in state of the art cutting technology which allows us to provide pouches cut to individual patient specifications, ensuring comfort with the best possible fit. Through this complimentary service, the team cut in excess of 8,000 bags per week giving patients the highest level of security and comfort due to the increased precision from our state of the art cutting machine. The continual investment in technology provides capacity for up to 10,000 pouches cut to individual patient specifications with a turnaround time of as low as 48 hours on emergency orders.

United Drug’s specialist ostomy customer care team has over 50 years combined experience in Ostomy & Urology Care. Our teams upskill their product knowledge every 6 weeks, this high level of training allows them to deal sensitively and efficiently with your queries. They support over 20,000 customer care enquiries annually.

For more information on our Ostomy & Urology please visit udw.ie or contact the Customer Care Team on 01 4632347.

PHARMACYNEWSIRELAND.COM

Ireland’s No. 1 Provider of Ostomy Products & Services Customer Care Over 20,000 calls handled annually from our customer care team.

Complimentary Cutting Service

Training Partnership

Complimentary Wipes and Bags

Expanding Range

Cutting up to 10,000 bags per week.

Ostomy Excellence – we provide a complimentary education programme.

For Pharmacists to offer their patients.

We continue to expand our range as Ireland’s leading stockist for Ostomy & Urology products.

Contact our Ostomy Care team for further information

Telephone: 01 463 2300

Opioid Prescribing Updates Opioid Prescribing Updates from the Updated CDC Opioid Prescribing Guidelines

A 45-year-old gentleman was admitted to hospital with a fractured tibial plateau following a road traffic collision. He was admitted under the orthopaedic team and placed on the emergency surgical theatre list. Due to a high volume of trauma patients admitted to the hospital, there were significant waiting times for access to theatre. The orthopaedic intern on the ward prescribed paracetamol and modified-release oxycodone 20mg twice daily, which was uptitrated to 30mg twice daily after three days. Later that week, he underwent operative fixation of the fracture. The anaesthetic team avoided regional anaesthesia due to the risk of compartment syndrome. His pain did not decrease in the expected manner post-operatively and this affected his engagement with physiotherapy.

His modified-release oxycodone was uptitrated to 40mg twice daily. Due to substantial bed pressure that existed in the hospital, he was discharged on the third postoperative day with a script for analgesia and a follow-up appointment in the orthopaedic clinic in 6 weeks’ time. The discharging intern made sure he had sufficient analgesia to cover him for this period. When he presented to a busy orthopaedic clinic 6 weeks’ later, he remained on modified-release oxycodone. He requested that his script be refilled and this request was granted.

Opioid analgesics are highly effective in the management of acute severe pain.

However, their use in a chronic setting is associated with an increased risk of opioid misuse, overdose and tolerance among other risks. A systematic review

conducted by the Agency for Healthcare Research and Quality concluded that insufficient evidence existed for the long-term benefits of opioids in chronic pain.1 As higher doses are often required in order to maintain adequate analgesia, dose-related risks such opioid-induced respiratory depression, opioid-induced bowel dysfunction and dependence become more common. In addition, their use in the elderly comes with an increased risk of cognitive impairment and falls. Despite a lack of evidence for their benefit in chronic pain, their use has increased substantially in many developed countries, including in Ireland.2 Increased prescribing rates can lead to opioid-use disorder and opioid diversion, with many patients reporting not disposing of finished opioid prescriptions.

The 2016 Centers for Disease Control and Prevention (CDC) guideline for Prescribing Opioids for Chronic Pain was released to provide clinicians with a tool to assess the benefits and risks of opioid prescribing in chronic pain.3 Its introduction in the USA co-incided with rapid reductions in opioid dispensing rates per capita, with reductions in overall and high-risk prescribing, and increases in prescribing rates of nonopioids.4 Subsequent policies and legislation that arose out of this guideline, along with inflexible application of its recommendations, led to reports of overzealous tapering regimens, undertreated pain, acute withdrawals and

22 | PHARMACYNEWSIRELAND.COM

Written by Dr Cormac F. Mullins, MB, BAO, BCh, FCAI, FFPMCAI, DPMCAI, MSc Consultant in Anaesthesia and Pain Medicine, Cork University Hospital and South Infirmary Victoria University Hospital drcormacmullins@gmail.com

accompanying psychological distress and unnecessary patient harm.5 These reports led to the development of a revised CDC opioid guideline in 2022 with a greater emphasis on patient-centred care, individualised care plans and flexibility.6

In addition to this, more recent evidence was included to support its prescribing recommendations in acute pain (<1 month duration) and subacute pain (1-3 months’ duration).

The new CDC guideline includes evidence from recent systematic reviews that non opioid medications are at least as effective as opioids for improving pain, function, or both, in many types of acute pain conditions, such as low back pain, neck pain, musculoskeletal conditions, minor surgery, dental procedures, headache or kidney stones. The guideline recommends that nonopioids are maximised where appropriate and where no contra-indication exists (e.g., oral or topical nonsteroidal anti-inflammatory medications). Nonopioids can include nonpharmacological interventions, such as exercise and psychological therapies, nonopioid medications, including serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants, pregabalin and gabapentin, nonsteroidal anti-inflammatory drugs (NSAIDs), and paracetamol. Nonopioid therapies are preferred in subacute pain and chronic pain. In moderate-to-severe pain where nonopioids are insufficiently effective or contra-indicated, opioids can provide a useful role. Like the previous guideline, the 2022 guideline recommends that opioids be prescribed at the lowest effective dose for no longer than the expected duration of severe pain. Unlike in the case above, patients should not be provided with extended scripts for opioid medication, especially for acute or subacute pain. Tapering should be instituted where opioids are used continuously for greater than a few days.

Both 2016 and 2022 CDC guidelines advise that when commencing opioids for subacute or chronic pain, an assessment should take place of the expected benefits, risks and goals of treatment. The goals of treatment can be considered in terms of reductions pain intensity and improvements in activities of daily life. If the agreed thresholds for treatment goals are not reached after a reasonable trial, or if the side effects exceed the benefits, then the trial should be considered unsuccessful and the opioid should be weaned and stopped. Unlike in the case above, when commencing opioids for acute, subacute, or chronic pain, immediate-release opioids should be prescribed instead of modified-release or long-acting preparations.6 Other speciality bodies have release statements and publications warning of the increased risks associated with long-acting opioids, including opioid-use disorder, prolonged hospital admission, respiratory depression, and death.7,8 Extended-release preparations were introduced into surgical practice in the mistaken belief that they provided superior pain relief and reduced

“Where patients are already receiving opioids, the new guideline outlines how clinicians can work together with patients to determine whether opioids should be discontinued and how this can be done”

nursing workload. Marketing campaigns promoted the idea of steady state plasma concentrations and a simple dosing schedule. However, the trajectory of acute pain and postoperative pain is typically one of the intermittent exacerbations of pain, especially associated with mobilisation, physiotherapy and exercise, which requires additional analgesia on an as required basis to facilitate such activity. Therefore, many patients require additional doses of immediate release opioids on top of their extended-release opioid, which can contribute to additional side effects and worse pain control.9 The FDA has advised that some extendedrelease preparations should only be considered where patients have received a required dosage of an immediate-release preparation for at least one week.6 The new 2022 guideline specifically recommends that in cases of subacute opioid therapy (1 to 3 months), opioids should not be re-prescribed without carefully reassessing the goals, benefits and risks again, in order to prevent progression to unintentional long-term opioid therapy. This is illustrated in the case above. Frequently, opioids may be commenced in hospital and renewing the prescription may assumed by a different clinician, who may be unaware that the opioid was only commenced recently, and therefore, its continued

use should be re-assessed. Furthermore, many patients do not get a benefit in pain reduction or improvement in function from increasing opioid doses to greater than 50mg Morphine Milligram Equivalents (MME) per day and are likely to lead to diminishing returns, but with a substantially increased risk of side effects.

Where patients are already receiving opioids, the new guideline outlines how clinicians can work together with patients to determine whether opioids should be discontinued and how this can be done. Again, the benefits and risks of continuing opioid therapy should be weighed against the benefits and risks of stopping opioids. The guideline emphasises the importance of patientcentred care and shared decision-making especially as there may be reluctance or fear on the part of the patient to reduce their opioids. General principles are emphasised, rather than hard cut-offs, to avoid the application of inflexible standards that may be misapplied in certain circumstances. Tapering should be done slowly, especially where opioids have been used for a longer timeframe (e.g., ≥1 year), and reductions of approximately 10% per month should be better tolerated by patients than more rapid tapers. Patient motivation is optimal for successful tapers. Stopping opioid therapy after prolonged use can be very challenging and it is important that patients have effective support and do not feel abandoned. Clinicians should offer follow-up to patients at frequent intervals (ideally, at least monthly), and multidisciplinary input other team members including pharmacists and nursing is highly valuable. Tapers may have to be paused and recommenced if withdrawal symptoms appear or when the patient feels ready. Ideally, opioid tapering should be performed within the context of a multimodal and multidisciplinary approach to the patient’s pain management that is individualised and incorporates evidence-based treatment strategies and psychological support with the goal of improving patients’ function and quality of life, while minimising the risks of opioid therapy.

The central tenets of the updated CDC guidelines for opioid prescribing emphasise the importance of ensuring adequate access to effective pain management with an emphasis on improving function and quality of life, while minimising the risks associated with prescription opioid therapy.

Communication between healthcare professionals and patients around the risks and benefits of opioids are central to ensuring patient-centred approaches to pain management and addressing the unique needs of every patient.

References available on request

PHARMACYNEWSIRELAND.COM | 23

24

Sexual Health

Sexual Health Advice in Pharmacy With greater access to contraception now open for consultation by the HSE, and the recent news that PrEP is to be made available through community pharmacy in Ireland, pharmacy teams have a crucial role to play in the area of Sexual Health.

Community pharmacy has, for many years, been involved in providing support for sexual health, selling products ranging from condoms, lubricants, emergency hormonal contraception (EHC), sanitary goods, pregnancy and ovulation tests, herbal supplements for the menopause, treatments for cystitis and thrush and Viagra for erectile dysfunction.

This range of products and services is not available from any other single provider and so community pharmacy is wellplaced to position itself as a onestop shop for sexual health.

Condoms offer the best protection from both an unplanned pregnancy and sexually transmitted infections (STIs).

Encouraging use of condoms is of utmost importance and can be promoted by listing their advantages: 1. Many contain lubricant 2. 92-98% effective 3. Prevention of STI’s 4. Only contraception males have control of 5. Females can be prepared and carry them also If a customer knows or suspects that a condom has failed, they can access services at their local pharmacy to find out if this has happened and/or what the

consequences may be. These (obviously) include the sale of pregnancy tests and similar products. However, customers can also access STI screening and detection services at some Irish pharmacies.

Some available products provide simple kits that a customer may use themselves to extract and store a sample. The sample is then sent to a reputable laboratory to be tested for a range of STI types that are prominent in Ireland. These include chlamydia, gonorrhoea, HIV, herpes simplex and hepatitis.

A customer can request screening for a combination of these in accordance with their preferences.

The role of the pharmacy team in terms of STI screening, therefore, is mainly on advising on the availability of these kits, and of the potential benefits of screening.

If the customer is diagnosed with an STI, the treatment options available from their pharmacy may depend on a consultation with a GP or other health professional (e.g. staff in a sexual health clinic) and on any prescription they receive as a result.

pharmacists and the public combine to afford a unique opportunity to reach patients and discuss their sexual health.

It can be hard to reduce a whole conversation about sexual health into a 30-second-over-the-counter chat. It is much more beneficial if consultations can take place in an appropriately confidential space if possible. This helps to build up a trusting relationship with the patient as confidentiality is a priority when accessing sexual health services in any setting.

Sensitivity It is important that you are educated and confident in discussing personal details with patients and giving them advice in a non-judgemental manner.

Pharmacy team members need to be confident in discussing topics such as sexual health to develop a level of trust with the patient.

Sexual health topics need to be dealt with in a sensitive manner: • Greet the patient • Bring the patient into the consultation room

These factors are fundamental to ensure the patient feels at ease and comfortable in your presence.

There are some key opportunities to potentially broach the subject and promote sexual health. One such occasion is when emergency hormonal contraception is required. Advice about long term methods of contraception and information regarding STI’s are standard practice throughout the consultation.

A patient asking about irregular periods, spotting or genital warts is a signal that demonstrates the patient requires more knowledge and is open to any information that can be provided. A patient presenting with their first prescription for a contraceptive is another opportunity to utilise, to counsel on sexual health and how to reduce the risk of contracting STIs. Pharmacy staff can aid patients in several ways including: • Signposting and referral when necessary

Having the Conversation

• Maintain eye contact

• Sale of OTC items (pregnancy tests, condoms, self-care products)

As the most accessible healthcare professional, pharmacists are an important resource for STI prevention and control. The large number of pharmacy outlets, and the trust shared between

• Use appropriate body language

• Advice and information on STI’s

• Ask open-ended questions

• Supply of EHC where necessary and appropriate

PHARMACYNEWSIRELAND.COM

• Reassure them that all information remains confidential, as always

• Information on long term contraception options

Hayfever Allergy

55 mi micrograms/dose icrograms/s//ddose NNasal asal Spray a Suspension ay triamcinolone acetonide

For the treatment of the nasal symptoms of allergic rhinitis Nasal Congestion Sneezing and Itching Stuffy or Runny Nose

For Adult use only. Not for use in children under 18 years. A copy of the summary of product characteristic is available upon request or alternatively please go to www.clonmelhealthcare.ie. Supply through pharmacies only. PA23180/001/002. PA Holder: Opella Healthcare France SAS T/A Sanofi, 82 Avenue Raspail, 94250 Gentilly, France. Distributed by: Clonmel Healthcare Ltd., Clonmel, Co.Tipperary. Date Prepared: April 2023 2023/ADV/NAS/070H

Vimovo® 1 tablet, 2 active ingredients...

Sequential release of: • Esomeprazole (in the stomach) for gastroprotection; followed by • Naproxen (in the small intestine) for relief of inflammation and pain associated with osteoarthritis.1-5

Esomeprazole 20mg Enteric coating Naproxen 500mg

Scan QR code to view VIMOVO MODE OF ACTION VIDEO

1 tablet twice daily at least 30 minutes prior to food intake.2 Swallow whole with water.

Do not split, chew or crush.2

Vimovo® is indicated in adults for the symptomatic treatment of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis, in patients who are at risk for developing non-steroidal anti-inflammatory drug (NSAID)-associated gastric and/or duodenal ulcers and where treatment with lower doses of naproxen or of other NSAIDs is not considered sufficient.2

RECEIVE A CALL FROM A MEDICAL REPRESENTATIVE

RECEIVE INFORMATION FROM GRÜNENTHAL

Reference: 1. Goldstein JL et al. Aliment Pharmacol Ther. 2010; 32(3):401-413. 2. Vimovo Summary of Product Characteristics. 3. Wang-Smith L et al. J Clin Pharmacol. 2012 May; 52(5):670-80. 4. Hochberg MC et al. Curr Med Res Opin. 2011; 27(6):1243-1253. 5. Moore RA et al. Pain Pract. 2014; 14(4):378-39.

VIMOVO 500mg/20mg modified-release tablets (naproxen, esomeprazole magnesium trihydrate) Prescribing Information Refer to the Summary of Product Characteristics (SmPC) before prescribing.

Presentation: Modified-release tablet (oval, biconvex, yellow, marked 500/20 in black ink) containing enteric-coated naproxen (500 mg) and film-coated esomeprazole (20 mg).

Indication: In adults for the symptomatic treatment of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis, in patients who are at risk for developing non-steroidal antiinflammatory drug (NSAID)-associated gastric and/or duodenal ulcers and where treatment with lower doses of naproxen or of other NSAIDs is not considered sufficient.

Dosage and method of administration: Adults: Oral use. Swallowed whole (not split, chewed or crushed) with water. Recommended to take at least 30 minutes prior to food intake. One tablet twice daily. Use lowest effective dose for shortest duration possible.

Patients not treated with NSAID previously, or when 1000mg/day of naproxen is not considered appropriate, alternative therapeutic treatment with lower strength of naproxen or of other NSAIDS as non-fixed combination should be utilised. Review at regular intervals and discontinue if no benefit or if worsening. Not intended for relief of acute pain conditions. Flares of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis may be treated. Renal / Hepatic impairment: Use cautiously in mild to moderate renal/hepatic impairment and monitor closely. Consider reduction in total daily naproxen dose. Elderly (>65 years): older people are at risk of serious consequences of adverse reactions. Paediatric population: Safety and efficacy not established in 0 to 18 years. Contra-indications: Hypersensitivity to ingredients, history of asthma, urticaria or allergic-type reactions induced by administration of acetylsalicylic acid or other NSAIDs, third trimester of pregnancy onward, no breastfeeding if you are taking VIMOVO, severe heart failure, severe renal impairment, severe hepatic impairment (Child-Pugh C), active peptic ulceration, gastrointestinal (GI) bleeding, cerebrovascular bleeding or other bleeding disorders, must not be used concomitantly with atazanavir and nelfinavir.

Special Warnings and precautions: Avoid concomitant NSAIDs use. Can be used with low dose acetylsalicylic acid. Undesirable effects may be minimized by using lowest effective dose for the shortest duration necessary. Assess at meaningful intervals to prevent overtreatment. Risk-factors to develop NSAID related GI complications include high age, concomitant use of anticoagulants, corticosteroids, other NSAIDs including low-dose acetylsalicylic acid, debilitating cardiovascular disease, Helicobacter pylori infection, and a history of gastric and/or duodenal ulcers and upper GI bleeding. In Inducible porphyries and systemic lupus erythematosus and mixed connective tissue disease use only after rigorous benefit-risk ratio. Contains very low levels of methyl and propyl parahydroxybenzoate. Patients on long-term treatment should be kept under regular surveillance. Elderly: Naproxen: Older people have an increased frequency of adverse reactions especially GI bleeding, and perforation, which may be fatal. Gastrointestinal effects: Naproxen: GI bleeding, ulceration or perforation, which can be fatal with or without warning symptoms or a previous history of serious GI events. Risk is higher with increasing NSAID doses, patients with history of ulcers and in older people. Start with low dose and consider combination therapy with protective agents. Caution in patients receiving NSAIDs with concomitant medications which could increase risk of ulceration or bleeding. Withdraw treatment if GI bleeding or ulceration. Caution in patients with a history of GI disease. Esomeprazole: In the presence of any alarm symptom and when gastric ulcer is suspected, malignancy should be excluded. Dyspepsia could still occur.

May lead to increased risk of GI infections. May reduce absorption of vitamin B12 due to hypo- or achlorhydria. Cardiovascular and cerebrovascular effects: Naproxen: Appropriate monitoring and advice for patients with history of hypertension and/or mild to moderate congestive heart failure. The use of coxibs and some NSAIDs may be associated with a small increased risk of arterial thrombotic events. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with naproxen after careful consideration. Consideration should be made before initiating longer-term treatment of patients with risk factors for cardiovascular events. Renal effects: Naproxen: Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury.

Renal toxicity has been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. Patients at greatest risk of this are those with impaired renal function, hypovolemia, heart failure, liver dysfunction, salt depletion, those taking diuretics, angiotensin converting enzyme (ACE) inhibitors, or angiotensin II receptor antagonists and older people. Use with great caution in patients with impaired renal function and monitoring of serum creatinine and/or creatinine clearance is advised.

Contraindicated in patients with baseline creatinine clearance less than 30 ml/min.

Assess renal function before and during therapy in patients with compromised renal blood flow. Acute tubulointerstitial nephritis (TIN) has been observed in patients taking esomeprazole and naproxen containing products and may occur at any point during Vimovo therapy. Acute tubulointerstitial nephritis can progress to renal failure. Hepatic effects: Borderline elevations of liver tests may occur, due to hypersensitivity rather than toxicity. Rare cases of severe hepatic reactions, including jaundice and fatal fulminant hepatitis, liver necrosis and hepatic failure, some with fatal outcomes have been reported.

Hepatorenal syndrome: Use of NASAIDs may be associated with acute renal failure in patients with hepato-cirrhosis. These patients frequently also have concomitant coagulopathy related to inadequate synthesis of clotting factors. Antiplatelet effects associated with naproxen could further increase risk of severe bleeding. Haematological effects: Naproxen: Careful observation when administered to patients who have coagulation disorders or are receiving drug therapy that interferes with haemostasis.

Increased risk of bleeding if given to patients with high risk of bleeding and those on full anti-coagulation therapy. Naproxen decreases platelet aggregation and prolongs bleeding time. If active and clinically significant bleeding from any source occurs, withdraw treatment. Eye effects: Naproxen: recommend ophthalmic examination if any change or disturbance in vision occurs. Dermatological effects: Naproxen: Discontinue at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

Esomeprazole: associated with very infrequent cases of subacute cutaneous lupus erythematosus (SCLE). If lesions occurs and if accompanied by arthralgia, seek medical help promptly and consider stopping treatment. SCLE after previous treatment with a PPI may increase the risk of SCLE with other PPIs. Anaphylactic (anaphylactoid) reactions: Naproxen: anaphylactic (anaphylactoid) reactions may occur in patients with and without a history of hypersensitivity or exposure to acetylsalicylic acid, other NSAIDs or naproxencontaining products. They may also occur in individuals with a history of angio-oedema, bronchospastic reactivity, rhinitis and nasal polyps. Pre-existing asthma: Naproxen: Use with caution and should not be administered to patients with aspirin-sensitive asthma.

Inflammation: Naproxen: may reduce fever and other signs of inflammation thereby diminishing their utility as diagnostic signs. Female fertility: not recommended in women attempting to conceive. Combination with other medicinal products: Must not be used with atazanavir. Esomeprazole is a CYP2C19 inhibitor. When starting or ending treatment, the potential for interactions with drugs metabolised through CYP2C19 should be considered. Concomitant use with clopidogrel should be discouraged. Hypomagnesaemia: Severe hypomagnesaemia has been reported in patients treated with Proton Pump Inhibitors (PPIs). Consider measuring magnesium levels before starting PPI treatment and periodically during treatment in patients expected to be on prolonged treatment or those on concomitant digoxin or drugs that may cause hypomagnesaemia. Bone fracture: PPIs, if used in high doses and over long durations (>1 year), may increase the risk of hip, wrist and spine fracture, predominantly in older people or in presence of other recognised risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and have an adequate intake of vitamin D and calcium. Interference with laboratory tests: Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours. To avoid this interference, treatment should be stopped for at least 5 days before CgA measurements. Fertility: VIMOVO may make it more difficult to become pregnant. Interactions: Antiretroviral agents: Concomitant use of atazanavir and nelfinavir with esomeprazole is not recommended and concomitant administration with Vimovo is contraindicated. Concomitant use with precaution: Other analgesics including cyclooxygenase-2 selective inhibitors: Concomitant use with other NSAIDs except for low-dose acetylsalicylic acid (≤ 325 mg/day), is not recommended. Acetylsalicylic acid: Can be administered with low dose acetylsalicylic acid (≤ 325 mg/day). In clinical trials, Vimovo in combination with low-dose acetylsalicylic acid did not have increased occurrence of gastric ulcers. However, concurrent use may still increase risk of serious adverse events. Clinical pharmacodynamic data suggests concomitant naproxen usage for more than one day consecutively may inhibit the effect of low-dose acetylsalicylic acid on platelet activity and this inhibition may persist for up to several days after stopping naproxen. Clinical relevance of this interaction is not known. Tacrolimus: A

reinforced monitoring of tacrolimus concentrations as well as renal function should be performed and dose of tacrolimus adjusted if needed. Ciclosporin: caution when coadministered because of increased risk of nephrotoxicity. Diuretics: NSAIDs can reduce natriuretic effect of furosemide and thiazides in some patients. Observe patient closely for signs of renal failure as well as to assure diuretic efficacy. SSRIs: Concomitant use of NSAIDs, including COX-2 selective inhibitors, and SSRIs increases the risk of GI bleeding.

Corticosteroids: Increased risk of GI bleeding when combined with NSADIs including COX2 selective inhibitors. Caution when NSAIDS are concomitantly administered with corticosteroids. ACE-inhibitors/Angiotensin II receptor antagonists: caution when combined with NSAIDs in patients who are older, volume-depleted, or with renal impaired renal function as NSAID may diminish antihypertensive effect and increase risk of renal impairment associated with ACE-inhibitor or angiotensin II receptor antagonists. Digoxin: NSAIDs may increase plasma cardiac glycoside levels when co-administered with cardiac glycosides such as digoxin. Lithium: NSAIDs have produced an elevation of plasma lithium levels and a reduction in renal lithium clearance. Observe carefully for lithium toxicity.

Methotrexate: esomeprazole and naproxen could enhance the toxicity of methotrexate.

Caution when administered concomitantly with methotrexate. In high-dose methotrexate administration a temporary withdrawal of Vimovo is recommended. Sulphonylureas, Hydantoins: Naproxen is highly bound to plasma albumin; thus a theoretical potential for interaction with other albumin-bound drugs (sulphonylureas, hydantoins). When coadministered patients should be observed for adjustment of dose. Clopidogrel: Concomitant use should be discouraged due to inconsistent data on clinical implications of a PK/PD interaction of esomeprazole in terms of major cardiovascular events reported from observational and clinical studies. Anti-coagulants and thrombocyte aggregation inhibitors: NSAIDs may enhance the effects of oral anti-coagulants, heparins and thrombocyte aggregation inhibitors. Close monitoring when initiating and ending treatment with warfarin or other coumarine derivatives. Beta receptor-blockers: Naproxen and other NSAIDs can reduce the antihypertensive effect of propranolol and other betablockers. Probenecid: Probenecid given concurrently increases naproxen anion plasma levels and extends its plasma half-life significantly. Drugs with gastric pH-dependent absorption: gastric acid suppression during treatment with esomeprazole, and other PPIs might decrease or increase the absorption of drugs with a gastric pH dependent absorption. The absorption of drugs such as ketoconazole, itraconazole, posaconazole and erlotinib can decrease while the absorption of drugs such as digoxin can increase.

Concomitant use with posaconazole and erlotinib should be avoided. Other Information Concerning Drug Interactions: Studies evaluating concomitant administration of esomeprazole and either naproxen or rofecoxib did not identify any clinically relevant interaction. Concomitant administration of cholestyramine can delay absorption of naproxen. In healthy volunteers, concomitant administration esomeprazole resulted in an increase in area under the plasma concentration-time curve and prolonged elimination half-life but no significant increase in peak plasma levels of cisapride. Esomeprazole has been shown to have no clinically relevant effects on the pharmacokinetics of amoxicillin and quinidine. Esomeprazole inhibits CYP2C19, the major esomeprazole metabolising enzyme. Esomeprazole is also metabolised by CYP3A4. Drugs known to induce CYP2C19 or CYP3A4 or both (such as rifampicin and St. John's Wort) may lead to decreased esomeprazole serum levels. Omeprazole and esomeprazole act as inhibitors of CYP2C19.

Animal data indicate that NSAIDs can increase the risk of convulsions associated with quinolone antibiotics. Patients taking quinolones may have an increased risk of developing convulsions. Drug/Laboratory Test Interaction: Naproxen may decrease platelet aggregation and prolong bleeding time. Naproxen may result in increased urinary values for 17-ketogenic steroids. Suggested therapy with naproxen be temporarily discontinued 72 hours before adrenal function tests are performed if the Porter-Silber test is to be used. Naproxen may interfere with some urinary assays of 5-hydroxy indoleacetic acid (5HIAA). Pregnancy, lactation and fertility: You should not use VIMOVO during the first 6 months of pregnancy unless absolutely necessary and advised by your doctor. From the 20th week of pregnancy onward, VIMOVO use may cause oligohydramnios resulting from foetal renal dysfunction. This may occur shortly after treatment initiation and is usually reversible upon discontinuation. Antenatal monitoring for oligohydramnios and ductus arteriosus constriction should be considered after exposure to VIMOVO for several days from gestational week 20 onward. Do not breast-feed if you are taking VIMOVO. Fertility: The use of NSAIDs like naproxen may impair female fertility. The use of VIMOVO is not recommended in women attempting to conceive. Refer to full SmPC for further information.

Undesirable effects: Reported from Vimovo clinical trials: Very common (≥1/10): dyspepsia.

Common (≥1/100 to <1/10): dizziness, headache, taste disturbance, hypertension, abdominal pain, constipation, diarrhea, esophagitis, flatulence, gastric/duodenal ulcers, gastritis, nausea, vomiting, skin rashes, arthralgia, oedema. Other important undesirable effects: paraesthesia, syncope, arrhythmia, GI bleeding, stomatitis, urticaria, (Uncommon (≥ 1/1,000 to < 1/100), diverticulitis, hypersensitivity reactions, myocardial infarction, tachycardia, rectal bleeding, renal failure, (Rare (≥ 1/10,000 to < 1/1,000). Naproxen: adverse experiences reported during trial and through postmarketing reports: Common (≥1/100 to <1/10): diverticulitis, depression, insomnia, dizziness, drowsiness, headache, lightheadedness, vertigo, visual disturbances, tinnitus, hearing disturbances, palpitations, dyspnea, dyspepsia, abdominal pain, nausea, vomiting, diarrhoea, constipation, heartburn, peptic ulcers, stomatitis, pruritus, ecchymoses, purpura, skin rashes, fatigue, oedema, sweating, thirst. Other important undesirable effects: sepsis, agranulocytosis, eosinophilia, granulocytopenia, Pancytopenia, thrombocytopenia, anaphylactic reaction, anaphylactoid reactions, hypersensitivity reactions, coma, convulsions, optic neuritis, paresthesia, syncope, corneal opacity, papilloedema, arrhythmia, myocardial infarction, tachycardia, eosinophilic pneumonitis, pneumonia, respiratory depression, gastric/duodenal ulcers, gastrointestinal bleeding and/or perforation, pancreatitis, exacerbation of inflammatory bowel disease (ulcerative colitis, Crohn's disease), rectal bleeding, cholestasis, hepatitis, jaundice, liver failure, exanthema, urticaria, bullous reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis, erythema multiforme, systemic lupus erythematosus, pseudoporphyria, nephrotic syndrome, renal failure, renal papillary necrosis, tubular necrosis, Uncommon (≥ 1/1,000 to < 1/100), Rare (≥ 1/10,000 to < 1/1,000).

Esomeprazole: adverse drug reactions identified or suspected in clinical trial for entericoated esomeprazole and/or post marketing. None were found to be dose-related: Common (≥1/100 to <1/10): headache, abdominal pain, diarrhea, flatulence, nausea/ vomiting, constipation, fundic gland polyps (benign). Other important undesirable effects: paraesthesia, pruritus, urticaria, fracture of the hip, wrist or spine (Uncommon (≥ 1/1,000 to < 1/100). leukopenia, thrombocytopenia, hypersensitivity reactions e.g. fever, angioedema and anaphylactic reaction/shock, depression, paraesthesia, syncope, arrhythmia, gastrointestinal bleeding, stomatitis, pruritus, urticaria, (Rare (≥ 1/10,000 to < 1/1,000)). agranulocytosis, pancytopenia, hepatic failure, hepatic encephalopathy in patients with pre-existing liver disease, erythema multiforme, Interstitial nephritis, Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), , drug reaction with eosinophilia and systemic symptoms (DRESS) (Very rare (< 1/10,000)). Overdose: Effects of overdose expected to reflect the effects of naproxen overdose. Significant naproxen overdosage may be characterized by lethargy, dizziness, drowsiness, epigastric pain, abdominal discomfort, heartburn, indigestion, nausea, transient alterations in liver function, hypoprothrombinemia, renal dysfunction, metabolic acidosis, apnea, disorientation or vomiting. GI bleeding can occur. Hypertension, acute renal failure, respiratory depression, and coma may occur, but rare. Anaphylactoid reactions have been reported. A few patients have experienced convulsions. It is not known what dose of the drug would be life-threatening. The symptoms in connection with esomeprazole overdose are transient. Patients should be managed by symptomatic and supportive care following a NSAID overdose, particularly with respect to GI effects and renal damage. Haemodialysis does not decrease the plasma concentration of naproxen because of the high degree of protein binding. Emesis and/or activated charcoal and/or osmotic cathartic may be indicated in patients seen within 4 hours of ingestion with symptoms or following a large overdose. Forced diuresis, alkalinization of urine or hemoperfusion may not be useful.

Esomeprazole is not readily dialyzable. There are no specific antidotes for naproxen or esomeprazole. Prescribers should consult the SmPC in relation to all adverse reactions.

Legal classification: POM, CD (Part VIIIA Category C). Marketing Authorisation numbers, pack sizes: PA 2242/014/001, 60 packs. Marketing Authorisation Holder: Grünenthal Pharma Ltd 4045 Kingswood Road Citywest Business Park Citywest Co. Dublin Ireland.

Date of preparation: July 2023. JN: M-VMO-IE-07-23-0001.

Adverse events should be reported. Reporting forms and information can be found at www.medicines.ie/adverse-event-reporting.

Adverse events should also be reported to Grünenthal Ltd. Free phone: +44 (0)870 351 8960.

M-VMO-IE-07-23-0006 – July 2023

RCSILayout-AW

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Cervical Cancer

Vaccination of Children and Teenagers to Prevent Cervical Cancer smjobstetrics and gy Written by Ciara O’Connor1 and Fergal Malone2

RCSI

RCSI medical student Professor and Chair of Obstetrics and Gynaecology, Royal College of Surgeons, and Rotunda Hospital, Dublin

1 2

TABLE 1: Risk factors for human papillomavirus infection.

Ciara O'Connor

Professor Fergal Malone

Introduction

of penile,1 vaginal,2 urethral,3 and head and neck cancers have been found to contain carcinogenic HPV.4-6 Cervical cancer is the most important manifestation of genital HPV infection, and is one of the leading causes of cancer mortality in women worldwide.

The global disease burden of cervical cancer is estimated at 470,000 new cases, and 230,000 deaths, every year. Almost 80% of cases occur in developing countries, where it is the most common cancer among women.7 In Europe, 15,000 women die from cervical cancer each year, and it is the second most common form of cancer seen in women under 35 years of age. In Ireland, there

In disease control, prevention is superior, safer, and generally more cost-effective than treating illnesses after they develop. Vaccination, which is the administration of antigenic material to produce immunity to a disease, is one of the most important preventive measures currently at our disposal. The immune response to a vaccine may be cell-mediated or antibodymediated, or both. Human papillomaviruses (HPVs) comprise a group of about 100 DNA nonenveloped viruses. The burden of disease related to HPV is substantial. Variable proportions

d gynaecology review

.

29/01/2008

HPV genomes found in cervical carcinomas HPV viruses cloned

Women

Men

Young age (peak age group, 20-24 years) Increased number

Young age (peak age group, 25-29 years) Increased number

of sexual partners

of sexual partners

First sexual intercourse at an early age Male partner sexual behaviour

Lack of circumcision

Smoking Oral contraceptive use Uncircumcised male partners Taken from: Pichichero ME. Prevention of cervical cancer through vaccination of adolescents. Clin Pediatr (Phila) 2006; 45 (5): 393-8.

Mechanisms of transformation elucidated (true ‘tumour virus’) Epidemiological case-control studies completed

aredisease approximately new cases burden, particularly for developing In control,180 prevention is superior, safer, and generally more annually, and about 80 deaths countries where effective screening cost-effective than treating illnesses after they develop. Vaccination, a year are caused by cervical programmes are not available.12 8 the administration of antigenic material to produce which cancer.is Cervical cancer primarily The aim of this review was to affects women and of 45 the examine the evidence for and immunity to a between disease, 39 is one most important preventive years of age, thereby representing against vaccination of children and measures currently at our disposal. The immune response to a the an important opportunity cost teenagers against HPV and in terms may of potential years of life or antibody-mediated, development of cervical cancer.12 vaccine be cell-mediated or both. lost. The impact of the disease is Human papillomaviruses (HPVs) comprise a group of about 100 Methods accentuated further by the average DNA non-enveloped viruses.

The burden of disease related to HPV is age at death, often when women A MEDLINE and PubMed search are still raising children.

1 2 3 (1980-2007) was performed substantial. Variable proportions of penile, vaginal, urethral, using and In the United States, it is estimated

the search terms carcinogenic ‘HPV vaccination’, head andsix neck cancers have to contain that over million people are been found ‘HPV vaccination and children’, 9 4-6 infected Cervical with genital HPV.is Data HPV. cancer the most important manifestation ‘Cervical cancer and HPV’,of from the National Health and

Th pre pro red wh

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and leading ‘CIN’. Ancauses Englishoflanguage genital HPV infection, and is one of the cancer Nutrition Examination Survey restriction was imposed and the mortality in women worldwide.

The global disease burden of found a 26.8% prevalence of search continued up to August HPV among US girls and women, 20, 2007.

The references cited cervical cancer is estimated at 470,000 new cases, and 230,000 with increasing prevalence each in review articles were examined deaths, 80% of cases occur in developing year fromevery agesyear.

14 toAlmost 24 years,

the ‘Ce res 20

prevalence until 60.10 The risk

po of

followed bywhere a gradual in common countries, it is decline the most cancer among women.7 In The literature search yielded

160 papers, which 39 were Europe, 15,000 women die from cervical cancerofeach year, and it is factors for acquisition of HPV considered eligible for inclusion. the second most common form of cancer seen in women under 35 infection are shown in Table 1.

Results Infection is extremely common in years of age. In Ireland, there are approximately 180 new cases young women in their first decade cervical cancer cancer.8 11 annually, and about 80 deaths a yearHPV areand caused by cervical of sexual activity.

Condoms Key landmarks in the discovery of

afford some protection against Cervical cancer primarily affects women between 39 and 45 years of the link between HPV and cervical HPV transmission, although this age, thereby representing an important opportunity costininFigure terms of cancer are illustrated protection is incomplete.5 1. of Thethe first recognition of this potential years of life lost. The impact disease is accentuated The World Health Organisation

relationship was made by Harald

further by the average often whenin women are13 still Hausen the 1970s.

Using commented recently thatage a at death,zur sensitive molecular polymerase vaccinechildren. to prevent oncogenic raising chain reaction (PCR) techniques, HPV infection or premalignant the United States, it is estimated that over six million people are FIGURE 1: Discovery of the link between human papillomavirus and cervical In Walboomers et al detected HPV cervical lesions from progressing FIGURE 1: Discovery of the link between human papillomavirus and cervical 9 infected with genital HPV. Data from the and DNA inNational 99.7% ofHealth a series of cancer.

Adapted from: Pichichero ME. Prevention of cervical cancer through to cancer would offer a costcancer. Adapted from: Pichichero ME. Prevention of cervical cancer through 14 cervical cancers.

More than effective long-term strategy vaccination of adolescents.

Clin Pediatr (Phila) 2006; 45 (5): 393-8.

Nutrition Examination Survey found a 26.8% prevalence of HPV100 vaccination of adolescents. Clin Pediatr (Phila) 2006; 45 (5): 393-8. to reduce the cervical cancer strains of HPV exist, but types among US girls and women, with increasing prevalence each year from ages 14 to 24 years, followed by a gradual decline in The World Health Organisation commented recently that a vaccine to prevalence until 60.10 The risk factors for acquisition of HPV prevent oncogenic HPV infection or premalignant cervical lesions from PHARMACYNEWSIRELAND.COM infection are shown in Table 1. Infection is extremely common in progressing to cancer would offer a cost-effective long-term strategy to young women in their first decade of sexual activity.11 Condoms

15-20 HPV types classified as oncogenic

can vac

Introduction

for potentially eligible studies.

HPV defined as large, closely-related family: >100 types, 30-40 anogenital

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0 0 1 C I M DYNIAN AT E T O DAY NOM

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 DEADLINE MONDAY 2nd OCTOBER

RCSI 30

Cervical Cancer

TABLE 2: Comparison of human papillomavirus vaccines.

Gardasil (quadrivalent vaccine)

Cervarix (bivalent vaccine)

Manufacturer

Sanofi Pasteur MSD

GlaxoSmithKline

European license

Granted September 2006

Not granted yet; anticipated in 2008

Licensed for use in

Females 9-26 years

Females 10-55 years

What it is

L1 VLP (vaccine-like particle) vaccine in aluminium-containing suspension. Volume 0.5ml

L1 VLP vaccine in aluminium-containing suspension. Volume 0.5ml

Dosage

3-vaccine course

3-vaccine course

Administration

Doses at 0, 2 and 6 months, given by deep IM injection to deltoid or anterolateral thigh

Doses at 0, 2 and 6 months, given by deep IM injection to deltoid or anterolateral thigh

Targets

HPV 6/11/16/18

HPV 16/18 (may also target 31/45)

Efficacy

100% against precancerous lesions associated with HPV 16- and 18-related cervical cancer

100% against precancerous lesions associated with HPV 16 and 18

Common adverse effects

• Local injection site pain (up to 86%) • Erythema (up to 41%) • Swelling (up to 37%) • Headache (most common systemic adverse event)

• Local injection site pain (up to 93%) • Erythema (up to 36%) • Swelling (up to 34%) • Headache (most common systemic adverse effect)

Adapted from: Kenny N. HPV vaccine update. World of Irish Nursing 2007; 15 (2). changes.19-22 Most women will get oncogenic HPV at some stage in their lives, usually in their teens or twenties, and it will pass harmlessly.

A very smallprevalent proportion persists, and becomes 16 and 18 are the most controlled trials of HPVintegrated vaccines have demonstrated their in oncogenic strains the virus, into the cell DNA.ofThese pose a risk of cancer to the woman immunogenicity and ability to with HPV 16 accounting for more question.

500,000 precancerous lesions of Grade and 3 prevent incident and 2persistent than 60% About of cervical cancers, and type-specific HPV infection HPV 18 responsible for anothereach year in the United States, and (CIN 2 and 3) are diagnosed and associated cytological 10%. 50-60% The great about are majority attributable to HPV 16 and HPV 18.23 24 15-18

abnormalities in the cervix. of HPV infections, including Intramuscular injection of either infection by carcinogenic types, vaccine induces high titres of are transient, and resolve or HPV vaccines neutralising antibody, at more become undetectable within a Two vaccines have been developed to prevent HPVthe infection and than 50 times titres induced year or two, sometimes causing 25 details of these are shown in Table 2.

Randomised controlled trials by natural infection. Phase II trial mild cytopathological changes, results for both vaccines have including atypical squamous of HPV vaccines have demonstrated their immunogenicity and shown efficacy estimates of 100% cells (ASC), low-grade squamous ability to prevent incident and persistent type-specific HPVorinfection against either incident persistent intraepithelial lesions (LSIL) and 26 24 HPVin infection. and associated abnormalities the cervix.

Grade 1 cervicalcytological intraepithelial 19-22 neoplasia (CIN)injection changes.of Most vaccine induces high titres of Intramuscular either In a seminal randomised, women will get oncogenic HPV at double controlled trial by to neutralising antibody, at more than 50 timesblind, the titres induced some stage in their lives, usually assess the efficacy, safety, and 25 Phaseand in their teens or twenties, it results II trial for both vaccines have natural infection. immunogenicity of a bivalent HPV will passefficacy harmlessly.

A veryofsmall 16/18 either L1 virus-like particle shown estimates 100% against incident or vaccine proportion persists, and becomes (similar to Cervarix), Harper et al 26 persistent infection. integrated HPV into the cell DNA. randomised 1,113 women aged These pose arandomised, risk of cancerdouble to the blind, In a seminal controlled trial assess the between 15 and 25 to years.

These woman in question. About 500,000 received three doses efficacy, safety, and immunogenicity women of a bivalent HPV 16/18 L1 of precancerous lesions of Grade 2 either the vaccine or placebo on virus-like vaccine (similar to Cervarix), Harper et al and 3 (CINparticle 2 and 3) are diagnosed a 0-, 1-, and 6-month schedule in each year in the United States, andbetween randomised 1,113 women aged and 25 years.

These North 15 America and Brazil.

Women about 50-60% are attributable to were assessed for HPV infection women received three 23 doses of either the vaccine or placebo on a HPV 16 and HPV 18. for up to 27 months by cervical 0-, 1-, and 6-month schedule in North America Brazil. Women cytology andand self-obtained cervicoHPV vaccines vaginal for vaccine were assessed for HPV infection for up to 27samples, months and by cervical Two vaccines have been safety and immunogenicity. developed to prevent HPV The vaccine efficacy against infection and details of these are incident infection was 91.6% (95% CI, 64.5–98.0) and 100% shown in Table 2. Randomised

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cytology and self-obtained cervico-vaginal samples, and for vaccine safety and immunogenicity. The vaccine efficacy against incident infection was 91.6% (95% CI, 64.5–98.0) against persistent infection (95% those inand the 100% vaccineagainst group had a significantly lower CI, 47.0–100), as well as alsoCI, 47.0–100), persistent infection (95% as well as alsooccurrence protecting of high-grade CIN related to protecting against HPV-associated 27 against HPV-associated cytological abnormalities and lesions.

HPV 16 or HPV 18 comparedIn a cytological abnormalities and 29 27 with the placebo group.

Both lesions.

In a follow-up study follow-up study in 2006, Harper et al found that more than 98% of trials demonstrated high efficacy in 2006, Harper et al found that subjects who received all three doses remained seropositive for HPV against CIN 2 or worse related to more than 98% of subjects who 28 it is true that vaccination may 16 notand have effect 16/18. allWhile HPV types 18,an with a on received three doses remained 28 mean follow-up ofprofoundly three years seropositive for HPV cervical cancer for 16/18.

20 to 30While years, vaccination could (FUTURE II) and 15 months it is true that vaccination may not reduce the risk CIN incancer about 10 years.

(PATRICIA), respectively.31 have an effect on of cervical Two major randomised controlled trials – the FUTURE (Females for 20 to 30 years, vaccination Discussion could profoundly reduce the risk of United to Unilaterally Reduce Endo/Ectocervical Disease) II trial29 CIN in about 10 years.

It is important to vaccinate patients and the PATRICIA (PApilloma TRIal against Cancer Inwhich youngexposure Adults) before the age at Two major randomised controlled 31 review by to Rambout et al. study30 – were included in a systematic to HPV is likely occur, and from trials – the FUTURE (Females a public health perspective, routine This systematic review found that HPV vaccination was highly United to Unilaterally Reduce vaccination before sexual debut Endo/Ectocervical Disease) II effective in preventing vaccine type-specific infection, and or shortlyHPV thereafter is important. trial29 and the PATRICIA (PApilloma Recent among Irish data found that 12% precancerous cervical disease, particularly women aged 15 TRIal against Cancer In young of women had their first experience 30 Adults) – were included a vaccine doses, had no more than to 25 study years who received all in three of vaginal intercourse before the systematic review bypartners, Ramboutand et no prior abnormal results six lifetime sexual age of 17.8 years,32 and from a poll of al.31 This systematic review found 15- tofound 17-year-olds found that one cervical screening.

The FUTURE II study that in young women that HPV vaccination was highly in four had had sex.33 The 2007 effective in preventing vaccine who had not previously been infected with HPV 16the orAmerican HPV 18, those guidelines from type-specific HPV infection, and Cancer Society recommend routine in the vaccine group had a significantly lower occurrence of highprecancerous cervical disease, HPV vaccination for females aged grade CINamong relatedwomen to HPVaged 16 or HPV 18 compared with the placebo particularly 11 to 12 years but also state that 15 to 25 29 years who received all Both trials demonstrated high efficacy against CIN years 2 or group. females as young as nine three vaccine doses, had no more 34 may receive the vaccine. worse related to HPV types 16 and 18, with a mean follow-up of than six lifetime sexual partners, and no years prior abnormal In a population-based study to31 three (FUTURE results II) andfrom 15 months (PATRICIA), respectively. cervical screening. The FUTURE II assess parental consent and study found that in young women potential HPV vaccine uptake, who had not previously been Brabin et al used a questionnaire Volume 1: Number 2008 | Page infected with HPV 16 or HPV 18, to randomly sample1.parents of 43

31 HPV VIRUS

Over 100 subtypes, 40 infect the genital tract, half of these are oncogenic

18 months EXPOSURE Primary mode of transmission is by sexual intercourse, lifetime risk of infection 80% INFECTION Very common but mostly transient with spontaneous resolution within 18 months 18 months PERSISTENCE

Less than 20% of women show

signs of persistent infection 1-5 years MALIGNANT TRANSFORMATION Viral DNA integrates into the cells of the dividing cervix PRECANCER

Abnormal cells divide more rapidly lacking quality assurance of cell death 10 years CANCER 99% of cervical cancers are positive for high-risk HPV

FIGURE 2: Natural history of human papillomavirus infection.

Adapted from: presentation by Dr Grainne Flannelly entitled ‘HPV pupils aged 11 12National years in seven notMarch have a2007. national cervical Vaccination’, totothe Advisory does Group,

different secondary schools in the screening programme, their city of Manchester.35 They found a cost-effectiveness calculations HPV vaccine uptake rate of 80% may be skewed.

Discussion was achievable if the vaccine was estimated costatofwhich the It is important toand vaccinate patientsThe before the age perceived as safe effective. quadrivalent HPV vaccine is $360 However, the authors also exposure to HPV is likely to occur, and public in thefrom USA,aand ¤450health in Europe found that most parents lacked for a three-course series, making perspective, routine vaccination before sexual debut or shortly knowledge about HPV, and some it among the most expensive of were concerned about sexual thereafter is important.

Recent Irish data found38 that 12% of all vaccines. If consumers or health issues that would arise as women firstprogramme, experience ofinsurers vaginalwere intercourse before to pay, poor and the part of a had HPV their vaccine uninsured persons would bethat 32 and age of 17.8 a poll of 15to 17-year-olds found as well as theyears, possibility that unable to afford the vaccine, further administering the had vaccine 33 The 2007 guidelines from the one in four had sex.might exacerbating health disparities. actually encourage promiscuity.35 If the government is to pay, thisfor American Cancer Society recommend routine HPV vaccination Cost-effectiveness studies willstate require funds from the central females aged 11 to 12 years but also that females as young of HPV vaccination have had budget, perhaps reducing health 34 as nine years receiveon the vaccine. variable results,may depending spending for other programmes. assumptions about effectiveness In a population-based study to assess parental consent and In the wake of concerns about and safety.36 The major financial potential HPV vaccine uptake, Brabin et al used a questionnaire measles-mumps-rubella (MMR) to benefit of the vaccine to the Irish have in become health service is likely to be the randomly sample parents of pupils vaccines, aged 11 parents to 12 years seven more cautious about vaccine prevention of anogenital warts 35 different secondary virus schools in the city of and Manchester.

They safety some parents are less that the quadrivalent affords. of scientific found a HPV vaccine uptake rate oftrusting 80% was achievable if the Anogenital warts represent about evidence.39,40 There are scant data 10% of sexually-transmitted HPVand effective. vaccine was perceived as safe However, the authors on the duration of HPV vaccineinfections and 4,147 cases of also found that most parents lacked knowledge about HPV, and induced immunity.

Following anogenital warts were notified in 8 occurring infection, Irelandwere in 2004.

A research group some concerned about sexualnaturally health issues thatHPV would arise many women do not develop at Stanford University found that as part of a HPVgirls vaccine programme, as well HPV as the possibility that detectable antibodies if all 12-year-old currently and, in encourage the case of HPV 16, the 35 administering the States vaccine might actually promiscuity. living in the United were available serological assays detect vaccinated, more than 1,300 type-specific antibodies in only deaths from cervical cancer 54-60% of infected women.20 during their lifetimes would be Page 44 |37Volume 1: Number 2008 Therefore, longer-term follow-up averted, but as the United 1.

States

have variable of Cost-effectiveness vaccinated subjects studies cannot of HPVInvaccination January 2006, thehad Minister relyresults, on routine measurement of for about Health effectiveness and Children, Mary depending on assumptions and HPV vaccine-induced antibody Harney, announced the rollout safety.36 The major financial benefit of the vaccine to the Irish titres. Furthermore, because of of the Irish Cervical Screening service likely to be the prevention anogenital warts thehealth extended time is involved in the Programme of (ICSP).

In parallel progression from HPV infection with the ICSP, she announced the that the quadrivalent virus affords.

Anogenital warts represent to cervical cancer, it will be many establishment of the Board of the about 10% of sexually-transmitted HPV infections and 4,147 cases years before a reduction in cancer National Cancer Screening Service 8 A incidence and mortality of anogenital warts rates werecan notifiedand, in Ireland in 2004. research in a press release, stated be verified within a vaccinated that: “issues be examined group atThe Stanford University that if allto12-year-old girls population.

Canadian federal found included the effectiveness and currently recently living inannounced the United States were vaccinated, more than government cost-effectiveness of the vaccine, a $300 million investment in a categories of women who would should be 1,300 deaths from cervical cancer during their lifetimes programme for vaccinating girls be vaccinated, immunity duration averted, butthe ascurrently the United States does not have a national and women37 with and booster requirements, and available Gardasil vaccine. cervical screening programme, their cost-effectiveness calculations the implications for the national Questions have been raised, screening programme”.49 In a may be skewed. however, as to whether a universal properly screened programme, immunisation programme at this The estimated cost ofis,the quadrivalent HPV vaccine is $360 the vaccination of young girls in the time, premature and could have USA, and €450 in Europe for a three-course series, making it will prevent CIN and colposcopy, unintended negative consequences as well as prevent cervical theand most foramong individuals for expensive society as of all vaccines.38 If consumers or cancer. Vaccination provides 41 a whole. repeated comment insurersAwere to pay, poor is and uninsured persons would be a new approach to preventing that there is no epidemic of cervical cancer in Ireland unable to afford the vaccine, further exacerbating healthand cervical cancer in Canada to in other countries with a high warrant the sense of urgency for a is to disparities.

If the government pay, this will require funds incidence of the disease and zero vaccination programme. from the central budget, perhapsorreducing health spending poorly developed screening for According to the 2006 Canadian programmes.47 It is conceivable other programmes. cancer statistics,42 cervical cancer that if a vaccination programme In the concerns about measles-mumps-rubella (MMR) is the 11thwake mostof frequent cancer were introduced in the absence affecting women, and have the 13th vaccines, parents become more cautiousprogramme, about vaccine of a screening the most common cause of cancerrate of cervical cancer could safety and some parents are less trusting of scientific related deaths, accounting for actually increase. This message evidence.39,40 on the duration approximately 400There deathsare perscant data is reiterated

by AdamsofetHPV al, who year.

Earlier this year immunity. the states Following stressnaturally the need to implement vaccine-induced occurring HPV of Texas (by executive order) or continue a cervicalHPV screening infection, many women do not develop detectable and Virginia made quadrivalent programme to complement HPV vaccine mandatory forcase of HPV antibodies and, in the 16, the available vaccination, which willserological optimise 43 girls entering sixth grade. prevention in whoof receive assays detect type-specific antibodies in only those 54-60% infected However, the Texas legislature the vaccine and prevent cervical 20 women. follow-up of vaccinated subjects recently voted Therefore, to overturn longer-term the cancer in older women where the governor’s order, the state cannot rely onand routine measurement vaccine-induced valueof of HPV vaccination is currently of Virginia granted parents 50 unclear.

Vaccination willtime reduce antibody titres.

Furthermore, because of the extended 44 generous “opt-out” provisions. the risk of cervical cancer by Nearly 20 additional states are from HPV infection involved in the progression to cervical cancer, another 20%.37 considering similar legislation.45 it will be many years before a reduction in cancer incidence and Research in the US on the Conclusion mortality rates can be verified within a vaccinated population. issue of mandatory vaccination HPV vaccination has high efficacy concluded that making thegovernment The Canadian federal recently announced a $300 against the major HPV types that HPV vaccine mandatory might million investment in a programme forlife-threatening vaccinating girls and cause disease. paradoxically contribute to Vaccination appears to be safe, long-standing parental concerns women with the currently available Gardasil vaccine. Questions and so delaying vaccination may about the safety of school-based have been raised, however, as tomean whether a universal that many women will miss vaccination, and increase parental an opportunity for long-lasting immunisation programme time, premature and could and public apprehension about is, at this 46 protectionfor against cervicaland cancer. thehave vaccine. unintended negative consequences individuals for On the other hand, a cautious Australia has a 41 A repeated approach societyalready as a whole. commentmay is that there is no be warranted in government-funded programme the light important epidemic of cervical cancer in Canada toofwarrant theunanswered sense of offering vaccination to girls and questions about overall vaccine urgency foraged a vaccination young women 12 to 26 programme. efficacy, duration of protection 47 years.

The United has 42 cervical According to theKingdom 2006 Canadian cancer statistics, and possible adverse effects.50cancer just announced that universal HPV The adventwomen, of HPV vaccines is the 11th most frequent cancer affecting and the 13th vaccination of girls aged 12 to represents the most important 13most years common will begin in September cause of cancer-related deaths,toaccounting for breakthrough date in cervical 2008, and the UK Heath Secretary cancer prevention, and will haveof approximately 400 deaths per year.

Earlier this year the states Alan Johnson has confirmed that positivemade consequences for public (byscreening executive order) and Virginia quadrivalent HPV theTexas cervical programme health worldwide. will continue after the introduction vaccine mandatory for girls entering sixth grade.43 However, the

of the HPV vaccine. It is expected Acknowledgements Texas voted to overturn the governor’s order, that they legislature will use the recently quadrivalent 48 would like to thank“opt-out” my family vaccine Gardasil. and the state of Virginia granted Iparents generous for their encouragement to write 44 Nearly 20ofadditionalthis states areand considering In provisions.

Ireland, the Department paper, Professorssimilar Health and Children has not Malone and Prendeville for their yet introduced routine cervical helpful comments. cancer vaccination, or even a systematic screening programme.

Refences available on request

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32

Eye Health

Age-Related Macular Degeneration Article contributed by The Irish College of Ophthalmologists Age related macular degeneration (AMD) is the leading cause of sight loss in the over 50s in Ireland. More than 100,000 people in Ireland aged over 50 are living with AMD. Its prognosis has been greatly improved with modern treatment modalities. Without treatment, severe (wet) AMD can lead to loss of central vision and it is the most common cause of legal blindness in the over 60s.

The severity of the disease varies between individuals. Early detection is critical. Usually, even in its most aggressive form, side or peripheral vision is preserved allowing the patient to move around independently and to continue those tasks that do not require fine central vision.

vision. Light focused on the retina is transformed to an electrical signal that is sent to the brain where ‘seeing’ takes place. The macula is responsible for central and fine vision such as reading, colour vision and recognising facial details.

AMD affects the central vision, where the sharpest vision occurs, and can cause difficulty undertaking daily tasks such as reading, driving and recognising faces.

What causes AMD?

What is AMD?

Risk factors for AMD include age, genetic predisposition, dietary and environmental factors such as smoking and cardiovascular disease. Ultraviolet exposure may also have a role. The greatest risk factor is age: a person’s risk typically begins to escalate after age 50. Studies show that after age 75, AMD affects nearly 40 percent of seniors. Smoking poses a significant risk for AMD especially in women.

Age related macular degeneration is an ageing change in the macula.

The macula is the central part of the light sensitive retina. The retina lines the inside of the back of the eye and is responsible for

There are two main types of AMD, ‘Dry’ (atrophic) and ‘Wet’ (neovascular) AMD. Wet AMD represents an advanced stage of the disease. It is almost always preceded by Dry AMD.

Early diagnosis and treatment by an ophthalmologist is recommended which results in a better visual outcome for patients.

Dry AMD

Wet AMD

Wet AMD is the less common but Dry AMD is the most common more severe form (affects less (80-90%) and the mildest form than 10%). In this form of AMD, an of the condition. In this type, abnormal blood vessel complex there are typical age changes grows in under the macula as such as age spots or ‘Drusen ‘ in part of the ageing change. The the macula. Very often patients growth of this complex occurs with Dry AMD maintain good due to local release of a chemical central vision, needing perhaps called Vascular Endothelial Growth more magnification and lighting Factor(VEGF). This process results for reading. A small percentage in a cycle of leakage, bleeding of patients with Dry AMD will and scar tissue growth in the develop more severe patchy macula leading to destruction of dry changes with consequential central vision and potentially legal progressive difficulty with reading blindness without Thererelease o and fine vision. At this time there this complex occurstreatment. due to local is a significant risk of Wet AMD is no known cure for Dry AMD, This process cycle of leakage affecting the results second in eyeaover time but progression can be slowed destruction ofsecond centraleye vision and (>50%). The needs to potential by stopping smoking, eating a carefully monitored.the second eye over healthy diet rich in Lutein (found of be Wet AMD affecting in the leafy green vegetables), and looking after cardiovascular risk factors such as high blood pressure and elevated cholesterol.

Dry AMD usually affects both eyes. Dry AMD can progress to Wet AMD.

Symptoms: Symptoms:

DryAMD AMD symptoms symptoms are In InDry areoften often mild, su mild, such as needing stronger When progression to Wet AMD occurs, the glasses or better lighting for reading. When progression to distortion (due to fluid or blood under th Wet AMD occurs, the patient moment to cover or close one eye at a time may notice the onset of blurring seek help promptly from their eye doctor. of reading vision with distortion (due to fluid or blood under the

Amsler Grid macula).

Sometimes patients

are unaware until they take a moment to cover or close one eye at a time. At this stage, the progression can be rapid and patients should seek help promptly from their eye doctor.

Amsler Grid An Amsler Grid is a simple test designed to pick up symptoms of Wet AMD. However, it is not a

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distortion (due to fluid or blood under the macula). Sometimes patients are unaware until they take a moment to cover or close one eye at a time. At this stage, the progression can be rapid and patients should seek help promptly from their eye doctor.

Eye Health Amsler Grid

macula due to a chemical stimulant Looking after general health, being called vascular endothelial growth a nonsmoker, eating a healthy diet factor (VEGF). Intravitreal injections rich in leafy greens (Lutein), and of anti- VEGF drugs, which block sensible use of sunglasses can vascular endothelial growth all help to slow the progression factor, can break the cycle of of AMD. An ophthalmologist will leakage, bleeding and scar tissue often recommend a patient take a growth. Anti-VEGF treatment Lutein based vitamin supplement. offers stabilisation and very often Monitoring the vision in each eye improvement in vision. They are separately using an Amsler grid delivered through an injection can lead to early detection of AMD into the eye, administered by an and an improved visual outcome. ophthalmologist, usually a retinal Knowing the symptoms and specialist. While some pressure signs to be aware of: will be felt during the injection, the eye is first numbed to minimise any 1. Symptoms: look out for discomfort. The aim of treatment straight lines appearing wavy is to preserve existing vision or distorted, e.g. a doorframe. but many patients do have an If you see a smudge, gaps improvement in vision. Intravitreal or dark spots appearing in your field of vision, or have anti-VEGF are administered on difficulties in reading small a monthly basis until stability An Amsler Grid is a simple test designed to pick upissymptoms of Wet AMD. However, it iswith notglasses, a substitute print, even or achieved. Injections may be difficulty in recognising on a regular basis for an eye examination. The patient checks eachneeded eye separately withover reading glasses on.

If theyfaces, notice it is recommended to make an slow the progression of early AMD substitute for an eye examination. several years to maintain vision. appointment an eye new blurring or distortion of the lines on the grid There this could indicate the presence of Wet with AMD anddoctor, they and reduce the risk of conversion The patient checks each eye is extensive research in this optometrist or GP as soon as to Wet AMD. Supplements separately with reading glasses area and it is likely that new drugs should be examined promptly by their eye doctor. possible. containing vitamins C and E, zinc & and new drug delivery systems will on. If they notice new blurring or copper, and lutein and zeaxanthin distortion of the lines on the grid soon become available.

2. Risk groups: People over 50 this couldDiagnosis indicate the presence of AMD are recommended. should have a regular eye exam Laser Photocoagulation of Wet AMD and they should be (every 2 years or as directed The AREDS2 study reformulated examined promptly by their by the is doctor). fair Laser photocoagulation is another A Fluorescein angiogram is a photographic dye test used to assess AMD. The patient givenIf you an have injection the AREDS Formulation.

Betaeye doctor. skin, light eyes, high blood treatment modality for Wet AMD. carotene is replaced by two Fluoresceinanti-oxidants dye into alutein/zeaxanthin, vein in the arm. The dye islessfollowed it goes pressure,as or have beenthrough exposed It is much commonlywith used photographs Diagnosisof of yellow AMD to prolonged periods of sunlight, now with the advent of intravitreal and zinc levels are reduced theangiogram retinal circulation and will show up changes therapy. due toLaser AMD. An OCT is a special ultrasound that will then you should also have A Fluorescein is a light is used to substantially. The study also regular check-ups. photographic dye test used to seal the leaking blood vessels. showed that although there is assess AMD. The patient is given Although laser can be effective, evidence that dietary intake of 3. Healthy diet: eat a diet low an injection of yellow Fluorescein many patients with Wet AMD are omega-3 fatty acids seem to play in saturated fats and rich in dye into a vein in the arm. The dye not suitable candidates as often important roles in visual health, omega 3 fatty acids (oily fish is followed with photographs as it the leakage is centrally located and taking omega-3 as a supplement and walnuts). Green, leafy goes through the retinal circulation laser is therefore not the treatment did not reduce the risk of vegetables (spinach and kale) and will show up changes due of choice. Laser may stabilise the advanced AMD. contain antioxidants, eggs to AMD. An OCT is a special and yellow/orange-based fruit vision but is unlikely to improve it.

An ophthalmologist will speak ultrasound that will instantly detect contain nutrients such as lutein, to their patient about what changes in the macula due to Photodynamic Therapy (PDT) zeaxanthin and beta-carotene – supplements may work best for AMD. It is a quick and reliable test all work to protect the macula.

PDT is another treatment option them. They may also recommend and is as easy for the patient as for Wet AMD. The patient is given 4. Vitamin supplements: certain a comprehensive dilated eye exam a photograph. FA and OCT are an intravenous infusion of a light nutritional supplements at least once a year. The exam will valuable tools in distinguishing Dry sensitive dye called verteporphyrin containing vitamins C and help determine if the condition is from Wet AMD. . When the dye accumulates in the E, zinc, copper, lutein and showing signs of progression to Treatment options for AMD abnormal blood vessel complex zeaxanthin can slow down the the wet form. progression of AMD in people under the macula it is activated Currently, there are no medical In addition, lifestyle changes may already showing signs of the by a laser light resulting in closure treatments available to reverse Dry help slow the progression of AMD, condition. of the blood vessel.

PDT is less AMD, but research is advancing in such as stopping smoking, staying frequently used now following the this area to develop therapies. At 5. Get moving and stop smoking: active and eating a healthy diet advent of intravitreal therapy. PDT this time treatment for Dry AMD is every week we should engage filled with green leafy vegetables can stabilise the vision in certain conservative- and includes dietary in 150 minutes of medium-level and fish. circumstances but again is unlikely lutein supplements and assistance activity such as brisk walking, to improve vision.

Wet AMD Treatment with stronger glasses and better swimming and light jogging.

Smoking poses a significant risk lighting where necessary. An iPad How to Protect Eye Health & Intravitreal therapy - Antifor AMD especially in women. or kindle can often make reading Vision Preservation vascular endothelial growth more enjoyable.

Further information resources: factor (anti-VEGF) drugs Regular eye examination with Supplementation and Lifestyle your ophthalmologist (eye doctor) • The Irish College of The current standard treatment, Dry AMD or optometrists is recommended Ophthalmologists www.

Intravitreal injection therapy has especially if there a family history eyedoctors.ie proven to be a major advance for Age-Related Disease Studies of the condition. This should be patients with Wet AMD. Without (the National Eye Institute (NEI) • The Macular Society www. done every two years for the over treatment these patients would of the US National Institutes of macularsociety.org 50s and annually if there is any face irreversible loss of central Health Age-related Eye Disease hint of AMD. It is important that vision and legal blindness. When Study - AREDS1 and AREDS2) • Retina International also has an patients self-monitor using an Wet AMD develops, abnormal have shown that a combination of international AMD toolkit on their website Amsler grid between visits. vitamins and antioxidants may help blood vessels grow under the

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Clinical Focus

35

Establishing a National Cancer Mission Hub The NCCP Collaborates with the All-Island Cancer Research Institute (AICRI) to establish a National Cancer Mission Hub in Ireland Written by Professor Donal Brennan (NCCP), Professor William Gallagher (AICRI), Dr Rosemarie Gannon (AICRI) and Dr Ozlem McDonnell (NCCP)

Establishing a Na�onal Cancer Mission Hub

Establishing a Na�onal Cancer Mission Hub

a Na�onal Cancer Mission Hub Sub-heading: TheEstablishing NCCP Collaborates with the All-Island Sub-heading: The NCCP Collaborates with the Cancer Research Ins�tute (AICRI) to establish a All-Island Cancer Research Ins�tute (AICRI) to establish a Na�onal Cancer Mission Hub in Ireland Sub-heading: The Na�onal Cancer Mission Hub in NCCP IrelandCollaborates with the All-Island Written by Professor Donal Brennan (NCCP) and Professor William Gallagher Cancer Research Ins�tute (AICRI) to establish a (AICRI)Written by Professor Donal Brennan (NCCP) and Professor William Gallagher (AICRI) Na�onal Cancer Mission Hub in Ireland Written by Professor Donal Brennan (NCCP) and Professor William Gallagher Professor William Gallagher Dr Rosemarie Gannon (AICRI) Dr Ozlem McDonnell (NCCP) (AICRI)

Professor Donal Brennan

and citizens in cancer-related policy dialogues at EU, national, regional and local levels. It will help to advance better integration of cancer research and policy.

Further information on the hubs is available on the ECHoS website (https://cancermissionhubs.eu/)

and the involvement of citizens in how Ireland shapes its health services. It is a key step towards strengthening the voice of national stakeholders in cancer policies in Europe. It will foster national and international collaboration, promote inclusivity, and drive innovation in cancer care. It will Bridging cancer care, cancer also help to accelerate cancer policy and research research in Ireland. The NCMH is an opportunity to tailor our cancer This establishment of a NCMH moving policy-making processes towards people-centric healthcare research systems in landscape to the precise needs in Ireland alignsand with Ireland’s waysHubs: that cannot be achieved through individual and three-year fragmented ini�a�ves. of our patients and society and National Cancer Strategy 2017Establishing of Cancer Mission Networks and Synergies (ECHoS) isnew a new Establishing of Cancer Mission Hubs: Networks and Synergies (ECHoS) is aefforts three-year it is expected to develop some 26, which has a particular focus European consortium supported byEU theMission EU Mission on Cancer and brings together from 58 European consortium supported by the on Cancer and brings together from 58 The NCMHs will encourage participation from stakeholders and patients citizens inincancer-related guidelines and tools that can help on involving their own organisations from governmental, healthcare, research, academic and non-profit sectors the consortium coordinators and Establishing of Cancer Missionpolicy organisations from governmental, healthcare, academic and sectors dialoguesresearch, at EU, national, regional andnon-profit local levels.care It will help to advance better other organisations to implement cancer and further developing experts across Europe, Hubs: Networks and Synergies distributed 28 countries (€6 leading million funding 2023-2026). distributed across across 28 countries (€6integration million funding 2023-2026). of cancer research and policy. Further information the hubs to is available the role ofonresearch improveon the relevant, impact-driven, research to establish a National Cancer (ECHoS) is a new three-year ECHoS website (https://cancermissionhubs.eu/) and policy dialogues in meaningful cancer services, as well aligning Establishing of Cancer Mission Hubs: Networks and Synergies (ECHoS) is a as new three-year Mission Hub (NCMH) in Ireland.

In European consortium supported Na�onal Cancer Mission Hubs (NCMHs) will be created incountries 28 countries (25 with Member States, 3 of Sláintecare the principles areas of health and beyond.

Na�onal Cancer Mission Hubs (NCMHs) will be created in 28 (25 Member States, 3 European consortium by the EUProf.

Mission on Cancer and brings together from 58 terms ofsupported project leadership, by the EU Mission on Cancer Associated Countries). Ireland is represented within the ECHoS project by the HSE Na�onal Associated Countries).

Ireland within theisECHoS project byresearch, the HSE Na�onal Donalgovernmental, Brennan the healthcare, National and brings together from 58 is represented organisations from academic and non-profit sectors Cancer Control Programme (NCCP:Clinical htps://www.hse.ie/eng/services/list/5/cancer/) as the Lead for (€6 Cancer Research organisations from governmental, distributed 28 countries million funding 2023-2026).

Cancer Control Programme (NCCP: across htps://www.hse.ie/eng/services/list/5/cancer/) as the primaryresearch, na�onal lead and and the chairs All-Island Cancer Research Ins�tute (AICRI: the NCCP Cancer healthcare, academic primary na�onal lead and the Research All-IslandGroup.

Cancer Research Ins�tute (AICRI: Prof. and William and non-profit sectors distributed htps://www.aicri.org/) as co-par�cipant.

Both the (NCMHs) NCCP AICRI will collaborate closely (25 Member States, 3 Cancer Mission Hubs will be created in 28closely countries htps://www.aicri.org/) asNa�onal co-par�cipant.

Both of theis NCCP andthe AICRI will collaborate Representatives AICRI and NCCP Gallagher a cancer biologist across 28 countries (¤6 million with the consor�um coordinators and leading experts across Europe, to establish a Na�onal Representatives of AICRI and Associated Countries). is represented the aECHoS project by the HSE Na�onal attended the launch of theacross ECHoS projectDublin intowithin based inIreland University College funding 2023-2026). with theCancer consor�um and leading Europe, establish Na�onal Missioncoordinators Hub (NCMH) in Ireland.

Inexperts terms of project leadership, Prof. Donal Brennan is the NCCP attended the launch Lisbon in early May 2023.

The kick-off and co-lead of AICRI. Both the Cancer Control Programme (NCCP: htps://www.hse.ie/eng/services/list/5/cancer/) as the Cancer Mission HubClinical (NCMH)Lead in Ireland.

In terms of project leadership, Prof.

Donal Brennan is of the ECHoS project in Lisbon National Cancer Mission Hubs the Na�onal for Cancer and chairs theproject NCCP Cancer Research Group. meeting in Research Lisbon allowed thecollaborate NCCP and AICRI will primary na�onal lead and thethe All-Island Cancer Group.

Research Ins�tute (AICRI: in early May 2023. The kick-off the(NCMHs) Na�onal Clinical Lead for Cancer Research and chairs NCCP Cancer Research will be created in 28 Prof. William Gallagher is apartners cancer biologist based University Dublin and co-lead of to meet,to toestablish learninmore about College the closely a NCMH in meeting in Lisbon allowed the htps://www.aicri.org/) as co-par�cipant.

Both the NCCP and AICRI will collaborate closely countries Member Prof.

William Gallagher isStates, a cancer biologist basedThis inCancer University College Dublin andinco-lead Strategy on andto hear about Ireland. combined effort AICRI.(25 Both the NCCP and 3European AICRI will collaborate closely establish a NCMH Ireland.ofThis project partners to meet, to learn Associated Countries). with Ireland is consor�um the coordinators and leading experts across Europe, to establish a Na�onal other EU-funded projects in cancer research will coordinate research and AICRI. Both the NCCP and AICRI will collaborate closely to establish a NCMH in Ireland. combined effort coordinate research and innova�on and healthcare ac�ons on This cancer, more about the European Strategy represented within thewill ECHoS service delivery. and The launch meeting Cancer and Mission Hub inhealthcare Ireland.

Inactions terms of project is Cancer and hear about other combined effort will coordinate researchinnovation and(NCMH) innova�on and healthcare ac�ons onleadership, cancer, Prof. Donal Brennanon project by the HSE National provided a cancer, better understanding of EC on moving policy-making EU-funded projects in cancer the Na�onal Clinical Lead for Cancer Research and chairs the NCCP Cancer Research Group.

Cancer Control Programme expectations for ECHoS and the National processes people-centric research and service delivery. The 1atowards Prof. William Gallagher is cancer biologist based in University College Dublin and co-lead of (NCCP: https://www.hse.ie/eng/ Cancer Mission Hubs. and Partners also learned healthcare research systems launch meeting provided a better 1 and services/list/5/cancer/) AICRI. as the Both more the about the ECHoS project’s six work willbecollaborate closely to establish a NCMH in Ireland. This inNCCP ways thatAICRI cannot achieved understanding of EC expectations primary national lead and the Allpackages. through individualresearch efforts and for ECHoS and the National Cancer combined effort will coordinate and innova�on and healthcare ac�ons on cancer, Island Cancer Research Institute fragmented initiatives.

Mission Hubs. Partners also (AICRI: https://www.aicri.org/) as learned more about the ECHoS co-participant. Both the NCCP and The NCMHs will encourage project’s six work packages 1 AICRI will collaborate closely with participation from stakeholders Bridging cancer care, cancer policy and research This establishment of a NCMH in Ireland aligns with Ireland’s Na�onal Cancer Strategy 2017PHARMACYNEWSIRELAND.COM 26, which has a par�cular focus on involving pa�ents in their own cancer care and further developing the role of research to improve cancer services, as well as aligning with the

are now championing a pan-European coopera�on towards a Health in All Policies (HiAP) approach, and a data-informed, ci�zen-focused, research-driven agenda. The �me to act is now.

36

Clinical Focus

Stephen Donnelly, TD, will provide a keynote address at this event.

There will be five main sessions as follows: Session 1: Ireland’s Participation in EU Cancer Mission Projects Session 2: How Can We All Benefit from Europe’s Beating Cancer Plan?

Session 3: The Lived Experience at the Heart of National and European Cancer Initiatives Session 4: Co-ordination of Cancer Research at National and European Levels Session 5: Engagement with Ireland’s National Cancer Mission Hub going forward Attendance in-person at this event is now sold out, however, if you are most welcome to join the event EU Mission on Cancer, cancer Mission Day – Ireland in Dublin Time to Act online by registering on Eventbrite on 26th September 2023. This occupies a central place within Cancerinrepresents a global with health the the event Mission will provideDay a platform for in (https://www.eventbrite.ie/e/euAICRI, collabora�on NCCP, is organising an EU Cancer – Ireland European political agenda. challenge and the fight against cancer-mission-day-ireland-onlineacademic researchers, clinician political leaders are now th September 2023.Europe’s This event will provide a pla�orm for academic researchers, tickets-682109025457) and to view Dublin cancer on can26 no longer be an scientists and other healthcare championing a pan-European isolated endeavour. professionals, partners andas the agenda. cooperation towards a Healthcharity in clinician scien�stsCurrently, and other healthcare professionals, partners andcharity policymakers, research, innovation and policymakers, as well as those All Policies (HiAP) approach, and well as those witharea largely lived experience of cancer, to come together and experience share their insights, Contact: Dr Ozlem McDonnell, healthcare initiatives with a lived of cancer, a data-informed, citizen-focused, NCCP ECHoS Project Coordinator siloed within specific communities to together and share research-driven agenda.approaches The time knowledge and experiences to explore innova�ve tocome address cancer challenges. (ozlem.mcdonnell@cancercontrol.ie) and the engagement of citizens their insights, knowledge and to act is now.

Minister for Health, Stephen Donnelly, TD, will provide a keynote address to atexplore this event.

There Dr Rosemarie Gannon, is either poor or non-existent. experiences innovative AICRI, in collaboration with the Supported by the European approaches to address cancer AICRI Project Manager will be five main sessions as follows: NCCP, is organising an EU Cancer (rosemarie.gannon@ucd.ie) Beating Cancer Plan and the challenges. Minister for Health,

Session 1: Ireland’s Par�cipa�on in EU Cancer Mission Projects Session 2: How Can We All Benefit from Europe’s Bea�ng Cancer Plan?

Session 3: The Lived Experience at the Heart of Na�onal and European Cancer Ini�a�ves Session 4: Co-ordina�on of Cancer Research at Na�onal and European Levels Session 5: Engagement with Ireland’s Na�onal Cancer Mission Hub going forward Atendance in-person at this event is now sold out, however, if you are most welcome to join the event online by registering on Eventbrite (htps://www.eventbrite.ie/e/eu-cancermission-day-ireland-online-�ckets-682109025457) and to view the agenda.

3

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Prescribing information

CPD: Cold & Flu Continuing Professional Development

CPD

39

AUTHOR: Written by Damien O’Brien, Pharmacist, Adrian Dunne Pharmacy Baldoyle

60 Second Summary The common cold and flu are both viral upper respiratory tract infections. Symptoms are generally self-limiting, with symptoms of a cold including blocked or runny nose, sneezing, cough and sore throat. Symptoms of flu include fever, fatigue, body aches, headache, dry cough and nausea.

Patients should be screened for warning signs or complications associated with respiratory tract infections. Pharmacists and pharmacy staff should carry out a structured approach to each consultation to ensure each patient receives appropriate counselling, treatment and referral if necessary. Prevention is important in reducing the spread of flu, with vaccination the best approach in preventing and reducing severity of symptoms. Hand hygiene and other measures can also be effective in reducing transmission of respiratory viruses. The diagnosis of cold and flu is generally based on symptoms and physical examination, with laboratory tests used only if necessary.

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

4 previous steps, log and record your findings.

Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author.

Solpa Cold & Flu has no editorial oversight of the CPD programmes included in these modules.

Pharmacy Role in Cold & Flu Care Introduction and epidemiology The common cold and flu are both upper respiratory tract illnesses caused by viral infections. They both tend to be acute, selflimiting and may sometimes involve the lower respiratory tract.1 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.1 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.2

Complications and Warning Signs 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. Rarer complications in children can include myocarditis, pericarditis, encephalopathy, encephalitis and Reye’s syndrome. The most common complications of flu in adults are pneumonia and bronchitis, which can lead to respiratory failure, acute respiratory distress syndrome, septic shock or multi-organ failure. Flu can often cause dehydration, which can exacerbate underlying chronic medical conditions.6 Patients that are aged 65 years or older, pregnant or have a long-term medical condition are at an increased risk of complications from flu. As patients with asthma, COPD, diabetes and heart failure are at a higher risk of complications, there may be a need to refer to a medical doctor for further treatment.

Pharmacists and pharmacy staff should be aware that patients may need referral to a doctor if their symptoms don’t improve after 7 days or they have a weakened immune system, due to HIV or chemotherapy.7

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Antibiotics are not effective in treating cold and flu, and their use can lead to the development of antimicrobial resistance. Antimicrobial stewardship is a set of measures to counteract resistance and pharmacists have an important role in this process. Depending on the symptoms; analgesics, antihistamines, decongestants, antitussives and expectorants can be used to provide Symptoms symptomatic relief. Nonpharmacological treatment The common cold and flu and self-care can also play a can share some similarities in role in the treatment of cold symptoms but differences exist and flu. Antiviral treatment may between the viruses. The common be initiated within 48 hours of cold generally has a gradual symptom onset in patients who onset of symptoms, compared Solpa Cold & Flu Strip ad CPD v4 (HIRES).pdf 1 31/07/2023 17:12 are deemed to be at risk of to the more sudden onset of complications. flu symptoms, which usually

appear within a few hours. Both viruses can be unpredictable, but symptoms generally start to resolve after one week. 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 include blocked or runny nose, sneezing, cough, sore throat and fever.3 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.4, 5 Influenza can be classified into uncomplicated and complicated.

Uncomplicated flu is characterised by the sudden onset of the typical symptoms outlined above, with symptoms generally resolving in less than two weeks. Complicated flu occurs when the viral infection causes a potential wide range of complications that can result in severe disease.6

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution and Solpa Cold & Flu Multi Relief Capsules. See SmPC for full list of side effects and further information.

Product not subject to medical prescription. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

IRE SCF 2023 12

40

CPD: Cold & Flu

In the event of patients experiencing any warning sign symptoms, then they should seek medical attention immediately.

Pharmacies are often the first port of call for patients with symptoms, therefore pharmacists and pharmacy staff should recognise when referral is necessary. Some of the more common of these warning signs are outlined in the table to the right.7, 8

Warning Signs Coughing up blood Worsening of chronic medical conditions Difficulty breathing or shortness of breath Seizures Pain or pressure in the chest or abdomen Persistent dizziness or confusion Not urinating or dehydration Fever or cough that improves but returns or worsens Bluish lips or face

to antimicrobials without having a negative effect on clinical outcomes such as duration of illness, length of hospital stays, morbidity or mortality.

Antimicrobial stewardship will also ensure a reduced risk in the development of superbugs.12

to an increase in duration of illness, hospital stay, cost, morbidity and mortality (12).

Antibiotic resistance is a major threat and a concerted effort, including not prescribing antibiotics for cold and flu, must be made (13).

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Pharmacists can play an important role in antimicrobial stewardship, particularly in the context of cold and flu. Encouraging hand hygiene techniques and vaccination Community Pharmacy Role in reduces transmission of viral Cold and Flu infections and therefore reduces Community pharmacy is often inappropriate prescribing of the first port of call for patients antibiotics. Pharmacists can have when they have symptoms of discussions with prescribers about cold or flu. Most symptoms can the inappropriate prescribing of be effectively treated by using antimicrobials for viral infections use of a framework essential for illnesses. Overuse of antibiotics over-the-counter (OTC) medicines such as the common cold and can lead toand the development of retrieving information.

Who is the Community Pharmacy Role in Cold Flu from community pharmacies, flu. Pharmacists can mention the antibiotic-resistant pathogens.11 patient, What are the symptoms, which can help reduce the lack of effectiveness of antibiotics Studies have estimated that How long has the patient had burden on other primary care in treating cold and flu, with the approximately half of antibiotic the symptoms, Action to date is often the first port of call for patients Community pharmacy when they have symptom providers and emergency potential for adverse effects and use is either unnecessary or and other existing Medication cold or flu.

Most symptoms can be effectively treated by using over the counter (OTC) departments. A systematic the development of antibiotic inappropriate. Therefore, there are being taken (WWHAM) is the approach to each consultation As drug experts,on other prim medicines community pharmacies, which can help resistance. reduce the burden major concerns about potential most common from framework should be implemented to ensure pharmacists can contribute adverse effects from overuse of used information gathering. careinproviders and emergency departments.

A systematic approachstewardship to each consultatio to antimicrobial a consistent high-level of care to antibiotics, as well as the selection Effective communication skills by influencing those crucial each patient presenting with cold should be implemented a consistent high-level of care to each patient presen of antibiotic-resistant pathogens. are necessary to counsel each to ensure prescribing decisions. Pharmacists and flu symptoms. A patientThe slowing of the development of patient and communication style with cold and flu symptoms.

A patient-centred approach should be followed can discuss other treatmentin commun centred approach should be new antimicrobials have left fewer may be required to be tailored to options with the prescriber that followed in community pharmacy. pharmacy.

All pharmacy staff should be fully trained and competent in conducting OTC treatment options for antibioticeach patient. Pharmacists should focus on symptomatic relief for the All pharmacy staff should be resistance pathogens, leading to consultations.

There is a great importance in tailoring each consultation to reflect the oversee consultations to ensure patient.15 The HSE have thorough fully trained and competent in an increase in duration of illness, correct treatment options are different role, responsibility and knowledge of the staff members. staff should guidelines on Pharmacy antibiotic prescribing conducting OTC consultations. hospital stay, cost, morbidity and selected or patients are referred community infections that There is a great importance in 9 know when to refer to the pharmacist whenresistance carrying outfor each consultation (9).are mortality.12 Antibiotic if necessary.

16 very useful. Pharmacists are also tailoring each consultation to is a major threat and a concerted ideally placed to counsel patients reflect the different roles and Antimicrobials and Antimicrobial effort, including not prescribing on the lack effectiveness of to ensure responsibility and knowledge of Stewardship Effective consultations between pharmacy staff and patients areoffundamental antibiotics for cold and flu, must antibiotics on viral infections and 13 the staff members. Pharmacy staff be made. appropriate recommendations are made and desired patient outcomes arewith achieved.

Antimicrobial resistance (AMR) potential risks associated their should know when to refer to the occurs when bacteria, viruses, Antimicrobial stewardship is a set use.

Pharmacists can effectively Optimal management of these consultations require effective information gathering from pharmacist when carrying out fungi and parasites adapt over measures that has the objective communicate to patients that each consultation.9 patient, with proper use of aof framework essential for retrieving information. Who is the time and are no longer treatable of improving the appropriate these illnesses are generally Effective consultations between by antimicrobials. patient, WhatThis aremakes the symptoms, How long has the patient had the use of antimicrobials.

It does self-limiting andsymptoms, symptomatic Action to pharmacy staff and patients are infections much more difficult to thisbeing by ensuring the correct treatment cancommon be much more and other existing Medication taken (WWHAM) is the most framework u fundamental to ensure appropriate treat and increases the spread of antimicrobial treatment is selected useful than antibiotic treatment.15 10 Effective communication skills are necessary to counsel each in information gathering. recommendations are made and disease, morbidity and mortality. for the appropriate infection, as desired patient outcomes are Antibiotics are not effective in well as may the correct duration of to be Prevention patient and communication style be required tailored to each patient. Pharma achieved. Optimal management treating viral infections such as therapy, dosage and route of Prevention is key in reducing should oversee consultations to ensure 14 correct treatment options are selected or patien of these consultations require the common cold and influenza administration. Antimicrobial the burden of cold and flu in effective information gathering and should not be aretherefore referred if necessary (9).stewardship has been shown to society. Pharmacists are trusted from the patient, with proper used in the treatment of these reduce a pathogen’s resistance healthcare professionals and therefore can reshape patient Antimicrobials and Antimicrobial Stewardship perceptions and reinforce the messaging around prevention of infection. Vaccination is an Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites adap important preventative measure over time and are no longer treatable by antimicrobials. against This makes influenza.infections Unfortunately,much mo due to many different serotypes difficult to treat and increases the spread of disease, morbidity and mortality (10). Antib of the common cold, it is not are not effective in treating viral infections such as the common andagainst influenza and possible to cold vaccinate this illness. Simple measures of including therefore should not be used in the treatment of these illnesses.

Overuse antibiotics regular handwashing with soap, lead to the development of antibiotic-resistant pathogens (11). touching Studies estimated avoiding thehave face and cleaning surfaces that people approximately half of antibiotic use is either unnecessary or inappropriate.

Therefore, th touch can help prevent are major concerns about potential adverse effects fromregularly overuse of antibiotics, as well a spread of respiratory viruses. selection1 of31/07/2023 antibiotic-resistant pathogens. The slowing of the development of new Solpa Cold & Flu Strip ad CPD v4 (HIRES).pdf 17:12 Covering coughs and sneezes with a tissue and discarding the antimicrobials have left fewer treatment options for antibiotic-resistance pathogens, lead tissue immediately after use,

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution and Solpa Cold & Flu Multi Relief Capsules. See SmPC for full list of side effects and further information.

Product not subject to medical prescription. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

IRE SCF 2023 12

r resolve resolve within within 4848 hours. hours.

Taking Taking paracetamol paracetamol and and resting resting e areare advised advised if these if these side side effects effects area e experienced. experienced.

More More serious serious side side effects effects areare rare rare and and should should bebe reported reported to the to the HPRA HPRA (24).

(24).

41and A A wide A wide number number of people of people in Ireland in Ireland areare eligible eligible forfor a free a free flu flu vaccination vaccination in Ireland in Ireland and these thes a areare outlined outlined in the in the table table below below (24).

(24). improving ventilation in buildings and avoiding close contact with other people when symptomatic are all also practical measures that patients can be counselled on to reduce spread of common cold and flu.17, 18 Vaccination

A person A person is eligible is eligible forfor a free a free fluflu vaccination vaccination if they if they are: are: A 6565 years years and and older older • ageage age age 2 to 2 17 to 17 years years • a healthcare worker worker • a healthcare Pregnant Pregnant • living in ainnursing a nursing home home or or other other long-term long-term care care facility facility • living in regular contact contact with with pigs, pigs, poultry poultry or or waterfowl waterfowl • in regular someone someone with with a health a health condition condition that that puts puts youyou at higher at higher riskrisk of flu of flu which which includes: includes: • - chronic - chronic heart heart disease disease - chronic - chronic liver liver disease disease - chronic - chronic kidney kidney failure failure - chronic - chronic respiratory respiratory disease disease - chronic - chronic neurological neurological disease disease - diabetes - diabetes - Down - Down syndrome syndrome - haemoglobinopathies - haemoglobinopathies - a-body a body mass mass index index (BMI) (BMI) over over 4040 - immunosuppression - immunosuppression due due to disease to disease or or treatment treatment - children - children with with a moderate a moderate to severe to severe neurodevelopmental neurodevelopmental disorder disorder - children - children onon long-term long-term aspirin aspirin therapy therapy - any - any condition condition that that cancan compromise compromise respiratory respiratory function function living living with with someone someone who who has has a health a health condition condition that that puts puts them them at higher at higher risk risk of flu of flu • a carer forfor someone someone who who hashas a health a health condition condition that that puts puts them them at higher at higher riskrisk of flu of flu • a carer

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Vaccination is the best method of protection against flu.19 Vaccines contain weakened or inactive parts of a pathogen that triggers an immune response in the body, that will produce antibodies and offer protection if exposed to the pathogen later.20 The flu vaccine should be administered annually as the antibodies reduce over time, as well as the fact that flu strains can change from year to year. The vaccine is generally available from October to April, but it is ideal to get it as early as possible, before the commencement of flu season.

Vaccination generally reduces the risk of getting flu by 40% to 60% and can also reduce intensity and duration of symptoms. There are usually two vaccines available in Ireland; the quadrivalent influenza vaccine (QIV) which is generally used for over 18 years old and the live attenuated influenza vaccine (LAIV) which is used for those aged 2 to 17 years old.21 The preferred administration site for the QIV is in the deltoid muscle via their primary care physician, influenza and other respiratory symptoms. Side effects associated intramuscular injection.22 The LAIV infections Covid-19. with diphenhydramine pharmacists havehave a have verybeen important P Pharmacists Pharmacists been providing providing a seasonal aincluding seasonal influenza influenza vaccination vaccination service service ininclude community in community is administered nasally, with half of Reliability can be anservice issue for in all community drowsiness, dry mouth and blurred role in this. Pharmacists can the dose administered via ap spray pharmacies pharmacies since since 2011 2011 (25).

(25).

Flu Flu vaccination vaccination service in community pharmacies pharmacies has has been been these methods of diagnosing.28 vision.31 Second-generation counsel patients on the benefits in both nostrils.23 Mild side effects r reported reported to improve to improve uptake uptake of the of the vaccine. vaccine.

Recommendations Recommendations e from from healthcare healthcare workers workers have hav Therefore, diagnostic tools are antihistamines are ineffective in of vaccination, risks of not getting are possible and can include fever, 32 not very useful, and treatment can treating symptoms of cold andpharmacy flu. vaccinated andto ease a also also shown shown greatly to patient greatly improve improve vaccination vaccination rates. rates.

AsAs patients patients visit visit their their community community pharmac fatigue, soreness or swelling at be initiated if required basedpharmacists onpharmacists concerns regarding potential injection site, body aches and m much much more more often often than than their their primary primary care care physician, physician, have have a very a very important important role role Decongestants clinical symptoms, patient history side effects.26 headaches. Nasal congestion 29 i in this. in this.

Pharmacist Pharmacist can can counsel counsel patients n patients on on the the benefits benefits of vaccination, of vaccination, risks risks of not of not getting getting and physical examination. is also common with nasal Decongestants have been shown Diagnosis vaccinated vaccinated and and ease ease patient patient concerns concerns regarding regarding potential potential side effects effects (26). va administration of the vaccine. toside have clinical(26). effectiveness Treatment These are generally self-limiting in reducing symptoms of The diagnosis of common and will resolve within 48 hours.

Treating based on symptoms that rhinorrhoea, nasal congestion cold and flu is generally based Taking paracetamol and resting a patient exhibits is the mainstay and sneezing.31 Pseudoephedrine on symptoms and physical Diagnosis Diagnosis D are advised if these side effects of treating common cold and and Phenylephrine are two examination.

As these illnesses are experienced. More serious flu. Getting a full knowledge of decongestants that are licensed are usually self-limiting, symptoms side effects are rare and should be clinical symptoms and patient for OTC use in those aged can bediagnosis examined by a common physician The The diagnosis of of common cold cold and and flu flu is generally is generally based based on on symptoms symptoms and and physical physical T reported to the HPRA.24 history is important in selecting an 12 years and older in Ireland. and a diagnosis made without examination. examination.

As As these these illnesses illnesses are are usually usually self-limiting, self-limiting, symptoms symptoms can can be be examined examined by by a a e appropriate treatment Potential side effects can the need for further diagnostic A wide number of people in Ireland 27 option.

OTC analgesic options include agitation, hypertension, physician physician and a diagnosis a diagnosis made made without without need need for for further further diagnostic diagnostic tools tools (27).

(27).

Rapid Rapid p tools.

Rapidand influenza diagnostic are eligible for a free flu vaccination including paracetamol anddiagnose tachycardia, nausea and tests (RIDTs) diagnostic candiagnostic be used to influenza influenza tests tests (RIDTs) (RIDTs) cancan bebe used used to to diagnose influenza influenza by by detecting detecting antigens antigens i n in Ireland and these are outlined in ibuprofen are useful in treating dysrhythmia. Decongestants can diagnose influenza by detecting 24 the table above. that that stimulate stimulate an an immune immune response. response.

Molecular Molecular assays assays that that detect detect genetic genetic material material of t h aches and pains, as well as also be used in combination with of a antigens that stimulate an immune lowering fever associated with the first-generation oral antihistamine. influenza influenza can can be be used used and and are are more more accurate accurate than than RIDTs. RIDTs. Both Both tests tests take take less less than than 2020 i n response.

Molecular assays Pharmacists have been 30 virallaboratory infection.

Xylometazoline is a decongestant that detect to genetic material ofSpecialised providing a seasonal influenza minutes minutes perform. to perform.

Specialised laboratory tests tests such such as as polymerase polymerase chain chain reaction reaction (PCR) (PCR) m that can be used topically to influenza can be used and are vaccination service in community Antihistamines tests tests can can be be used used for for diagnosing diagnosing influenza. influenza.

These These tests tests are are usually usually not not required required but but can can bebe t e reduce nasal symptoms. Side more accurate than RIDTs. Both pharmacies since 2011.25 Flu effects of nasal decongestants tests take less than 20 minutes to vaccination service in community First-generation antihistamines can include irritation of nasal perform. Specialised laboratory pharmacies has been reported to such as brompheniramine and membranes, rebound congestion tests such as polymerase chain improve uptake of the vaccine. chlorpheniramine have been shown and nosebleeds.31 reaction (PCR) tests can be used Recommendations from healthcare to provide some symptomatic for diagnosing influenza. These workers have also shown to relief. This involves a reduction Cough medicines Solpaimprove Cold & Flu Strip ad rates.

CPD v4 (HIRES).pdf 1 31/07/2023 tests are usually not required17:12 greatly vaccination in symptoms such as sneezing but can be useful in differential As patients visit their community and nasal discharge, as well Codeine is an opioid antitussive pharmacy much more often than diagnosis between common cold, as a reducing the duration of and used to be the gold standard

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution and Solpa Cold & Flu Multi Relief Capsules. See SmPC for full list of side effects and further information.

Product not subject to medical prescription. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

IRE SCF 2023 12

42

adolescents aged 13 years and over, with a bo children aged from 1-12 years, the weight-adju below is recommended.

CPD: Cold & Flu

treatment for cough. It is no longer recommended due to lack of evidence of efficacy and many side effects associated with its use including dependence, drowsiness and constipation.33 Dextromethorphan is a non-opioid antitussive and does have efficacy in suppressing cough caused by upper respiratory tract infections.31 Expectorants and mucolytics have efficacy in treating productive cough caused by acute upper respiratory tract infections. They work by increasing the volume of sputum in the airway and decreasing the viscosity, which promotes effective clearance of mucus. Clinical studies have shown the efficacy of expectorants in treating acute upper respiratory tract infections, where excess mucus and cough are symptoms.34 Carbocisteine (from 2 years and older) and guaifenesin (from 6 years and older) are available OTC in Ireland.35, 36 Non-pharmacological treatment Daily administration of zinc has effectiveness in reducing the number of colds per year, particularly in children. Other

supplements such as vitamin C, vitamin D and garlic have mixed results, with studies showing no benefit versus placebo. Natural products including ginseng and echinacea showed no clear evidence of benefit. Homeopathy also does not have a positive effect on preventing or treating the common cold or flu.37 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.38 Self-Care Pharmacists and pharmacy staff should ensure patients are counselled on the importance of self-care in the treatment of cold and flu. Patients should be advised to keep warm, avoid smoking and eat well. Getting plenty of rest and sleep are important in self-care treatment, with the

Body Weight 10 kg to 15 kg > 15 kg to 23 kg > 23 kg to 40 kg > 40 kg

Recommended dose 30 mg twice daily

patient advised not to return to normal activities until they feel well enough to do so. Patients should be counselled to drink plenty of water as dehydration can lead to complications. Urine should be a light yellow or clear colour.3

45 mg twice daily 60 mg twice daily 75 mg twice daily condition generally do not need antiviral therapy, unless the clinician feels the patient is at risk of developing complications.

Symptomatic treatment is generally recommended for these patients. Patients who are deemed to be at risk of complications should be commenced on Oseltamivir as soon as possible, even without laboratory confirmation of diagnosis.

Oseltamivir is also recommended for treating flu in pregnancy due to potential adverse clinical outcomes for this patient group.

Initiating antiviral treatment within 48 hours of symptom onset can reduce risk of complications including pneumonia and respiratory failure. It can also reduce risk of hospitalisation, morbidity and mortality.39

3 mg/kg twice daily is the recommended dose dosing regimen is not suitable for infants with a (40). Duration of treatment is usually 5 days, w immunocompromised adults and adolescents r Antiviral treatment suspected, zanamivir can be initiated within 48 Flu can also be treated orally with Oseltamivir (Tamiflu) and by dose is inhalations) every 12 hours. T inhalation with10mg Zanamivir (2 (Relenza).

These are both antivirals of the as it is not marketed in Ireland, it is only availa neuraminidase inhibitor class, which have activity against bothsought if considering initiating advice should be influenza A and B. Previously healthy patients with no underlying

The recommended treatment dose of Oseltamivir is 75mg twice daily for adults and adolescents aged 13 years and over, with a body weight of greater than 40kg. In infants and children aged from 1-12 years, the weight-adjusted dosing regimen outlined in the table at the top of the page is recommended.

Solpa Cold & Flu Strip ad CPD v4 (HIRES).pdf

1

31/07/2023

17:12

3 mg/kg twice daily is the recommended dose for infants 0 - 12 months of age. However, this dosing regimen is not suitable for infants with a post-conceptual age less than 36 weeks.40 Duration of treatment is usually 5 days, with 10 days for oseltamivir in immunocompromised adults and adolescents recommended.39 If oseltamivir resistance is suspected, zanamivir can be initiated within 48 hours of symptom onset. The recommended dose is 10mg (2 inhalations) every 12 hours. The product is authorised for use in the EU but as it is not marketed in Ireland, it is only available as an unlicensed product. Specialised advice should be sought if considering initiating zanamivir.39

N

EW

References available on request

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution and Solpa Cold & Flu Multi Relief Capsules. See SmPC for full list of side effects and further information.

Product not subject to medical prescription. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland.

IRE SCF 2023 12

News New Treatments for Epilepsy In a discovery that could lead to new treatments for epilepsy, a study led by RCSI University of Medicine and Health Sciences and FutureNeuro has identified a previously unknown ‘master controller’ of electrical signals in brain cells.

The study showed that the molecule could be a useful target for future medicines to help control seizures in epilepsy, which is one of the most common chronic brain diseases, affecting around 65 million people worldwide.

Around one in three people with epilepsy have uncontrolled seizures despite being treated with currently available antiseizure medication.

The study, which was published in the journal Proceedings of the National Academy of Sciences of the United States of America (PNAS), took a broader look at what naturally controls how our brain cells communicate.

All of our brains need electrical signals to function. These signals begin with the entry of charged sodium ions into neurons through dedicated channels, which act like gates or doorways on the surface of the cells. In people with epilepsy these channels become overactive, leading to higher-frequency signals that generate seizures.

The ‘master controller’ molecule discovered by the team at RCSI and FutureNeuro, the SFI Research Centre for Chronic and Rare Neurological Disease, is called microRNA-335, a type of ribonucleic acid (RNA) that occurs naturally in our brain cells. By sticking to the messages that instruct how to assemble the channels, microRNA-335 lowers the amounts of sodium channels in brain cells.

In a series of experiments on human-derived cells growing in the lab, the study found that reducing the amount of microRNA-335 in neurons increased the amount of sodium ions that moved into the cells and caused the brain cells to become more excitable. This finding underscores the calming actions of microRNA-335.

43

Researching Deprescribing given Grant 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, Senior Lecturer at RCSI School of Pharmacy and Biomolecular Sciences

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 patient-centered 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 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.

Commenting on the announcement, Dr Moriarty said, “The support from this award will enable me to build a team to pave the way for highquality 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. This is an important milestone which recognises our dedication to advancing cuttingedge 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.

Dr Sophie Hawkesworth, Senior Research Manager in Discovery Research at Wellcome commented: “I’m delighted that Wellcome are supporting this exciting award in such an important research area.

Our Discovery Research schemes are designed to enable a really broad range of research questions that have the potential to transform our understanding of health and disease.

This award is a great example of the research we are aiming to support that will bring new knowledge and new research tools to a really important and under-studied area. I will be following the progress of the project with interest.”

PHARMACYNEWSIRELAND.COM

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Awards

Mark’s Pharmacy Staying at the Top

Awards The Irish Pharmacy

2023

The key to any successful pharmacy is Teamwork and this award recognises the power and potential of a focused and unified approach to healthcare initiatives.

Mark’s Pharmacy, Ardee were delighted to win the title of the Viatris Community Pharmacy Team of the Year Award for 2023, making it their second Award of the evening.

Winners of Viatris Community Pharmacy Team of the Year Award from Mark’s Pharmacy, Ardee with Mark McPhillips, Pharmacist & Owner (centre) and Melissa Fisher, General Manager, Viatris (3rd left)

The diverse skillset and responsibilities of each team member at Mark’s Pharmacy contributed to the successful execution of the vaccination service project and the ongoing growth and success of the business. Through collaboration, communication, and a shared commitment to excellence, the team consistently delivers exceptional patient care and service to their community.

This community pharmacy team excels in team spirit and enhancing patient care at all levels. They consistently collaborate and support each other, fostering an environment of trust and respect that allows each member to contribute their unique skills towards shared goals.

Owner and Pharmacist Mark explains, “Our community pharmacy team excels in team spirit and enhancing patient care at all levels. We consistently collaborate and support each other, fostering an environment of trust and respect that allows each member to contribute their unique skills towards shared goals.

“We embrace innovation and forward thinking in our pharmacy operations, using technologies like Asana and Geckoboard to optimise processes and implementing new services to cater to diverse customer needs. Our dedication to continuous improvement keeps us ahead of industry trends, ensuring better service for our patients.”

Mark highlights this his team, whether within a single

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organisation or across multiple organisations, unifies around common objectives.

“This focused and unified approach to healthcare initiatives has resulted in numerous successful projects over the past year, showcasing our excellence in quality, innovation, productivity, and prevention.

“Examples of our achievements include the integrated vaccination service, in which we partnered with local stakeholders to improve community vaccination rates, and the expansion of healthcare offerings such as 24-hour BP monitoring, HbA1c testing, and mole scanning. These initiatives demonstrate our commitment to enhancing patient care and meeting diverse healthcare needs.

“Our team has actively engaged with local stakeholders, including GPs, businesses, schools, and nursing homes, to promote our services and support community health.

This collaborative approach has positioned us as a reliable healthcare partner and strengthened our ties to the community” “Additionally, we have implemented process improvement models like TOTE and Lean, fostering a culture of ongoing evaluation and enhancement that drives our team’s success.”

45 The team who were Finalists for this prestigious Award in 2022, list their achievements as having stemmed from shared principles such as trust, collaboration, innovation, and patient-centricity.

“We actively support each other in reaching our goals and overcoming challenges, resulting in a positive and productive work environment,” Mark adds.

One recent project that showcased their teamwork was an ‘Integrated Vaccination Service and Expanded Healthcare Offering.’

Mark’s Pharmacy effectively implemented an integrated vaccination service project, which led to enhanced vaccination rates, an influx of new prescription customers, improved customer satisfaction, and a broader range of healthcare services. Collaboration and proactive engagement with local stakeholders were vital to the projects’ success.

All pharmacists efficiently administered vaccinations using a vaccine recording sheet. Sales assistants ensured accuracy in maintaining records within vaccination and MPS PMR systems. Patients received personalised thank-you messages, gifts, and follow-up calls from pharmacists for feedback and satisfaction assessments. The growth in loyalty card uptake enabled the introduction of new services, including BP monitoring, HbA1c measurement, cholesterol testing, mole scanning, Strep A testing, digital otoscopy, wax removal, and hearing checks.

Mark adds, “We partnered with GPs, businesses, schools, nursing homes, and employed various promotional strategies to inform the community about our services.

“Our strategy resulted in higher vaccination rates, contributing to improved public health. Our proactive customer engagement substantially boosted new prescription customers and dispensing figures.

“We were able to show the importance of teamwork, communication, and community engagement in achieving success for both our pharmacy and the community we serve.

“Our community pharmacy team at Mark’s Pharmacy is proud to have been finalists last year for the Community Pharmacy Team of the Year Award, and we believe that this year, we have further elevated our performance, making us deserving recipients of the 2023 title. We have demonstrated unwavering commitment to exceptional patient care, innovation, collaboration, and

continuous improvement, all of which are hallmarks of a community pharmacy team deserving of this prestigious award.

“We have embraced innovation and forward thinking in our pharmacy operations by adopting new technologies such as Asana and Geckoboard for project management and KPI tracking.

Additionally, we have implemented new services like 24-hour BP monitoring, HbA1c testing, mole scanning, and many others to cater to the diverse healthcare needs of our customers.

“Our team’s strength lies in our ability to work together towards a common objective. This focused and unified approach has driven our success in various healthcare initiatives, such as the Integrated Vaccination Service project and the introduction of expanded healthcare services. These efforts have solidified our reputation as a comprehensive healthcare provider in the community.”

They have also been able to achieve ambitious targets. Mark says, “We have set and surpassed ambitious targets, including a 50% increase in vaccination rates, 85% of Google reviews being 5-star, and a 10% yearon-year growth in prescription items. These achievements are a testament to our team’s dedication to excellence and continuous improvement in pharmacy practice.

“Our team has actively engaged with local stakeholders, including GPs, businesses, schools, and nursing homes, to promote our services and support community health. This collaborative approach has positioned us as a reliable healthcare partner and strengthened our ties to the community.

Mark McPhillips, Owner and Pharmacist at Mark’s Staywell Pharmacy with his pharmacy team online presence and helped us better serve our patients.”

Mark went on to explain that the use of Geckoboard and Asana has streamlined the teams data tracking and project management efforts, enabling them to efficiently monitor progress, delegate tasks, and work together as a cohesive unit.

“Our team’s unwavering commitment to providing exceptional patient care and service has translated into tangible results, including increased vaccination rates, enhanced customer satisfaction, and growth in prescription items dispensed.

These accomplishments have positioned our pharmacy as a trusted and valued resource within the community.

“We have prioritised staff satisfaction and professional growth, conducting weekly meetings, feedback sessions, and training events. By investing in our team’s development, we have fostered a culture of learning and continuous improvement.

In conclusion, our community pharmacy team at Mark’s Pharmacy has demonstrated the qualities and achievements deserving of the Viatris Community Pharmacy Team of the Year Award 2023. Our dedication to collaboration, innovation, patient care, and continuous improvement has resulted in a significant positive impact on both our pharmacy operations and the community we serve. As finalists last year, we have further honed our skills and elevated our performance, making this year our time to shine as the Viatris Community Pharmacy Team of the Year Award 2023.”

“We have effectively utilised social media to connect with our community and keep them informed about our services and health initiatives. This engagement has contributed to our growing

Orla Fisher, General Manager with Viatris told us, “The Irish Pharmacy Awards is a time for us to come together as a community to recognise the hard work, dedication, and expertise of our

“Demonstrating our commitment to community health and safety, we have installed a defibrillator at our pharmacy for use by the entire community.

This life-saving equipment reinforces our pharmacy’s role as a vital healthcare resource for the community.

local community pharmacy teams who play a crucial role in ensuring that we all have access to safe and effective medicines.

Every day, the community pharmacy teams across the country provide advice, knowledge and empathy to their patients and are a trusted source of information reflecting all that is good in our communities .

Being the sponsor of this year’s Community Pharmacy Team award resonates strongly with our 1,800+ people working at Viatris across six sites in Ireland whose purpose is to provide access to medicine and empower people to live healthier at every stage of life.

For me personally, I am delighted to congratulate the eight worthy finalists at this year’s Irish Pharmacy Awards who have demonstrated such commitment and dedication to their communities throughout the year.

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Awards

A Rising Star in Community Pharmacy The JPA Brenson Lawlor Young Community Pharmacist of the Year Award recognises rising talent – those individuals who despite being in the early stages of their pharmacy careers are already demonstrating that they can make a difference to the pharmacy profession and the companies for whom they work and the communities they serve.

Awards The Irish Pharmacy

2023

Jason Bradshaw, Partner, JPA Brenson Lawlor with Daniel McCormack, McCauley Health & Beauty Pharmacy, Dungarvan winner of the JPA Brenson Lawlor Young Community Pharmacist of the Year Award and Julieanne Moore, McCauley Health & Beauty Pharmacy

The Award for 2023 was won by Daniel McCormack, McCauley Health & Beauty Pharmacy, Dungarvan. Daniel’s proactive approach to administering Covid-19 vaccinations and providing flu vaccinations demonstrates his dedication to improving the health and well-being of his community.

By offering weekend clinics for children’s flu appointments, he is accommodating busy parents who may have difficulty attending during the week.

Daniel’s free blood pressure monitoring service has shown his commitment to preventing and

managing chronic diseases such as hypertension. Overall, Daniel’s actions show his commitment to providing excellent healthcare services to his community and his willingness to go above and beyond to meet their needs. His efforts will undoubtedly have a positive impact on the health and well-being of those he serves.

Supervising Pharmacist at Daniel’s pharmacy store, Shane O’Neill told us, “Daniel’s efforts to engage with the local community and understand their healthcare needs demonstrate his commitment to providing patient-centered care.

By attending meetings with local

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prescribers and understanding their challenges, he is better equipped to support them and provide tailored healthcare solutions to the community.

“His engagement with local employers also shows his willingness to go beyond the traditional pharmacy setting and provide services where they are needed. By offering onsite and offsite vaccinations to the local County Council, Daniel is ensuring that a large group of people are protected from the flu and Covid-19 during the winter months, which is particularly important during a pandemic.

“Overall, it is clear that Daniel is a deserving candidate for the ‘Young Pharmacist of the Year’ award and a valuable asset to the pharmacy profession. With his passion for patient care, commitment to continuous improvement, and leadership skills, he has the potential to make a significant impact in the field of community pharmacy”

47 “Overall, Daniel’s approach to community engagement and collaboration with local stakeholders is commendable. By working closely with others, he is able to provide healthcare services that are specifically tailored to the needs of the local community, ultimately improving health outcomes for all.”

Judges heard how the significant growth of the McCauley Health & Beauty pharmacy business in Dungarvan, by almost 15%, in just one year is a testament to Daniel’s hard work and dedication to providing outstanding healthcare services to his community.

His engagement with existing customers and the wider community has clearly had a positive impact on the pharmacy’s reputation and business growth.

Daniel’s efforts to engage with the local community and understand their healthcare needs demonstrate his commitment.

By attending meetings with local prescribers and understanding their challenges, he is better equipped to support them and provide tailored healthcare solutions to the community.

His engagement with local employers also shows his willingness to go beyond the traditional pharmacy setting and provide services where they are needed. By offering onsite and offsite vaccinations to the local County Council, Daniel is ensuring that a large group of people are protected from the flu and Covid-19 during the winter months, which is particularly important during a pandemic.

By working closely with others, he is able to provide healthcare services that are specifically tailored to the needs of the local community, ultimately improving health outcomes for all.

Furthermore, the close to 500 vaccinations provided by the pharmacy over the Winter Flu season demonstrates Daniel’s commitment to protecting those most vulnerable in the community.

By providing this vital service, he is contributing to the overall health and well-being of the community, and ensuring that the pharmacy is seen as a trusted provider of healthcare services.

Shane went on to add, “Daniel’s focus on training and upskilling his team has also had a positive impact on the pharmacy’s operations. By having ample

levels of support within the store, the pharmacy can provide patient-centered care at all times, without relying on locum technicians or pharmacists.

This ensures continuity of care for patients and strengthens the pharmacy’s reputation as a reliable healthcare provider.

“Daniel is an exceptional pharmacist who truly embodies the values of patient-centered care and continuous improvement.

His focus on streamlining operations, embracing technology, and fostering a culture of open communication and training are all admirable qualities that make him an effective leader within his team.

Additionally, his commitment to personal development and seeking out learning opportunities is a testament to his dedication to his profession.

“The growth of the pharmacy business under Daniel’s leadership is impressive and demonstrates his ability to positively impact both his customers and the overall success of the business. His desire to expand services such as 24-hour blood pressure monitoring, and travel vaccinations shows that he is constantly looking for new ways to serve his community and improve the health outcomes of his patients.

“Overall, it is clear that Daniel is a deserving candidate for the ‘Young Pharmacist of the Year’ award and a valuable asset to the pharmacy profession. With his passion for patient care, commitment to continuous improvement, and leadership skills, he has the potential to make a significant impact in the field of community pharmacy.

“His dedication and hard work have had a significant impact on the growth and success of the pharmacy business in Dungarvan. His focus on patientcentered care, community engagement, and professional development of his team has clearly paid off, benefiting both the pharmacy business and the wider community.”

Commenting after receiving his Award, Daniel stated, “I honestly wasn’t expecting a nomination, I wasn’t expecting to be shortlisted as a finalist and to be standing here now with the JPA Brenson Lawlor Young Community Pharmacist of the Year Award is simply amazing.

Daniel McCormack, McCauley Health & Beauty Pharmacy, Dungarvan “The team we have right now is phenomenal and couldn’t be any better. Everyone puts so much work and effort in and without their help, the help of the wider pharmacy staff and without the help and support of our local community I wouldn’t be standing here now.

“As pharmacists working in the community every day it can be easy to get overlooked as a profession and so these Awards present us with the platform to get together and celebrate achievements across the industry.

It makes each of us very proud to be in the job we are in.”

Jason Bradshaw, Partner, JPA Brenson Lawlor said, “JPA Brenson Lawlor would like to congratulate all the finalists of the Irish Pharmacy Awards 2023. I am the Corporate Finance Partner with JPA Brenson Lawlor and have over twenty years’ experience specialising in the community pharmacy sector. We provide a range of services from buying and selling pharmacies to advice on overall business strategy. Over the years, I have had the pleasure of meeting many pharmacists and

seeing many of our pharmacy clients develop and grow.

“The past few years have been incredibly difficult, but we have all seen how pharmacists are working hard to meet the needs of their patients. Young pharmacists have an ever-growing role and I have been able to meet many of them while providing business lectures to the pharmacy students at Royal College of Surgeons in Ireland (RCSI). I have also had the pleasure of providing 1:1 meetings with interested first time buyer pharmacists in order to assist them with acquiring their first pharmacy.

“JPA Brenson Lawlor provide awards and bursaries for the pharmacy colleges as we believe young pharmacists are the future of pharmacy.”

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Awards

Raising the Bar for Community Pharmacy Technicians

Awards The Irish Pharmacy

2023

The shift in emphasis from dispensing to healthcare provision has meant that the wider pharmacy team has to pull together – pharmacy technicians capture the essence of this in everything that they do. It was Adrian Dunne Balbriggan Pharmacy Technician Dominika Wikowicz that scooped the title on the night.

Simon Racklyeft, Sales Manager, TouchStore with winner of the TouchStore Community Pharmacy Technician of the Year Award, Dominika Witowicz, Adrian Dunne Pharmacy Balbriggan

Dominika Wikowicz is a Senior Technician in Adrian Dunne Pharmacy Balbriggan. She qualified as an EU Pharmacy Technician in Poland and joined Adrian Dunne group in 2019. In this short period of time she has become the most valuable part of the team.

She is hard working and she is totally committed to her job. Her gentle personality has won the hearts of everybody around her in the Pharmacy. The main way Dominika has enhanced the role of the Pharmacy Technician is through her commitment and attention to detail when it comes to stock accuracy. She has achieved the highest live-stock accuracy score in the company.

Dominika qualified as an EU Pharmacy Technician in Poland and

joined Adrian Dunne group in 2019.

In this short period of time she has become the most valuable part of the team. She is hard working and she is totally committed to her job.

Her gentle personality has won the hearts of everybody around her in the Pharmacy.

Adrian Dunne Pharmacy Balbriggan is a community pharmacy branch of the Adrian Dunne Pharmacies group - serving the Balbriggan community for 18 years and in this time the team has built a very loyal customer base.

Ana Romero, Supervising Pharmacist with the store told us, “Our pharmacy is a vibrant and busy pharmacy within the community with a strong emphasis on customer service. We are very involved in local community projects. We sponsor local clubs

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and schools in the area. We often hold fund raising events, our latest being a raffle to raise funds for the victims of the earthquakes in Turkey and Syria.

“Last year we moved to a brand new shop in a new location in Balbriggan. This was a big boost of energy and motivation for the team, but also very challenging and all the staff showed great commitment and determination to make the transition as smooth as possible for our customers.”

Dominika has enhanced the role of the pharmacy technician in a number of ways, including through her commitment and attention to detail when it comes to stock accuracy. Ana says, “She has achieved the highest live-stock accuracy score in the company.

She is in charge of the ordering and

“Her work rate and attention to detail is simply second to none. With the role of the pharmacy technician ever changing and new HSE guidance constantly coming out it can be difficult to stay up to date. Dominika rolls with the punches and educates herself.

Her ability to adapt then allows the rest of the team to learn from her.” she has a very rational approach to it. She makes sure she orders only what is needed, avoiding unnecessary waste of medicines.

She has also achieved the lowest

49 dead stock and the lowest stock overall within the company. She has inspired the rest of the team and now everybody makes sure all the processes around the stock are implemented properly.

“She is also in charge of the claim at the end of the month and her precision has made her achieve great results in this area too, reducing the rejects to a bare minimum, with 100% of the claim paid in the last month.

“These two achievements have a great impact in pharmacy finances.”

Another way that Dominika has enhanced the role of a Technician is by liaising with patients and prescribers about potential therapeutic alternatives when a particular drug is in short supply.

This has been a very big problem for the last few months and she has gone to great lengths trying to source alternative medications.

She is also constantly in contact with local surgeries with queries on prescriptions making sure there is continuity in patient care. She makes sure vulnerable patients always have their prescriptions up to date and their medication ready on time.

Dominika has been described as a ‘real team player.’ In her only three years working with the Adrian Dunne Balbriggan team, she has become the point of contact in the dispensary. “She is always happy to help other team members and she has been mentoring new members of staff making sure they can fulfil their tasks to the highest standards.

“She is our 5th year Pharmacy student’s buddy and she works along him making sure he has the best insight on what the role of the Pharmacy Technician is about,” Ana adds.

Furthermore, she is always putting her patients first. Ana continues, “Dominika was going on holiday to Greece last summer and two days before her trip we received a phone call from a patient saying they had forgotten to bring their medication. This was especially worrying as this patient suffers from anxiety and bouts of psychosis. The patient happened to be on holiday in the same part of Greece that Dominika was heading to and she brought the medication with her to bring to the patient. The patient was extremely thankful. We were amazed that Dominika would do this on her holiday but it is just one of many stories in where she goes above and beyond for our patients.

“Her dedication to our patients is phenomenal, one of our patients was suffering from an

eye infection after having cataract removal surgery and he required one of us to instil the eye drops daily. Dominika was the one who stepped up and did this for him for three weeks. Her compassion and dedication to him went further than was required of her and the patient was extremely grateful and regularly reminds us about what a great job she did.

“Dominika has always been the driving force behind our team. She recently asked our head office if we could raise funds for the hurricane relief in Turkey and Syria.

She came up with the idea to run a raffle for hamper with all the funds going to relief in these countries. It was a super idea which gained a lot of support from the community and money that can be put to good use.

“She also heard that the local secondary school Loreto Balbriggan were struggling to raise enough money for their Transition Year Musical and she offered to help. Because of her attitude to support the local community we were able to offer three tickets to a Manchester United vs Chelsea premier league football match in April as a raffle prize. This raffle has greatly helped the school to put on their musical and they were extremely grateful.

“Dominika has always been a mentor for other staff members.

Most recently our 5th year pharmacy student has been looking to Dominika for advice on a variety of things. Her ability to explain things that can seem daunting such as the claim in simple easy to understand ways has allowed him to get a grasp on it. She was appointed his buddy at the beginning of the year and she has been approachable and very insightful. Her friendly manner makes it easy to ask her any questions that you may have. She is playing a crucial role in preparing new pharmacists for the future!

“When we moved the shop our Hi Tech patients were worried about receiving their medicines on time. Dominika single handedly moved each patient’s file to the new pharmacy through the Hi Tech Hub and also got consent from each individual patient to authorise the change. This allowed our Hi Tech medication ordering to be uninterrupted. This is an example of Dominika carrying out huge tasks under strict deadlines that most of us would not be able to do.

“Her work rate and attention to detail is simply second to none.

With the role of the pharmacy technician ever changing and new HSE guidance constantly coming out it can be difficult to stay up

to date. Dominika rolls with the punches and educates herself.

Her ability to adapt then allows the rest of the team to learn from her.

The team looks to her for guidance and her attention to detail and her knowledge of pharmacy is something we all strive to achieve.”

Speaking after collecting her Award, Dominika said, “I am speechless at having been awarded this title. I was honoured to have been nominated by my colleagues and to be included with all the finalists here tonight.

Over the last number of years, especially during Covid, everyone in pharmacy worked that bit harder and went that extra mile for their patients and customers. “To be recognised for my work gives me great pride and is a real motivating factor in always wanting to do as much as I can do and be the best I can be.”

Gerard Cassidy MD and Chairman at TouchStore stated, “We at TouchStore are delighted to have the opportunity to sponsor the Community Technician of the Year Award. The public perception of community pharmacy is at an all time high, and the contribution of the pharmacy technicians to that perception is immeasurable.

TouchStore Community Pharmacy Technician of the Year Award, Dominika Witowicz, Adrian Dunne Pharmacy Balbriggan

continues to encounter, and it must, therefore, continue to strive for innovations and efficiencies.

“I firmly believe that technology has a significant role to play in this regard. At TouchStore, we continue to innovate. We are continuously adding and improving functionality to our systems. Last year we launched our new till application, next year, we will launch a new dispensing application making use of the technology advances that have been made in recent years.

A specific aim is to enhance the communications between the POS and the dispensing system, with a mind to increased efficiencies and improved patient safety. We hope you enjoy this celebration of community pharmacy, and the magnificent contribution it makes to Irish healthcare.”

“Having spent many years in community pharmacy, I am well aware of this. There are challenges that community pharmacy

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50

Awards

Mark and Team ‘Making a Point’

Awards The Irish Pharmacy

2023

Mark’s Pharmacy, Ardee landed the title of Point of Care Testing Award for 2023, securing the top spot against three other finalists.

Mark’s community pharmacy team exemplifies exceptional team spirit and dedication to enhancing patient care at all levels. Working together efficiently and effectively, they create a collaborative and supportive environment, fostering trust and respect among team members and empowering each individual to contribute their unique expertise towards shared goals. Innovation and forward-thinking are central to their operations.

Linda Callaghan, Jennifer Trainer, Mark McPhillips, Pharmacist and Owner, Gemma McCormick, Irene Caffery and Tara McKenna from Mark’s Pharmacy, Ardee, winners of the Point of Care Testing Award

The team unites around common objectives. This focused and unified approach to healthcare initiatives has led to numerous successful projects, showcasing our excellence in quality, innovation, productivity, and prevention.

One example of these collaborative efforts is the establishment of point-of-care testing services, such as diabetes screening, to promote prevention, early detection, and disease management. This initiative demonstrates their ability to work together to improve patient access to care through effective and rapid technology.

Supervising Pharmacist Mark told us, “Our community pharmacy team successfully managed a project focused on the implementation of point-ofcare testing services, including diabetes screening, to promote prevention, early detection, and disease management. This project exemplifies our ability to collaborate and communicate effectively while delivering positive results.

“The project’s set-up involved thorough planning and resource allocation, with each team member contributing their expertise.

Pharmacists received specialised

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training in administering tests and interpreting results, while support staff were trained in appointment scheduling, patient intake, and record-keeping. We also engaged with local healthcare providers to ensure seamless referral processes and integrated care.

“Throughout the project’s execution, our team maintained open communication channels, holding regular meetings to discuss progress, address challenges, and share best practices. We utilised tools such as Asana for task management and Geckoboard for monitoring key

“What is truly really important about the Irish Pharmacy Awards is that they put pharmacists and their teams in a position whereby we can represent our profession on a national level and in a position to advance where we, as pharmacists, can ultimately be.” performance indicators, ensuring that all team members remained informed and engaged.

“Our collaborative approach yielded several positive results, including: Improved Patient Access: The introduction of point-of-care testing services provided patients with faster access to critical

51 health information, enabling timely interventions and better disease management.

Enhanced Collaboration: By working closely with local healthcare providers, we fostered stronger relationships and improved coordination of care, benefiting both our patients and the wider community.

Increased Patient Satisfaction: Our commitment to providing comprehensive healthcare services led to increased patient satisfaction and trust in our pharmacy as a reliable healthcare provider.

Streamlined Processes: The use of technology and the adoption of efficient workflows allowed us to optimize our service delivery, reducing wait times and improving the overall patient experience.

Positive Health Outcomes: The early detection and management of conditions such as diabetes resulted in better health outcomes for our patients, ultimately reducing the burden on the broader healthcare system.

“Our community pharmacy team’s successful management of this point-of-care testing project demonstrates our ability to collaborate and communicate effectively, leading to significant benefits for our patients and the community.”

Mark and his team’s commitment to collaboration, innovation, and patient-centered care has enabled them to establish a robust

point-of-care testing program, providing essential services such as anticoagulation clinics and diabetes screening.

They have demonstrated an ability to prioritise patient needs and strive to provide accessible, convenient, and efficient point-ofcare testing services.

Mark and his team were shortlisted for no fewer than five categories this year, winning two of them.

“These nominations aren’t just about Mark’s Pharmacy; they’re about our community. Each day we open our doors, we strive to make a difference, whether through a conversation, advice, or prescription. It’s heartening to see that commitment recognised on a national level,” he says.

Mark says the pharmacy prides itself on delivering superior customer service and has been an integral part of the Ardee community for over 11 years.

He also says the pharmacy’s nomination in five categories is a testament to its unwavering dedication to excellence and its commitment to the health and wellbeing of the community it serves.

Reflecting on the nominations he continued, “Being nominated for one award would have been an honour, but five nominations are truly overwhelming. It affirms that our commitment to providing the best possible care and service to our community is making a real difference. This moment is a

shared victory for our dedicated staff and loyal customers.”

Through these nominations, he says the pharmacy has proven that independent pharmacies can compete with larger chains while maintaining a personalised, community-focused approach and that their goal remains to provide

Mark McPhillips, Pharmacist and Owner, Mark’s Pharmacy, Ardee

unrivalled service grounded in genuine care for the health and wellbeing of every customer that walks through their doors.

“As an independent pharmacy we are delighted to have won this Award; the team always have a great night. This is a unique opportunity for us to not only come together as a team but to join with our colleagues across Ireland in celebrating the innovation and hard work that is ongoing.

“What is truly really important about the Irish Pharmacy Awards is that they put pharmacists and their teams in a position whereby we can represent our profession on a national level and in a position to advance where we, as pharmacists, can ultimately be.”

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52

News

Waking up to Pain Chronic Pain Ireland launches ‘Waking up to Pain’ campaign for Pain Awareness Month The World Health Assembly (WHA), a subsection of the World Health Organization (WHO), has declared September as Pain Awareness Month. Throughout the month of September, many organisations around the globe contribute and raise awareness of chronic pain. Chronic Pain Ireland is supporting the 2023 global campaign with the theme ‘Waking up to pain’.

Martina Phelan, Chair, Chronic Pain Ireland

1. Chronic cancer-related pain is chronic pain that is due to cancer or its treatment, such as chemotherapy. This type of pain was represented for the first time in ICD-11.

2. Chronic postsurgical or posttraumatic pain is chronic pain that develops or increases in intensity after a tissue trauma (surgical or accidental) and Waking up to persists Pain beyond three months.

It is also part of the ICD for the Sub-heading; Chronic Pain Ireland launches ‘Waking up to Pain’ campaign for Pain Awareness Month first time.

3. Chronic secondary

The theme ‘Waking Up to Pain’ expresses the reality for up to 1 in 3 individuals in Ireland of waking up to pain each morning. Some people feel pain throughout the day, every day. Chronic Pain Ireland wants people in Ireland to wake up to the facts of chronic pain, which can affect anyone over their lifetime.  Waking up to the prevalence of pain: The University of Galway Prevalence, Impact and Cost of Chronic Pain (PRIME) study estimates up to 1 in 3 adults in Ireland experience chronic pain.  Waking up to the economic cost: The societal cost of chronic pain is significant in terms of healthcare costs and lost productivity. The Irish Pain Society estimates that chronic pain costs the Irish economy around ¤4.7 billion per year, more than 2.5% of GDP.  Waking up to the personal cost: According to The Irish Pain Society, 42% of people living with chronic pain think others doubt the existence of their pain even though 21% said their pain was so intense they wanted to die.  Waking up to the inadequacy of services: According to figures released by the Irish Pain Society, Ireland has just 27 dedicated pain consultants operating across the public system, meaning that 41% of patients are currently waiting more than 12 months for their

first appointment witha subsection a chronic The World Health Assembly (WHA), of the World Health Organization (WHO), has declared September pain aspain Pain Awareness Month. while Throughout the month many organisations around the globe is contribute specialist, 18% are of September,musculoskeletal and raise awareness of chronic pain. Chronic Pain Ireland is supporting the 2023 globalin campaign with joint the theme chronic pain bones, waiting the same length of time ‘Waking up to pain'.

and tendons arising from an for their first treatment. classified The theme ‘Waking Up to Pain’ expresses the reality for up to 1underlying in 3 individuals in disease Ireland of waking up to pain each morning. Some people feel painacute throughout the day, every day. Chronic Pain IrelandItwants in Ireland to wake Chronic pain, unlike pain, elsewhere. canpeople be due up to the facts of chronic pain, which can affect anyone over their lifetime. is pain that persists beyond the to persistent inflammation ● Waking the prevalence of pain: Prevalence,with Impact and Cost of Chronic Pain normal timeupofto healing and thisTheisUniversity of Galway associated structural (PRIME) study estimates up to 1 in 3 adults in Ireland experience chronic pain. changes or caused by altered generally accepted as pain that ● Waking up to the economic cost: The societal cost of chronic pain is significant in terms of healthcare costs biomechanical function due €4.7 to lasts longer than three months. and lost productivity.

The Irish Pain Society estimates that chronic pain costs the Irish economy around billion per year, more than 2.5% of GDP. diseases of the nervous system.

The International Association for ● Waking up to the personal cost: According to The Irish Pain Society, 42% of people living with chronic pain the Study of Pain redefined think others doubt(IASP) the existence of their pain even though 21% said their pain was so intense they wanted to 4. Chronic secondary visceral pain indie.

2020 as “An unpleasant painreleased is chronic pain secondary ● Waking up to the inadequacy of services: According to figures by the Irish Pain Society, Ireland has sensory and emotional experience just 27 dedicated pain consultants operating across the public system, meaning thatcondition 41% of patients are to an underlying associated resembling currentlywith, waitingor more than 12 months for their first appointment with a chronic pain specialist, while 18% originating from internal organs are waiting the with, same length of timeor for their first treatment. that associated actual of the head or neck region or of potential damage”.

This Chronic pain,tissue unlike acute pain, is pain that persists beyond the normal time of healing and this is generally accepted the thoracic, abdominal or pelvic as pain that lasts longer than three months. The International Association for the Study of Pain (IASP) redefined pain expanded definition encompasses regions.

It resembling can bethat caused by in 2020 as “An unpleasant sensory and emotional experience associated with, or associated with, pain arises indamage”. the absence ofdefinition encompasses actualthat or potential tissue This expanded pain that arises in the absencevascular of any persistent inflammation, evidence of tissue damage or disease. any evidence of tissue damage or mechanisms or mechanical disease. factors.

Chronic primary pain represents chronic pain as a disease in itself.

Chronic primary pain is characterised by significant functional disability or emotional distress that is not better accounted for by another diagnosis. This may Chronic primary pain represents include chronic widespread pain, chronic primary musculoskeletal pain (previously termed "non specific"), 5. Chronic neuropathic painas well is as primary headaches andaconditions suchin as chronic pelvic pain and irritable bowel syndrome. They are recognised as chronic pain as disease chronic pain caused by a lesion a group of chronic pain syndromes for the first time in the International Classification of Diseases 11th Revision – the itself.

Chronic primary pain is or disease of the somatosensory global standard for diagnostic health information (ICD-11).

characterised by significant nervous system. This category Chronic secondary pain is chronic pain where the pain is a symptom of an underlying condition. Chronic secondary functional disability or emotional includes peripheral and central pain is organised into the following six categories: distress that is not better accounted neuropathic pain. This type of for by diagnosis.

1. another Chronic cancer-related pain isThis chronicmay pain that is due topain cancer is or its treatment, suchrepresented as chemotherapy. also newly type of pain was represented pain, for the first time in ICD-11. includeThis chronic widespread in ICD-11. chronic primary musculoskeletal 6. Chronic secondary headache pain (previously termed “non or orofacial pain contains the specific”), as well as primary chronic forms of symptomatic headaches and conditions such headaches – those termed as chronic pelvic pain and irritable primary headaches in the bowel syndrome. They are International Classification of recognised as a group of chronic Headache Disorders 3rd edition pain syndromes for the first time in (ICHD-3) are part of chronic the International Classification of primary pain – and follows Diseases 11th Revision – the global closely the ICHD-3 classification. standard for diagnostic health Chronic secondary orofacial information (ICD-11). pain, such as chronic dental Chronic secondary pain is chronic pain where the pain is a symptom of an underlying condition. Chronic secondary pain is organised into the following six categories:

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pain, supplements this section of ICD-11.

What causes chronic pain?

There are many causes of chronic pain such as an illness or injury

where you recover, but pain persists. There may be an ongoing cause of pain, for example arthritis or cancer. Many people suffer chronic pain in the absence of any past injury or evidence of illness.

How is chronic pain treated?

Chronic pain impacts on every aspect of a person’s life. A multidisciplinary approach to pain management is often required, providing interventions that help manage the pain. Public pain management programmes are available in some hospitals.

How can Chronic Pain Ireland help?

Chronic Pain Ireland (CPI) is the national charity providing information, education and support services to people living with chronic pain, their families, friends, caregivers and other interested parties. We advocate on their behalf and work closely with all stakeholders.

Pain Awareness Month (PAM) Activities Chronic Pain Ireland are supporting our members during Pain Awareness Month by providing:  A 5-week self-management course based on the biopsychosocial model of pain.  Two 7-week Living Well with Chronic Pain programmes for members in collaboration with The Health Service Executive (HSE).  A 7-week Lifestyle Education Awareness Programme (LEAP) programme specifically for those living with fibromyalgia.  A facilitated chronic pain and mental health support group in partnership with Turn2Me. Chronic Pain Ireland will host informative talks throughout September and have distributed information leaflets on chronic pain to pain teams and social prescribers across the country.

To learn more about our activities for Pain Awareness Month, visit www.chronicpain.ie.

References available on request

HIV Updates

53

The Role of HIV Viral Suppression The World Health Organization (WHO) is releasing new scientific and normative guidance on HIV at the 12th International IAS (the International AIDS Society) Conference on HIV Science.

New WHO guidance and an accompanying Lancet systematic review released recently describe the role of HIV viral suppression and undetectable levels of virus in both improving individual health and halting onward HIV transmission.

The guidance describes key HIV viral load thresholds and the approaches to measure levels of virus against these thresholds; for example, people living with HIV who achieve an undetectable level of virus by consistent use of antiretroviral therapy, do not transmit HIV to their sexual partner(s) and are at low risk of transmitting HIV vertically to their children. The evidence also indicates that there is negligible, or almost zero, risk of transmitting HIV when a person has a HIV viral load measurement of less than or equal to 1000 copies per mL, also commonly referred to as having a suppressed viral load.

HIV and Mpox

Antiretroviral therapy continues to transform the lives of people living with HIV. People living with HIV who are diagnosed and treated early, and take their medication as prescribed, can expect to have the same health and life expectancy as their HIV-negative counterparts.

In the light of these findings, WHO recommends countries integrate mpox detection, prevention, and care with existing and innovative HIV and sexually transmitted infection prevention and control programmes.

“For more than 20 years, countries all over the world have relied on WHO’s evidence-based guidelines to prevent, test for and treat HIV infection,” said Dr Tedros Adhanom Ghebreyesus, WHO DirectorGeneral. “The new guidelines we are publishing will help countries to use powerful tools have the potential to transform the lives of millions of people living with or at risk of HIV.” At the end of 2022, 29.8 million of the 39 million people living with HIV were taking antiretroviral treatment (which means 76% of all people living with HIV) with almost three-quarters of them (71%) living with suppressed HIV. This means that for those virally suppressed their health is well protected and they are not at risk of transmitting HIV to other people. While this is a very positive progress for adults living with HIV, viral load suppression in children living with HIV is only 46% - a reality that needs urgent attention.

Here is an overview of other key scientific and normative updates being released by WHO at IAS 2023 conference:

An analysis of global surveillance data reported to WHO during the multi-country outbreak of mpox, identified that among more than 82 000 mpox cases, around 32 000 cases had information on HIV status. Among those, 52% were living with HIV, most being men who have sex with men (MSM); and more than 80% reported sex as the most probable route of getting infected with mpox.

Among 16 000 people diagnosed with mpox and living with HIV, around one quarter (25%) had advanced HIV disease or immunosuppression – leading to an increased risk of hospitalization and death. People living with HIV who were taking HIV treatment and with good immunity had similar hospitalization and death outcomes as those who were HIV negative.

To understand how to better prepare for and respond to future increases in mpox transmission, WHO led a rapid electronic survey in May 2023 to assess community experiences of the 2022-2023 mpox outbreak in Europe and the Americas.

More than 24,000 people participated in the survey which focused on men who have sex with men, and trans and genderdiverse people, with 16,875 eligible individuals completing the survey.

Almost 51% changed their sexual behaviour (such as reducing the number of sexual partners), and 35% had maintained these changes one year later.

Findings from this survey provide valuable insights into the experiences and needs of affected communities and emphasize the importance of increasing access to mpox vaccination and diagnostics globally.

HIV and COVID-19 An updated analysis from WHO global clinical platform for COVID-19 up through May 2023 revealed a persistent high risk of death in people living with HIV

“The new guidelines we are publishing will help countries to use powerful tools have the potential to transform the lives of millions of people living with or at risk of HIV.” hospitalized for COVID-19 across pre-Delta, Delta and Omicron variant waves, with an overall in-hospital mortality rate of 20%24%. For people without HIV, the risk of death fell during the Omicron variant wave by 53%— 55% compared to pre-Delta and Delta variant waves; but for people living with HIV, the percentage decline in mortality during the Omicron wave period compared to the other waves was modest (16%-19%). This difference resulted in a 142 times increased risk of death among people living with HIV when compared with people without HIV during the Omicron wave period.

Risk factors for in-hospital death that were common across all variant waves of the pandemic were low CD4 count (less than 200 cells per m3), and severe or critical COVID-19 illness at hospital admission.

“Uncontrolled HIV remains a risk factor for poor outcomes and death in the mpox outbreak and COVID-19 pandemic”, said Dr Meg Doherty, Director of WHO’s Global HIV, Hepatitis and Sexually Transmitted Infections Programmes. "We must ensure the integration of HIV considerations in pandemic preparedness and response. Protecting people living with HIV from future pandemics is vital and reinforces the need to ensure access to HIV testing and treatment and preventive vaccines for mpox and COVID-19 to save lives; community-led responses that work for HIV will also be beneficial for addressing future pandemics."

Optimizing HIV testing services through expanded testing options and simplified service delivery With new recommendations on HIV testing, WHO is calling on countries to expand use of HIV self-testing and promote testing through sexual and social networks to increase testing coverage and strengthen uptake

of HIV prevention and treatment services in high-burden settings and in regions with the greatest gaps in testing coverage.

The recommendation comes at a pivotal time, where self-care and self-testing are increasingly being recognized as ways to increase access, efficiency, effectiveness and acceptability of health care across many different disease areas, including HIV. Primary health care and HIV A new policy framework on primary health care (PHC) and HIV will help decision-makers optimize work and collaboration underway to advance primary health care and disease-specific responses, including HIV. In the second year of implementation, the Global Health Sector Strategies on HIV, viral hepatitis and sexually transmitted infections for 2022-2030 actively advocate for synergies within the framework of universal health coverage and primary health care.

“Ending AIDS is impossible without optimizing opportunities across and within health systems, including with communities and in the context of primary health care”, said Dr Jérôme Salomon, WHO Assistant Director-General, Universal Health Coverage, Communicable and Noncommunicable Diseases.

This latest research and guidance are being presented at a time when progress towards ending the global AIDS epidemic has lagged, after the COVID-19 pandemic; but the response is rapidly catching up, with some countries now charting a path to end AIDS, including Australia, Botswana, Eswatini, Rwanda, United Republic of Tanzania, and Zimbabwe and 16 other countries that are close to reaching the 9595-95 global targets, which aim for 95% of people living with HIV knowing their status, 95% of those diagnosed receiving ART and 95% of those on treatment having suppressed viral loads.

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54

Foot Care

Let’s Talk Foot Care with Patients As the summer draws to a close, podiatrists and pharmacies alike are inundated with patients. From a podiatrist’s perspective, it essential to maintain a good working relationship with our local pharmacies. By working with each other as health care professionals, we can ensure the highest quality care possible is delivered to our patients. The warmer weather of the latter months of summer mixed with the back-to-school rush, brings an array of ailments to surface, some of which I discuss below.

Written by Rebecca Conway (BSc.Hons Podiatrist)

If a patient has a lesion or spot that is changing in nature, it is important to get it checked out by a podiatrist or G.P. Corn plasters: A no from me!

Corns vs. Verrucae The reason I have categorised these different complaints together is because corns and verrucae are often misdiagnosed as one another. Most days in clinic, a patient comes in with what they suspect to be a corn but on examination is a verruca or vice versa. Corns are hard skin built up at a point of pressure; often due to an external source such as a tight shoe or due to the way a person is walking (their gait pattern). Verrucae contrastingly are a viral infection - often transferred from one person to another in areas of shallow water or wet surfaces.

This could be the floor surface of swimming pool changing rooms or communal showers. Verrucae can appear with small superficial black dots which are tiny blood capillaries. Unfortunately, not all verrucae have these marks.

The demographics of a patient can also be used as a clue to distinguish between corns and verrucae. Verrucae are classically seen in younger patients. Young adults and children are more susceptible to such viruses, especially with exposure during swimming lessons and a stilldeveloping immune system.

Corns often have an external cause, as mentioned above.

Corns and verrucae can be very similar in appearance, and if there is uncertainty, a podiatrist opinion may be indicated. We must remember more sinister lesions, such as malignant melanoma.

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As a podiatrist, I can see why people use them; however, I am strictly against the use of corn plasters. Many corn plasters contain salicylic acid, which is caustic to healthy skin tissue.

These corn plasters usually have a standard shape and size; however, corns can vary. Therefore, there can be a discrepancy between the size of the plaster and the size and shape of the offending lesion.

As a result, surrounding healthy skin may be damaged by the application of this caustic plaster, resulting in a bigger problem for the patient. When a corn plaster is applied and the patient starts walking around with a shoe and sock on, the corn plaster can move and burn surrounding healthy tissue. When a patient has vulnerable skin, these problems can escalate, skin can break and ulcers can form.

The solution to a corn is to treat the source of the pressure. This may be achieved by altering footwear, using a urea-based emollient to soften the hardened skin, or by the removal of the corn by a trained health care professional, i.e., a podiatrist.

Verruca Treatment: Verrucae are commonly seen at this time of year, after summer holidays spent swimming by a pool. In my opinion, the best solution to this common problem is prevention. Prevention against verrucae can include swimming socks for children. It can be as simple as wearing flip-flops in communal showers and changing areas rather than going barefoot.

Although children are more susceptible to catching verrucae as their immune system is still developing, this also means that it can be easy for the virus to be eradicated from a child’s foot.

Low percentages of salicylic acid and cryo treatments can be found over the counter. Care must be taken not to spread the verrucae

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Foot Care

and to not cause any harm to the healthy tissue surrounding the verruca. My best piece of advice is to keep the verrucae covered with an occlusive tape that is hypoallergenic if possible.

This can stop the verruca from spreading and can be found to eradicate the verruca completely in some patients’. For more resistant cases in older patients, a podiatrist may be consulted, and the use of swift microwave therapy may be indicated, which can be very successful.

Back-to-school As children go back to school, there are a few points to keep in mind about their feet and footwear. If children are not wearing appropriate shoes, we can see a range of ailments, from ingrown toenails and corns to blisters and chilblains.

When children are still growing, it is important to get a good shoe that fits well on their foot and will last the winter. Shops such as Clarke’s and Cripps have a selection of shoes and well-trained fitters on hand to ensure shoes are long and wide enough for the child. Although

shoes that are too big can cause friction, a shoe half a size bigger allows the young foot enough room to grow within it. When shoes are too short or too narrow, ingrown toenails are a common occurrence in young children. A wide and deep toe box are characteristics of a good shoe, with lace or strong velcro ideal for keeping the shoe secure on a child. Laces and good velcro straps can prevent excessive tripping or falling by giving the foot support and stability. It is necessary to keep within the school shoe policy while keeping in mind the Irish weather. School shoes are often the shoes a child wears the most, so it is important to direct consumers in the right direction.

Ingrown Toenails As I mentioned above, ingrown toenails can often be caused by ill-fitting shoes. If a shoe is too short or narrow, it can pinch on the nail and cause excessive pressure. This excessive pressure can cause the nail to become involuted and the nail to press against the skin around the sulcus of the nail. Once this ingrown nail

edge pierces the surrounding skin, we now have a problem.

There is a portal or opening for infection, resulting in the classic signs and symptoms we attribute to ‘an ingrown toenail’. The toe can become red and inflamed with infection, and often yellow or green exudate can be seen. In order for immediate relief and to relieve some infection, the patient can bathe the toe in warm, salty water. However, often, even with an antibiotic prescribed by the G.P. to reduce the infection, the patient must go to a podiatrist or G.P. to remove the root cause of the problem-the offending piece of nail. To prevent such problems from occurring, patients can be encouraged to wear appropriate shoes that are wide and long enough for their feet.

Fungal skin & fungal nails Fungal nail and skin infections can present with various symptoms.

Tines pedis, commonly known as ‘athlete’s foot’, can present with red, sweaty, hot, and itchy feet. It is very common during the warmer months and can

be accompanied by small red pustules on certain areas of the foot. It can be seen interdigitally and underneath the arch profile on the plantar aspect of the foot.

The risk of leaving tinea pedis untreated is that small tears in the skin epidermis form, resulting in a portal for infection that can escalate to cellulitis. In warm weather, feet tend to sweat more, and such conditions as tinea pedis can be exacerbated.

Unfortunately, fungal toenails are notoriously common, and the patients coming in to see us are getting younger and younger.

Again, if possible, prevention is the best solution! This can include the use of sandals during warmer weather or around the house.

Giving the nails a break from nail varnish and letting air at the feet can be very effective.

The most effective treatment for presenting fungal infections are over-the-counter antifungal powders and creams such as Desenex or Daktarin. In persistent cases, an anti-fungal prescription such as Terbinafine may be required.

News

Community Acquired Pneumonia A collaborative group led by Trinity researchers has published the first guidelines for treating patients with severe community-acquired pneumonia (sCAP) – a high-mortality condition that describes people admitted to ICU. These guidelines, published in two journals – Intensive Care Medicine, and the European Respiratory Journal– will benefit physicians dealing with the care of critically ill patients and help standardise the current treatment and management of sCAP. Community-acquired pneumonia (CAP) is a very common respiratory infectious disease but approximately 40% of patients will require hospitalisation and 5% of those will be admitted to ICU, at which point they are clinically classified as having sCAP. Patients with sCAP are primarily admitted to ICU due to organ shock or the need for invasive or noninvasive mechanical ventilation and, because their mortality could be as high as 50% at this point, the new guidelines fulfil a pressing need.

Ignacio Martin-Loeches, Professor in Clinical Medicine at Trinity’s School of Medicine and Consultant in Intensive Care Medicine at St

James’s Hospital, is the lead author of the new guidelines.

He said, “Implementing treatment is obviously challenging in any critical care setting, and depends on the healthcare systems and resources allocated, but these new guidelines provide clear, focused, and concise recommendations from which patients with the highest severity and mortality risk will benefit.

We have also been careful to incorporate recommendations from specialists from different healthcare systems and medical domains, in order to ease implementation and obtain a transversal approach.”

The guidelines have been created based on the European Respiratory Society (ERS) launching a task force, which brought together the Trinity team and other European societies, including the European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del

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Tórax (Latin American Thoracic Association; ALAT).

This multi-disciplinary group of clinicians has extensive expertise in

managing patients with respiratory tract infections across Europe and North America, but the guidelines should also help the management of sCAP patients worldwide.

Colief® Multibiotic Drops: For a happy gut Scientifically proven friendly bacteria developed to help maintain baby’s natural gut flora.

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

After completing this module, you should recognise the different types of cough 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.

Cough is a natural defence reflex that involves the sudden expulsion of air from the breathing passage. Coughing is vital in preventing aspiration and is important in airway clearance of foreign particles, fluid, microbes and irritants. Although, cough is a vital protective mechanism, excessive and chronic coughing can be disabling for patients and reduce quality of life. Cough is a common presentation in primary care and is the leading cause of outpatient visits, more than any other symptom.

Cough can be classified on the basis of duration of the symptom.

Acute cough: lasting for less than 3 weeks Subacute cough: lasting 3–8 weeks Chronic cough: lasting greater than 8 weeks.

An acute cough is often as a result of an upper respiratory tract viral infection such as influenza, the common cold or covid-19.

Subacute cough is often the residual cough that remains after an infection has resolved.

Chronic cough can be as a result of a wide variety of medical conditions. Chronic cough can be further categorised into two different subtypes: (i) presence of pulmonary lesions on radiography and (ii) lack of identifiable abnormalities on radiography.

Cough can also be classified as non-productive, also known as a dry cough, or productive, also

known as a wet cough. A nonproductive cough will produce a sputum volume of less than 10 ml per day, while a productive cough will produce a volume of more than 10ml per day.

The underlying cause of cough can be difficult to ascertain. There are a wide variety of causes of cough and it is important to determine the cause to ensure the correct treatment option is selected.

Aetiology can depend if the cough is acute, subacute or chronic.

Pharmacists are often a patient’s first port of call when they initially develop symptoms. Pharmacists can be involved in screening for warning signs that may require immediate referral to another healthcare professional.

Pharmacists are accessible healthcare experts and can be involved in a more systematic approach to arriving at a diagnosis and ensuring the patient receives the right treatment and guidance. If it is a regular patient, pharmacists can check the patient medication record to see if any recently initiated medications are causing a drug-induced cough. Pharmacists can also provide advice and thorough counselling about the use of over-the-counter (OTC) treatment options.

There are a number of OTC treatment options available in Ireland for the treatment of cough, depending on the nature of the cough or the underlying aetiology.

Expectorants and mucolytics are commonly used to treat productive cough. They exert their effect by increasing the volume of sputum in the airway and decreasing its viscosity, therefore promoting effective coughing and clearance of mucus.

Codeine is available OTC in Ireland as an antitussive for an

Consider:  Have I, or any of my team, established the type of cough?  Can I, or any of my team, explain the benefits of each cough medication?  Is the pharmacy team aware of the guidelines for children under the age of 6?  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 cough medications?  Is there any further training required to assist the team discussing cough remedy advice with customers?

58 | PHARMACYNEWSIRELAND.COM

unproductive cough, although use is contraindicated in children below the age of 12 years.

Non-opioid antitussives are preferred in the treatment of cough. Dextromethorphan is the most commonly used drug in this class. It lacks the inhibitory effect on the respiratory centre compared to codeine, as well as the analgesic and sedative effects.

Antihistamines are often used in the treatment of cough.

Diphenhydramine is a first generation H1-antihistamine that has been demonstrated to have efficacy in treating cough. It is particularly useful for acute cough caused by the common cold.

Herbal medicines are popular in the treatment of minor medical conditions, including coughs.

Herbal medicinal products on

Key Points: Check your pharmacy team are aware and understand the following key points:  Customers that should be referred to the pharmacist  Those with persistent cough that should be referred to their GP  The types of OTC medicine options depending on nature/ aetiology of the cough  Customers should be advised of nonpharmacological measures, such as adequate hydration and proper rest

the Irish market must be either authorised or registered with the HPRA. Effective regulation of herbal medicines is considered necessary in order to ensure that safe products of appropriate quality continue to be available in pharmacies and other outlets.

Some complementary and alternative medicines including eucalyptus, marshmallow, liquorice and thyme are commonly used in treatment of cough. These products can also interact with other medications, which should be taken into consideration.

Actions:  Prior to recommending OTC cough products, pharmacists should ascertain whether selftreatment is appropriate  Pregnant and lactating women and those with chronic medical conditions should always consult their GP before using any OTC cough medication.  Those with a smoker’s cough should be advised to take part in the pharmacy smoking cessation programme  Update the team’s knowledge of available cough remedies by type/cause, indications and doses to ensure appropriate product selection for each customer  Train the team to meet all the above considerations

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60

Osteoporosis

Osteoporosis – Preventing the Silent Killers “Fractures” The disease Osteoporosis is commonly considered to affect just “Old” women, and many people do not appear to be aware that this disease is preventable and treatable in most people. Women over 65 are the highest risk group for fractures, however it affects all age groups, including our young. Only 19% of people with Osteoporosis are diagnosed, which is why everyone should be checking to see if they have any of the 200 causes of bone loss.

Written by Michele O'Brien, CEO, The Irish Osteoporosis Society

protect bone and to also help in the formation of Vitamin D and absorption of calcium. When Vitamin D levels are low, bone loss occurs which increases the person risk of fractures.

The lesson to be learned is that prevention of breaking bones is much cheaper and less painful than just targeting the highest risk group for bone loss.

An example of this is the DXA scan below (figure 1). It shows the results of a 21 year old female who was diagnosed with severe bone loss at 19 in her spine.

Her DXA results show she now has marked Osteopenia in L1 and L3, Osteoporosis at L2 and severe bone loss at L4.

Thankfully she was diagnosed, investigated and put on a treatment plan. You can see from the graph named “AP spine: L2-L4 (L3) (BMD) % change vs Previous”, that in two years she has significantly improved her bone health.

The fact that two of her vertebrae had been eliminated from her DXA scan results, shows that even the young can develop Osteoarthritis, which is why L1 and L3 vertebrae were eliminated. Osteoarthritis can give false higher readings falsely showing the bones are healthier than they are.

have heard this, it is not accurate.

A DXA scan exposes a patient to 10% radiation of a regular Chest X-ray. A person flying from Dublin to New York will be exposed to more radiation than a DXA scan.

DXA scanning is what the IOS, the Osteoporosis national experts recommend for the screening, diagnosing and monitoring of bone loss.

Do you want to be the person or NOTE Depo Provera has been a loved one of yours who ends proven to cause bone loss, up with multiple fractures which therefore unless a young person is could have been prevented, very high risk to become pregnant, as research shows that most the Irish Osteoporosis Society fractures are preventable?

(IOS) would recommend a different – Preventing the Silent Killers “Fractures” the possibilityOsteoporosis of a Dowager’s The Irish Osteoporosis Society form of contraceptive. hump which is not reversable. The believe that focusing on over 65’s individual reduced the amount Women lose bone leading up to is playing “Russian roulette” with of exercise she was doing to the menopause, going through people’s lives, especially women’s “normal levels”, which resulted Written

by Michele O'Brien the menopause and the most lives. On the top of page 40 (figure in her periods returning, which significant bone loss occurs in 2) shows why all women should be assisted with her improvement the 10 years post menopause. In CEO screened for bone loss. The results of bone health, as her oestrogen general, we can only assume that also show that when a person has levels returned to normal. She been diagnosed with Osteopenia, The Irish Osteoporosis Society the more risk factors for bone loss also learned some stress coping a person has, the higher the bone which is the early stages of bone techniques that she could use loss they will experience. loss, they MUST be monitored. The at her office desk, as she had reason monitoring is so important 1 in 7 women will get breast previously increased her running is because bone loss is silent, NO cancer and there is a breast times in an attempt to decrease one feels bone loss. There are no screening service available.

In an her stress levels. symptoms of bone loss ideal world it would be wonderful The disease Osteoporosis is commonly considered to affect justsigns “Old”orwomen, and many and logically all disease’s should After the menopause, the ovaries if DXA would is become people do notoestrogen appear to be aware thatscanning this disease preventable treatable in DXA most be and monitored and the scan stop producing and part of an overall health plan tied showit the woman’s bone the adrenal glands produce people.

Women over 65the are the into highest group for fractures, results however affects all age a peririsk menopause screening, health in her spine had declined male hormone testosterone, whichOnly as 19% 1 in 2 of women aged 50 will groups, including our young. people with Osteoporosis areindiagnosed, by 40% ten years andwhich 23% inis is then converted into oestrogen break a bone from Osteoporosis why everyone bea checking to see if they have any of the her 200hips. causes of bone loss. by the peripheralshould fat. When in their lifetime. person is underweight, they An example of thisperipheral is the DXA scan below shows results Some peopleItare of thethe belief that of a 21 year old female who do not have enough scans place a person at high fat todiagnosed assist with this process. was with severe boneDXA loss at 19 in her spine. risk of radiation exposure, if you Oestrogen is necessary to help Figure 1

This person’s causes of bone loss was due to overexercising, which caused irregular periods and she also had high cortisol levels due to a stressful job. By early intervention occurring the person so far has been able to improve her bone health and prevent vertebral fractures from occurring.

Research shows that most fractures occur in the moderate to marked Osteopenia range, which is a T score of -1.5 to -2.49.

It was explained to her the consequences of her lifestyle choices and the effects of what vertebral fractures can do to a person’s quality of life. No one wants to end up disfigured with

Her DXA results show she now has marked Osteopenia in L1 and L3, Osteoporosis at L2 and severe bone loss at L4.

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Thankfully she was diagnosed, investigated and put on a treatment plan. You can see from

61 Figure 2 2018 her causes of bone loss had been investigated and addressed, there is a very high chance, the vertebral fractures could have been prevented.

Monitoring of bone health is essential, it is common sense. If a person had a heart attack, what cardiologist do you know would say “Come back in 5 years for a check up”. There are those who believe repeat DXA scans should be every 5 years. This woman is a example of why if a person and the DXA scan results show the woman’s bone health in her spine had declinedprime by 40% has bone loss, they need to be regularly monitored. in ten years and 23% in her hips.

Osteoporosis is not like most

The woman’s DXA scan results below show that she had a DXA scan done in 2012. other diseases because there

are no signs or symptoms prior to someone fracturing. Most Her DXA results (aged 60) from 18 06 2018 show her bone density in her spine had declined people are taking treatments 22.8% from her previous DXA scan which was done 6 years prior on 02 08 2012 (aged 54).symptoms or slow to suppress down the progression of other Her latest DXA scan results (aged 64) on 15 08 2022 show her bone density in herdiseases, spine Osteoporosis treatments have been proven to reduce had declined by 17.2% since 18 06 2018, in 4 years. fracture risk. It is essential to ensure a person is responding to their treatment and if a decline occurs switching a treatment should not be the first option.

Investigating and addressing why their DXA scan results have declined or similar to the case above, investigating why they have The woman’s DXA scan results declined by 17.2% since 18 06 The most significant results were fractured is crucial to help keep the below (figure 3) show that she had from the LVA, which is a Lateral 2018, in 4 years. person independent. a DXA scan done in 2012.

Vertebral Assessment which is a The graph in the image on the top DXA side view of a person’s spine.

Cancer and Osteoporosis Her DXA results (aged 60) from 18 of page 41 (figure 4) shows how This woman went through the 06 2018 show her bone density in Anyone who is going to receive menopause at 51. her BMD (Bone mineral Density) her spine had declined 22.8% from chemotherapy or radiation for plummeted from age 54 to 64. her previous DXA scan which was The DXA LVA report at the bottom cancer should have a DXA scan done 6 years prior on 02 08 2012 of page 41 (figure 5) shows she Her DXA results from 18 06 2018 done prior to the initiation of either (aged 54). now has a T 5 Moderate Biconcavity treatment. If positive or negative show her bone density in her hips fracture at T5 and T9 and a severe for bone loss they should be put had declined by 13.3% in 6 years.

Her latest DXA scan results Biconcavity fracture at L1. on a bone health plan, as both (aged 64) on 15 08 2022 show Her latest DXA scan results in the cause significant bone loss. If the her bone density in her spine had Could these fractures have been person is negative for bone loss image below on 15 08 2022 show prevented? No one can say 100% prior to the treatment, they need her bone density in her hips had yes. However logically, if she had declined by a how furtherher 9.7%BMD in The graph in the image below shows (Bone Density) from on an Osteoporosis been mineral regularly monitored andplummeted when to be placed Figure 3 treatment to prevent bone loss four years. the initial bone loss occurred in age 54 to 64 occurring. For a person to fight cancer to stay alive and end up with multiple fractures is not acceptable. Ireland is not a third world country and for any of you or your customers who have had either treatment or are on Medications like Arimidex or aromatase inhibitors, they need to be informed to get a DXA scan done.

Diabetes and Osteoporosis There are two types of Diabetes Mellitus (DM). Type 1 which is a genetic disorder and people are usually diagnosed when they are young due to an insulin deficiency.

Type 2 DM usually develops due to a poor dietary intake, and this usually develops over time. People with Type 1 and 2 DM are at risk of fractures due to Osteoporosis.

Her DXA results from 18 06 2018 show her bone density in her hips had declined by 13.3% PHARMACYNEWSIRELAND.COM in 6 years.

62

Osteoporosis Figure 4

Menopause and Osteoporosis When a woman goes through the menopause, it is very important it is not assumed that this is the only cause of her bone loss, as there are approx. 200 other causes of bone loss.

Menopause and Bone Health Tips • HRT should only be given to those who go through an early menopause before age 45, who do not have contraindications, and those who have menopausal symptoms.

• HRT should not be prescribed just to protect bone health.

• For those who are going through an early menopause HRT should consist of oestrogen and progesterone. Oestrogen only should not be prescribed unless they have had a hysterectomy.

• Premenopausal females who have low oestrogen e.g. due to an eating disorder, can be prescribed either the contraceptive pill, i.e, an oestrogen and a progestogen, or HRT, that contains a different type of oestrogen and progestogen but ensure to tell them that it is not a contraceptive.

• Post-menopausal women who have an early menopause before age 45, if they still have a uterus, should be prescribed HRT consisting of oestrogen and progestogen, because otherwise

it can increase the risk of cancer of the body of the uterus.

• Initially, no lifting anything over 3 pounds

• Post-menopausal women who have an early menopause before age 45, If they have had their uterus removed they can go on oestrogen only.

• Put food items in a trolley and only half fill the bags

Severe bone loss A T score of -3.0 or higher on a DXA scan report • Avoid when possible, bending forward at your waist with legs straight

• Do not use a vacuum, stretch up for items, or twist your body to either side with your feet planted on the ground.

• No stretches or exercise that put stress on the bones in your back such as yoga.

• No lifting of children or pets in and out of a cot, car etc • Raised garden beds are ideal for those who love gardening Most people are not aware that fractures should be taken far more seriously, due to the secondary complications which can be life threatening, which are a blood clot, pneumonia or infection. 20% of those who fracture their hip aged 60+ will pass away within 6 to 12 months and 50% will lose their independence. Vertebral fractures significantly impact on activities of daily living, such as washing, dressing and walking.

A person can be diagnosed with Osteopenia and/or Osteoporosis.

Osteopenia is the precursor to Osteoporosis, and it is essential that the reasons why a person has lost bone is investigated and addressed, not assumed.

Figure 5

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NOTE A calcium and vitamin D supplement is not an Osteoporosis treatment. Calcium, vitamin D and first class proteins when ever possible should be from foods.

Men and Osteoporosis The diagnosis rate for Osteoporosis in men is very low and the IOS believe it is because of the myth that “Osteoporosis only affects old women”. 1 in 4 men over 50 will break a bone from Osteoporosis in their lifetime. More men pass away from Osteoporosis then get prostate cancer, which is why all men should be checking to see if they have risk factors for bone loss.

Exercise and Bone Health Appropriate weight bearing exercise is very important for those with bone loss, as well as improving muscle strength and balance. A very common stretch done by people is forward flexion which is shown in the image at the top of page 42 (figure 6). The IOS does not recommend this stretch for anyone other than athletes due to the damage it can inflict on a person. This stretch puts excess compression on the front of the body of the vertebrae and strain on the discs between the vertebrae.

This stretch also puts excess strain on your sciatic nerve in your back, that if irritated will cause pain to go down your leg.

The excess pressure on the vertebrae can cause Vertebral fractures. Professor Moira O’Brien who set up the first Osteoporosis

63 Figure 6

• Many people believe that it is normal to lose height as you get older, it can be a red flag for undiagnosed vertebral fractures.

• A person’s head protruding forward from their body or their shoulders becoming rounded or a hump developing on their upper back can be sign that vertebral fractures have occurred.

clinic in Ireland as well as being Walking, but the speed and course and no one should wear open back shoes as they are a tripping hazard. the only Osteoporosis consultant need to be altered.

We do not recommend the following for those with bone loss: in Ireland, has had patients in their Incontinence - There have been Walking up and down stairs 40’s who fractured vertebrae due in at theyour treatment Touching your while sittingthe position or when bendingadvances forward main muscles for standingsignificant to this stretch and toes the IOS havein the works incontinence, canriding, lead to walking, great for your overall waist, doing regular sit people ups, exercise onis trampolines, excessivefor weights, yoga,which horse received helpline calls from falls, due to people rushing to the health and helps to build up bone who havetwisting also fractured skiing, your from backthis with your feet on the ground (golf swing), vibrating machines, bathroom or slipping on urinehigh after in the hip area. So instead of forward flexion stretch. having an accident, please contact impact exercises such as jumping off boxes or heights your feet when walking. listening to the adverts on TVororpounding the Irish Osteoporosis NOTE: Many stretches in Yoga watching yourfor partner Jogging and running is not recommended thoseswitch whofrom have vertebral fractures. Society for more details. place stress on the bones in the one station to another during the spine, which is why the IOS do not breaks, why not walk upbone and down NOTE: The IOS does not recommend anyone with loss start onlineforexercise Riskan Factors Bone loss ever recommend yoga for those your stairs a couple of times. programme or weights programme, without having been individually assessed by a health with and without bone loss.

Family history of Osteoporosis When it is raining or very windy or broken bones (as care who on bone loss. Why? To help reduce the risk81% of people We doprofessional, not recommend the is up to date outside When the weather is not bone diagnosed), getting hurt.

In order professional to why put a loss menopause/ on a safe and following for those with for a healthvery wet and windy, notperson with hysterectomy, corticosteroids, bone loss: stand in front your favourite DXA TV scan appropriate exercise programme, they mustofunderstand results. ARadiation, person Arimidex, can Chemotherapy, programme and march on the spot Aromatase inhibitors, Physiological Touching your toes while the severe look perfectly fine butinhave bone loss. while watching it or while listening or psychological stress, RA, Protein sitting position or when standing to your favourite radio programme pump inhibitors, eating disorders bending forward at your waist, or walk around your home, & over exercisers, low vitamin doing regular sit ups, exercise on including going up and down your D levels, many medications for they trampolines, excessive weights, We DO recommend the following exercises/activities for those with bone loss, but stairs, as every step counts to help anxiety and depression. yoga, horse riding, skiing, twisting mayback not with be appropriate for everyone.

It will depend on the person’s age, if they have broken keep your independence. your your feet on the Signs and symptoms of possible any bones yet, their DXA scan results, medical of bone loss,Osteoporosis balance, ability ground (golf swing), vibrating Dancing, as long ashistory, you havecauses undiagnosed machines, and age.high impact exercises good balance, and you are not such as jumping off boxes or • A broken bone caused by a trip being swung around. heights or pounding your feet and fall from a standing position Walking, but the speed and course need to be altered when walking. Jogging and Strength and conditioning or less, even if on cement or ice. running is not recommended for programme, to include core Walking up and down stairs works the main muscles for walking, is great for your overall those who have vertebral fractures. stability. Senior citizens should health and helps to build up bone inout theactively hip area.

So instead of listening to the adverts on TV start exercising NOTE: The IOS does not their or watching yourwith partner fromlimbs onewithout stationweights. to another during the breaks, why not walk recommend anyone bone switch loss Light weights should be slowly start an online programme up and downexercise your stairs a couple of times. introduced, as rushing to increase or weights programme, without weights and resistance, can place having assessed Whenbeen it isindividually raining or very windy outside the weather is very wet and windy, why a senior citizenWhen at risk of muscle by a health care professional, not stand in front of your favourite and march on the spot while watching it or andTV jointprogramme soreness, which could who is up to date on bone loss. turn them off exercising, whileTolistening to your favourite radio programme or and walkplace around your home, including going Why? help reduce the risk of those with bone loss at risk of people In order foras a every step counts to help keep your independence. up andgetting downhurt. your stairs, possible fractures. health professional to put a person

• A person’s body shape changing, such as a pot belly developing, an increase in clothes size, or the person not being able to reach previously accessible shelves.

• Upper, middle or low back pain should be investigated, and Osteoporosis ruled out, as 75% of people with vertebral fractures have intermittent back pain.

The image below (figure 7) shows the effects of undiagnosed/ untreated bone loss at any age.

Summary People need the causes of their bone loss investigated and addressed People need to prevent falls by making their home safe People need to ensure they are doing appropriate exercise People need to ensure their bone health is monitored, as bone loss is silent!

Figure 7

with bone loss a safe For those who had previously lifted Dancing, asonlong asand you have good balance, and you are not being swung around appropriate exercise programme, weights, they should start with low they must understand DXA scan weights and gradually increase. results. A person can look perfectly Exercise in water can help fine but have severe bone loss. build up muscle strength and We DO recommend the following endurance, without putting excess exercises/activities for those with stress on joints. bone loss, but they may not be Fall Prevention - Balance and appropriate for everyone. It will depend on the person’s age, if they coordination including ensuring your home environment is safe. have broken any bones yet, their Example – A good pair of walking DXA scan results, medical history, shoes instead of wearing slippers, causes of bone loss, balance, ability and age. as most do not have good support

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64

Clinical Profiles

XBIOTECH ANNOUNCES FIRST PATIENT BEGINS NOVEL NATRUNIX THERAPY IN PHASE II RHEUMATOID ARTHRITIS (RA) CLINICAL TRIAL XBiotech Inc. (NASDAQ: XBIT) has began treating the first patient in a phase II, double-blind, placebo-controlled, randomized clinical study to evaluate Natrunix as a new treatment for Arthritis.

Natrunix blocks a key cause of inflammation involved in pain and joint destruction in rheumatoid arthritis (RA).

The primary endpoint of the Phase II is the American College of Rheumatology (ACR) 20% Response (ACR 20) rate at 12 weeks. Secondary and exploratory endpoints include ACR 50, ACR 70, numerical rating scale (NRS) for pain score, inflamed and painful joint counts, Health Assessment Questionnaire Disability Index (HAQ-DI), Routine Assessment of Patient Index Data 3 (RAPID-3), Clinical Disease Activity Index (CDAI) and safety. These endpoints reflect the expectation that Natrunix may provide needed improvement with respect to pain, tenderness, mobility of joints and quality of life. Approximately 210 subjects will be enrolled into three different arms in the study. All subjects will receive methotrexate (MTX) and be randomized to receive either one of two doses of Natrunix or placebo.

Natrunix is a monoclonal antibody indistinguishable from a naturally occurring antibody from a human donor. Natrunix binds and neutralizes the action of one of the most potent inflammation-causing substances known—interleukin-1.

For decades, interleukin-1 was seen as the key target for drugs to treat RA. However, to date, drugs that block interleukin-1 have not lived up to expectations as therapies for RA. XBiotech believes it has solved this puzzle.

Interleukin-1 actually describes two separate and distinct molecules—IL-1a and IL-1b—that are produced at different times and places in the body. XBiotech is the first to develop candidate therapies—like Natrunix—that directly and specifically neutralize IL-1a. In recent years, world-class research has shown that in many cases IL-1a may be the crucial target for blocking disease-causing activities of the interleukin-1 inflammatory pathway. Natrunix thus holds promise as a new generation anti-inflammatory therapy for arthritis. As a naturally derived human antibody, it is also by design expected to be among the safest and best tolerated medicines ever developed.

One in four adults, or over 50 million people in the United States are currently affected by Rheumatoid Arthritis, including 33% of those between the ages of 45-64 and 50% of person over 65 years of age. The number of persons affected by RA is expected to increase, with the CDC predicting that by the year 2040, 78.4 million adults, will suffer from RA in the United States. In addition, it is expected that 300,000 children will suffer from juvenile arthritis (Arthritis Foundation, 2023).

SPINAL INJURIES IRELAND (SII) CALLS ON BUSINESSES AND PUBLIC REPRESENTATIVES TO ‘BUDDY UP’ On average, three people sustain a Spinal Cord Injury (SCI) every week in Ireland with Spinal Injuries Ireland (SII) being the only charitable organisation dedicated to providing support for these 2,300+ people. This year, the charity aims to raise ¤100,000 by appealing to businesses and public representatives to get on the pathway to accessibility, and team up with service users of the charity by spending time in a wheelchair, as part of its largest national fundraising and awareness campaign for 2023 – ‘A Day in My Wheels’.

‘A Day in My Wheels,’ initially launched by SII in 2021, aims to highlight the need for a collaborative approach to create inclusive pathways to accessibility, while raising much-needed funds to support individuals living with SCI in Ireland.

The charity advocates on behalf of its members while also providing; one-to-one services from its community outreach team, and access to its trained peer mentor and comprehensive educational programmes. Another core element of SII’s work is counselling services for families and service users to help them cope with their new reality. This service delivery has changed post-Covid and in recent years, the charity has observed a significant increase in requests for these services.

In addition to all of these vital services, individuals and their families who are suddenly faced with SCI are faced with the cost of medical care, bowel and bladder care, pressure relieving equipment, and specialist requirements such as wheelchairs, hoists and adaptions to their car and home.

The aim of the campaign is not only to help the general public obtain a better understanding of living with this life-altering

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injury, but to offer employers and companies assistance to put the appropriate supports in place to help such individuals.

Fiona Bolger, CEO for Spinal Injuries Ireland (SII) explained that, “On average, three people sustain a Spinal Cord Injury (SCI) every week in Ireland. The impact can be devastating, and we want to be able to continue to provide support to our service users as they adjust to their life post-injury.

SII is inviting business leaders and public representatives (with up to four of their team members) to sign up now and join SII ambassadors and the Disability Federation of Ireland on Wednesday the 4th of October for approximately 2 hours at Cork County Hall for breakfast, talks and workshops.

Following this, participants will have the opportunity to ‘buddy up’ with a service user and spend the afternoon using a wheelchair.

The aim of the day is to provide a unique insight into the reality and accessibility issues those with SCI face every day, while raising much needed funds for SII. Companies or individuals are invited to contribute ¤5,000 to participate in ‘A Day in My Wheels’ 2023, where funds will directly support the 2,300+ individuals in Ireland with a Spinal Cord Injury and their families. A similar event will also take place in Dublin on the 27th of September.

For more on Spinal Injuries Ireland and the services it provides, see spinalinjuries.ie RANOLAZINE CLONMEL Clonmel Healthcare is delighted to announce the launch of Ranolazine Clonmel 375mg, 500mg and 750mg prolonged-release tablets.

Full prescribing information is available on request or alternatively please go to www.clonmel-health. ie. Medicinal product subject to medical prescription.

Please contact Clonmel Healthcare on 01-6204000 if you require any additional information.

PA 126/356/1-3. PA Holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Date prepared: July 2023. 2023/ADV/RAN/154H. LETTERKENNY UNIVERSITY HOSPITAL TAKES PART IN MAGNET4EUROPE Letterkenny University Hospital (LUH) is delighted be participating in a research project which aims to create a more positive work environment for nurses, with a focus on exemplary nursing practice. LUH is one of 67 hospitals across Europe participating in the Magnet4Europe project, it is an international programme designed to create a culture of excellence, and by doing so, improve the health and wellbeing of nurses in their workplace.

There is a large body of evidence which suggests that Magnet hospitals achieve higher employee retention rates, lower intention to leave, improved lower nurse burnout, higher levels of job satisfaction, better patient outcomes and improved patient safety. Magnet hospitals also report better clinical outcomes with shorter patient stay and reduced readmission rates.

The Magnet4Europe project spans across the EU, from Ireland to Sweden and the objective is to evaluate the impact of organisations redesign on nurses and clinician’s mental health and wellbeing in acute hospital settings.

65 Body Milk evenly and massage into your skin.

Available from Drh.ie and leading Dr Hauschka stockists ¤27.95 ABOUT DR. HAUSCHKA: Dr. Hauschka is a pioneering natural cosmetics brand from WALA Heilmittel GmbH, which has manufactured 100% genuine and effective natural cosmetics for over 50 years. “We naturally felt like rebels when we developed these unconventional cosmetics”, commented Elisabeth Sigmund, speaking about the early days of Dr. Hauschka in 1967. For Dr. Hauschka, natural cosmetics are not a trend but a tradition that has lasted for decades. Today, the foundation exports to over 50 countries.

From left: Elizabeth Neely, Assistant Director Of Nursing, Nurse Practice Development, LUH; Marie Callaghan, Assistant Director Of Nursing, Magnet Coordinator, LUH; Prof Jonathan Drennan, Irish lead, Magnet4Europe Project; Dr Anne Drake, Director of Nursing, LUH; Dr Noeleen Brady, Post-Doctoral Researcher, Magnet4Europe Project; and Sinead Fisher, Clinical Nurse Manager 3, Magnet, LUH

In LUH a lot of work has been done to embed the Magnet model in the hospital. The Magnet model framework aims to ensure that the organisation’s policies, procedures, structures and supports promote staff wellbeing and empower staff to achieve excellence in patient care. It is important that staff are encouraged to access resources and are aware of how to do so.

For example the hospital hosted a staff information day, which was an opportunity to showcase the wide range of staff supports already available and get feedback regarding what can be further done to support staff wellbeing.

Initiatives such as the launch of the LUH Rainbow badges, Africa Day and International Nurse Day celebrations ensure a culture of diversity and inclusion is visible within the organisation and that staff feel included, acknowledged and valued. Other plans involve optimising communication and being more innovative in how information is shared with staff, finding new ways to acknowledge and celebrate achievements, enhancing leadership capabilities within the nursing workforce and tailoring educational opportunities to the needs of staff.

The ‘Structural empowerment’ component of the Magnet model

focuses on ensuring nurses are supported to be involved in the decisions which affect their day-to-day work. This is done through having a clinical nursing voice on hospital committees and working groups and through the establishment of professional practice councils for different nursing grades.

The councils are nurse led and will be a voice of change within the LUH Nursing Service. They are forums for staff to convene to discuss nursing care issues and work together to find resolutions.

DR HAUSCHKA BERGAMOT LEMONGRASS VITALISING BODY MILK Discover a brand-new addition to the Dr. Hauschka body care range, the multi-layer formula of Bergamot Lemongrass Vitalising Body Milk provides long-lasting care with its uplifting formula that will awaken the skin and senses.

Containing vibrant ingredients such as lemongrass and quince – its fast-absorbing, lightweight composition vitalises and fortifies the skin while the essential oils of bergamot and neroli invigorate the body and mind. Precious oils including jojoba and olive oil lock in moisture, leaving skin feeling nourished and protected.

Firms the skin with the customary precious oils and medicinal plant extracts, releasing a bouquet of scents full of cooling and aromatic citrus notes.

The raw materials for the premium products, which are certified to the international NATRUE standard, are meticulously selected. Where possible, they are grown in biodynamic quality in the company’s own medicinal herb garden or on its own Demeter farm. They are often harvested in the early hours of the morning so that they retain their full natural strengths. The raw materials that are not cultivated in-house are sourced in part from wild harvesting methods and in part from organic cultivation projects worldwide. Alternatively, they are sourced from partners who work as fairly and sustainably as Dr. Hauschka itself.

New fragrance featuring bergamot – the Green Gold of Calabria For this light lotion, Dr. Hauschka perfumer Jörg Zimmermann has created a new fragrance that whisks you away on a sensory journey to southern Italy:

The products are free from synthetic fragrances, dyes and preservatives, silicones, PEG and min-eral oils and pay heed to the natural rhythms of nature and the skin.

In addition to the essential oils used for composing the fragrance, the new Dr. Hauschka Body Milk contains myriad other oils and essences, which work in harmony with each other to deliver their nourishing effect.

Trusted medicinal plant extracts Dr. Hauschka cosmetics draw on the healing power of nature. Every single medicinal plant has specific properties that enrich the overall composition. Lemongrass delivers its toning effect thanks to the light texture of the fast-absorbing new body milk. The blend of blackthorn, quince and field horsetail strengthens and maintains the natural balance of the skin.

Price: ¤27.95

Call to Action: Available from Drh.ie and official Dr Hauschka stockists nationwide

New. Bergamot Lemongrass Vitalising Body Milk.

Care with a vibrant, citrus scent

√Vegan √Gluten Free Usage Apply Bergamot Lemongrass

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66

Clinical Profiles

NEW SOLPA COLD & FLU LAUNCHED TO RELIEVE ALL COLD & FLU SYMPTOMS

of prostaglandin synthesis in hypothalamus (brain heat regulation centre).

Ahead of the impending winter cold & flu season, Perrigo has launched their new all-in-one solutions that relieves all cold & flu symptoms, making treatment choices easier for customers as well as helping to avoid the risk of over-medication.

For more information contact your Perrigo representative.

Solpa Cold & Flu Multi Relief Max Powder for Oral Solution contains Paracetamol - 1000 mg, Guaifenesin 200 mg, Phenylephrine Hydrochloride 12.2 mg and is the only max strength triple formulation now available.

Solpa Cold & Flu Multi Relief Capsules contain Paracetamol 500 mg, Guaifenesin 100 mg, Phenylephrine Hydrochloride 6.1 mg and starts releasing active ingredients in 5 minutes.

Cold & Flu remains one of the most commonly treated illnesses during winter with 1 in 3 people expected to catch a flu1 and 80% will seek treatment.2 Consumer research7 conducted on behalf of Perrigo in April 2023 shows that the majority of adults (86%) look to treat symptoms of cold & flu within 3 days and 76% expect they should be able to treat all symptoms with one medication.

Solpa Cold & Flu is a triple active formulation that works together on the most common cold & flu symptoms3 – runny nose, headache, sore throat, muscle ache and cough.

Phenylephrine4 reduces pressure and relieves blocked or runny nose and sneezing. It works by narrowing the blood vessels in the nose and sinus which reduces swelling and opens blocked airways. Constriction of nasal blood vessels also helps reduce nasal mucus production relieving congestion and runny nose.

Guaifenesin5 relieves chesty cough. It works by reducing the viscosity (stickiness) of respiratory secretions helping to break up congestion in the lungs and clear chesty coughs. It increases volume of respiratory secretions helping keep airways lubricated relieving irritation from dry coughs.

In tandem, the Paracetamol6 relieves headaches, muscle aches, fever & chills, and sore throat.

The analgesic (pain relieving) action is thought to be produced by inhibition of prostaglandin release and blocking pain impulse generation, while the antipyretic (fever reducing) action is thought to be produced by inhibition

Product Information 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 children 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 antidepressants or beta-blockers or other antihypertensive agents, patients who are taking or have taken monoamine 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 medicinal 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 paracetamolcontaining 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

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and further 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: htps://www.medicines.ie/ medicines/ solpa-cold-flu-multirelief-max- powder-for-oralsolution-35312/spc Solpa Cold & Flu Multi Relief Capsules, Paracetamol 500 mg, Guaifenesin 100 mg, Phenylephrine Hydrochloride 6.1 mg.

For the relief of symptoms of colds and flu and the pain and congestion of sinusitis, including aches and pains, headache, blocked nose, sore throat, chills, lowering of temperature, and to loosen stubborn mucus and provide relief from chesty coughs.

Adults, the elderly and children aged 16 years and over: Two capsules every 4-6 hours when necessary to a maximum of 4 doses in 24 hours. 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 antidepressants or beta-blockers or other antihypertensive agents, patients who are taking or have taken monoamine 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 medicinal products affecting hepatic function, glucose-6phosphate 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, decongestants or cold and flu medicines. 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 further information. Product

not subject to medical prescription.

PA1186/021/002. 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-multirelief-capsules- 35311/spc IRE SCF 2023 06 BOOTS IRELAND LAUNCHES THIS YEAR’S BOOTS NIGHT WALK IN AID OF THE IRISH CANCER SOCIETY Boots Ireland has partnered with Breast Cancer Survivor and Founder of the Good Glow Podcast Georgie Crawford to launch this year’s Boots Night Walk in aid of the Irish Cancer Society Night Nursing service which provides end-of-life care for people living with cancer in Ireland. The Irish Cancer Society Night Nursing service provides up to 10 nights of care and is free to people who avail of it. Boots Ireland has partnered with the Irish Cancer Society since 2012 and through the support of their team members, patients and customers have raised ¤2.8 million for the service so far, helping to provide over 8,000 nights of care.

This year, the Boots Night Walk is back, with Boots Ireland calling upon the public to sign up and walk 5km together this autumn in support of the Irish Cancer Society Night Nurses. The walk will take place on Friday the 8th September at Dublin’s Phoenix Park, or join us from afar to complete the walk a location of your choosing. Visit www.bootsnightwalk.com to make a donation or sign up* and start your own fundraising page to help raise money for this great cause.

Alongside the walk, Honour Tags are now on sale in Boots stores nationwide for ¤2. Customers can purchase a tag in honour of someone who has survived or passed away from cancer. The front of the tag allows for the name of the individual with space on the back for a personal message. One metre will be walked in honour of that person by members of the Boots Ireland team.

All funds raised from the Boots Night Walk will go towards the Irish Cancer Society Night Nursing service which provides end-of-life care for cancer patients, allowing them to spend their final days at home surrounded by family and loved ones, as well as giving much needed respite for the family caring for them.

Ambassador Georgie Crawford said, “This incredibly important service has made a difference

67 JANSSEN MARKS FIRST APPROVAL WORLDWIDE FOR AKEEGA® 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.

This year’s Boots Night Walk campaign ambassador Georgie Crawford and Annemarie Ward, Night Nurse for the Irish Cancer Society launch the 2023 Boots Night Walk in aid of the Irish Cancer Society Night Nursing service. You can visit www.bootsnightwalk.com to donate now or sign up and create your own fundraising page and start raising money for this great cause ahead of the walk on September 8th

to the lives of so many. I am so proud to be back as an ambassador this year, helping to raise awareness of such a worthy cause. I will be at the Nightwalk on Friday 8th September and hope that as many of you as possible will join me. Together, we can truly make a difference.”

Managing Director at Boots Ireland, Stephen Watkins, said, “The team at Boots Ireland are incredibly proud of the contribution already made to the Irish Cancer Society and we know that with the support of our colleagues, customers and members of the public we can continue to build on it. Boots has a longstanding relationship with the Irish Cancer Society where we continue to make a difference to people impacted by cancer and this years’ walk will be another truly special occasion.”

MORE THAN MEETS THE EYE Tired eyes look no further IMAGE skincare’s refreshing VITAL C Hydrating Eye Recovery Gel features a perfectly balanced blend of BV-OSC Vitamin C, anti-

ageing peptides, hyaluronic acid, and collagen recovery complex.

Clinically proven to improve the appearance of wrinkles and reduce appearance of dark circles, this light gel formula penetrates the skin’s surface around the delicate eye area for optimal efficacy without congesting pores.

Perfect for those seeking clean clinical skincare with proven ingredients to supercharge their skincare routine; this is the onestop solution for tired eyes to soothe an easily aggravated area.

For those who struggle with dark circles, puffiness, fine lines and crow’s feet wrinkles around the eye area, this light cooling gel works to brighten hydrate and refresh your look.

Our bodies naturally tire with time and one such effect of ageing is the loss of collagen which leads to looser skin, wrinkles, and reduced elasticity. 20 years after its initial launch, VITAL C is still IMAGE skincare’s best-selling collection. Powered by BV-OSC, a revolutionary form of Vitamin C that brightens skin and supports collagen synthesis, this range is

perfect for those who suffer from redness and rosacea. VITAL C combines powerful peptides and antioxidants to combat dryness and sensitivity and is great for all skin types, especially dry, sensitive and redness prone.

This refreshing eye gel has been newly modernised to meet IMAGE skincare’s clean clinical skincare™ standard and is formulated without parabens, phthalates, mineral oils, artificial fragrances, synthetic dyes or animal testing.

BV-OSC is an active form of Vitamin C and it improves collagen synthesis up to 50% better than traditional Vitamin C alone and ascorbic acid. This is because BVOSC is a concentrated form of the component of Vitamin C that promotes collagen synthesis, and it is more stable than plain Vitamin C. BV-OSC’s stability and oil solubility makes it a more reliable skin care product. Better yet, BV-OSC is gentler on the skin than ascorbic acid, another chemical used to encourage collagen synthesis, and it is full of antioxidants.

IMAGE Skincare RRP ¤53.50/£46.00

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). 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. 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.

The primary endpoint for MAGNITUDE was radiographic progression-free survival (rPFS), as analysed by blinded central review. 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). This improvement was most pronounced in patients with BRCA1/2 gene mutations, where a statistically significant 47 percent risk reduction was observed for rPFS. 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. 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).

The observed safety profile of the combination of niraparib and AAP was consistent with the known safety profile of each agent.

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Awards The Irish Pharmacy

2024

Save the Date Irish Pharmacy Awards

Saturday, 25th May, 2024 The Clayton Hotel, Burlington Road, Dublin