PAI Diary 2020

PAI

PHARMACY ASSIST IRELAND 2020

E D U C AT I O N T R A I N I N G D I R E C T O RY

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2020

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OUR PHARMACY No two pharmacies are the same. Whether you are working within a pharmacy chain or in a smaller, independent pharmacy; staff, opening hours, protocols and allied healthcare professionals will differ.

It is important therefore that you are knowledgeable as to your pharmacy's business and services provided. In addition, you should be educated in knowing the roles and remits of your colleagues.

Pharmacy name: Pharmacy address:

Pharmacy telephone number: Pharmacy fax number: Pharmacy email address:

Pharmacy website: Pharmacy opening hours:

Mon-Fri:

Sat: Christmas & New Year:

Pharmacy Holiday closures: Easter: Bank Holidays: Doctor Localities Local Health Centre: Address:

Telephone number:

Email:

Dentist Localities Local dentist surgery: Address:

Telephone number: Locum Contacts: 1 2 3 Lead Pharmacist: Pharmacy Manager: Pharmacy Technician: Accredited Checking Technician: Dispensing Assistant: Medicines Counter Assistant: Locum Pharmacist: Other:

Email:

Sun:

5

6

CONTENTS

Training guide content by page number and sources of further information

Heartburn & Dyspepsia Page 45

Our Pharmacy Page 5

Cold Sores Page 25

Adult Incontinence Page 9

Cough Page 27

Adult Pain – Pain Page 11

Cow’s Milk Allergy Page 29

Allergies Page 13

Dry Skin Page 31

AMD Eye Health Page 15

Eczema Page 33

Baby Skin Page 17

Eye Health in Elderly Page 37

Baby Health Vitamin D Page 19

Migraine Page 49 Mild to Moderate Pain Page 51 Nappy Rash Page 53 Omega Fish Oils Page 55 Oral Health Page 57

Psoriasis Page 67 Scarring Page 69 Skincare: Beauty Page 71 Smoking Cessation Page 73 Topical Analgesics Page 75 Vaginal Dryness Page 77

Haemorrhoids Page 39

Osteoarthritis Page 59

Winter Ailments Page 79

Bacterial Vaginosis Page 21

Hair Loss Page 41

Pain Relief Page 61

Diary 2020 Page 80

CBD Oil Page 23

Healthy Skin Page 43

Pre-Pregnancy and Company Listings Fertility - Page 65 Page 186

PUBLISHER IPN Communications Ireland Ltd. Clifton House, Lower Fitzwilliam Street Dublin 2 00353 (01) 6690562 ADVERTISING DIRECTOR - Debbie Graham 00353 (87) 288 2371 | debbie@ipn.ie ADVERTISING SALES - Amy Evans 00353 (0) 87 062 2025 | amy@ipn.ie www.pharmacynewsireland.com

The views and opinions expressed within this Pharmacy Assist directory are those of the authors and it is provided to you only as guidance. All of the information is published in good faith and for general information purposes only. Please share with your supervising pharmacist for his/her review in order to tailor it to the specific needs and practices of your individual pharmacy. It can be shared with counter staff at your discretion for training purposes.

All rights reserved by IPN Communication Ltd. All material published in Pharmacy Assist is copyright and no part of this document may be reproduced, stored in a retrieval system or transmitted in any form without prior written permission. IPN Communications Ltd have taken every care in compiling Pharmacy Assist to ensure that it is correct at the time of going to print, however the publishers assume no responsibility for any effects from omissions or errors.

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1 in 3 Women

experience light bladder weakness at some point in their lives.** This can be brought on by pregnancy, childbirth, obesity, menopause and natural changes in the body.

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www.tena.ie *Nielsen Scantrack data to 6th Oct 2019

ADULT INCONTINENCE

9

ADULT INCONTINENCE Incontinence is a condition that most people are too embarrassed to talk about, yet one that affects one in three women and one in nine men, and costs the HSE ¤100 million every year.

Urinary Incontinence (UI) can have a hugely negative impact on a person’s quality of life, mood and confidence with some sufferers becoming virtual prisoners in their own homes.

Urinary incontinence is loss of control of the bladder. It can affect anyone, regardless of age. It is a condition which ranges from mild to uncontrollable and embarrassing wetting.

Incontinence can often be caused by an illness, such as a urinary tract infection, and often when the infection gets better the incontinence improves.

Bladder control problems have a significant effect on the quality of life of sufferers on a physical, emotional and social level.

Continence is a necessity for comfortable social adjustment and conversely, urinary incontinence frequently causes profound psychological and social consequences and restricts social activities.

Stress incontinence - happens when a person wets themself during exercise, coughing, sneezing, laughing or other movements that put pressure on the bladder.

It is the most common type of incontinence and usually affects women, however, men can also develop stress incontinence after a prostate operation.

Urgency/urge incontinence - occurs when a person cannot hold on long enough to reach a toilet. This may be caused by an over-active bladder, infection, medication or poor mobility.

In men, it may be sign of an enlarged prostate.

Overflow incontinence - happens when the bladder does not empty completely. Urine builds up and then may overflow, often as frequent dribbling. This type of incontinence is more common in men and may be due to an enlarged prostate gland, but constipation may also be a cause.

Reflex incontinence - is where the bladder empties when it is full and the person is usually unaware of this. The cause is a break in the signals between the brain and bladder, which may be caused by a stroke or spinal injury.

Incontinence products While incontinence products aren’t a treatment for urinary incontinence, they are useful for managing the condition while a person is waiting to be assessed or for treatment to take effect.

• Absorbent products, such as incontinence pants or pads. Liners, pads, disposable underwear, and reusable underwear absorb moisture. Products made for incontinence control catch the leaks and pull moisture away from the skin. That allows sufferers to go longer between changes.Many disposable pads, liners, and undergarments have a waterproof backing. This helps prevent overflow from reaching clothes.

The waterproof systems use a “breathable” plastic film that helps reduce skin irritation.

There’s also a range of disposable undergarments with built-in protection - not just in the crotch, but throughout the entire garment. Styles range from pull-ons with elasticised legs and waists resembling a traditional cloth underwear to underwear that slips on with Velcro or adhesive tabs for a customised fit. There are also open-sided “thong style” pants held together by straps in the front and back that rest on top of the hip bone. Incontinence bed sheets are also available.

• Handheld urinals • A catheter, a thin tube that is inserted into the bladder to drain urine • Devices that are placed into the vagina or urethra to prevent urine leakage – for example, during exercise Treatments The treatment a medical professional will recommend for urinary incontinence will depend on the type of incontinence a patient has and the severity of their symptoms. If the incontinence is caused by an underlying condition, they may receive treatment for this alongside incontinence treatment.

Conservative treatments, which don’t involve medication or surgery, can be recommended first. These include:

The specialist will assess whether the person is able to squeeze (contract) their pelvic floor muscles and by how much. If they can contract their pelvic floor muscles, they’ll be given an individual exercise programme based on their assessment.

Bladder training When diagnosed with urge incontinence, one of the first treatments offered is bladder training. Bladder training may also be combined with pelvic floor muscle training if a person is suffering from mixed urinary incontinence. It involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course will usually last for at least six weeks.

Surgery Mid-urethral slings are minimally invasive procedures developed in Europe in the 1990s to treat female stress urinary incontinence.

These slings are narrow, polypropylene (a commonly used suture material) tapes that are surgically placed beneath the middle part of the urethra (water pipe) to provide dynamic support to stop leakage from the bladder. They have been shown to be as effective as more invasive traditional surgery with major advantages of shorter operating and admission times, and a quicker return to normal activities together with lower rates of complications.

Lifestyle changes • reducing caffeine intake – caffeine is found in tea, coffee and cola, and can increase the amount of urine the body produces • altering how much fluid is drunk a day – drinking too much or too little can make incontinence worse • losing weight Pelvic floor muscle training (Kegel exercises) The pelvic floor muscles are the muscles used to control the flow of urine as the body urinates. They surround the bladder and urethra, the tube that carries urine from the bladder outside the body. Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended. A GP may refer a patient to a specialist to start a programme of pelvic floor muscle training.

Who? Anyone, regardless of age.

Women are more prone to stress incontinence than men.

What are the symptoms? Depends on the type of incontinence, but generally wetting oneself or dribbling.

How long have they had the symptoms? Medical advice should be sought when symptoms present.

Action already taken? Lifestyle changes or pelvic exercises may help.

Medication?A range of products to manage the condition are available.

DON’T LET PAIN HOLD YOU BACK

ESSENTIAL INFORMATION Solpa-Extra 500mg/65mg Soluble Tablets contain paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and children over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Children 12-15 years: 1 tablet disolved 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, such as renal or hepatic impairment, chronic alcoholism and malnutrition or dehydration. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Patients should be advised not to take other paracetamol containing products concurrently. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions.

Unknown: nervousness, dizziness. Further information is available in the SmPC. PA 1186/017/001. P. MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. Date of preparation: April 2017. IRE/NHPT/SOL1/2019-003.

ADULT PAIN

11

ADULT PAIN Pain is something that many feel, but it cannot be seen and is quickly forgotten.

For those living with persistent chronic pain conditions they often feel isolated as others cannot comprehend the impact pain has on every aspect of life.

Chronic pain is thought to affect 1.65 million people in Ireland, with chronic back pain one of the more common diagnoses. It has been widely suggested that there is a strong case for community pharmacists and their teams to contribute more to cost-effective and timely pain management services for chronic pain.

Chronic pain, as the name implies, is pain that persists longer than usual tissue healing time, or in cases in which healing does not take place at all. The timeframe for a condition to be described as chronic is usually from three to six months.

The pain can be consistent or intermittent, and can be classified as follows: • Neuropathic pain: burning, stabbing, tingling, insect crawling, shooting, associated with allodynia, hypersensitivity or other sensory changes.

• Nociceptive pain: aching, worse on movement, anatomically defined, fluctuates in severity.

• Mixed pain: i.e. a combination of both neuropathic and nociceptive pain symptoms.

• Visceral pain: dull, diffuse, ill-defined.

• Autonomic symptoms: colour and temperature changes, sweating, trophic changes.

While neuropathic pain is caused by damage to or dysfunction of the nerves, spinal cord, or brain, nociceptive pain is the type of pain which results from injury or damage to body tissues, such as an accident or trauma, injury or burn, post-operative or due to a break or fracture.

Headache, in all its forms, is a very common type of pain, while musculoskeletal problems, such as lower back pain and osteoarthritis, are also widespread.

Neurological conditions, such as multiple sclerosis and thyroid disease, can also cause chronic forms of neuropathic pain.

According to the International Association for the Study of Pain, chronic pain can be experienced by those who do not have evidence of tissue damage or biological reason for pain, which can often make diagnosis difficult.

In terms of chronic pain, it is particularly important to take account of the type of pain the person is experiencing, how long they have been experiencing it, and if they are taking medication for relief.

Practically speaking, the two most common types of chronic pain seen in pharmacies are the result of headaches and back pain.

When it comes to patients complaining

of headache, it is important to consider that migraine is the most common form of chronic headache and it is still under-recognised by many health professionals and patients.

Back problems are also very common and have a variety of causes, from slipped disks to arthritis.

Osteoarthritis, caused by ageing and longterm wear-and-tear in the joints, is by far the most common form of arthritis and should be considered particularly in patients over the age of 40.

A much under-diagnosed chronic pain condition is fibromyalgia. The condition affects connective tissues which include the muscles, ligaments and tendons.

Myalgia, which means muscle pain, is the main symptom while debilitating fatigue, sleep disturbances, joint stiffness, headaches and mood disturbances can also occur.

Fibromyalgia commonly co-exists with psychiatric conditions such as depression, anxiety and other stress related disorders. It affects approximately 2% of people by the age of 20, increasing to 8% of people by the age of 70.

Treatment for chronic pain depends on the type of pain the person is experiencing.

For migraine, aspirin is the traditional first line of defence, and has anti-inflammatory properties that can help alleviate many of the physical symptoms.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for more severe migraine attacks, with evidence showing ibuprofen to be highly effective. Triptans are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70 to 80 per cent of patients.

Triptans target the neural serotonin receptors specifically involved in migraine attacks and can be used in the treatment of migraine

whether the patient is suffering from focal neurological symptoms <aura> or not.

Neuropathic pain remains among the most difficult to treat of all the chronic pain syndromes and often antidepressants are prescribed as an adjuvant therapy to alleviate the pain.

Antidepressants are also widely used to manage irritable bowel syndrome, temporomandibular joint dysfunction, atypical facial pain and fibromyalgia.

Tricyclic Antidepressants (TCAs) were the first medication category proven effective for chronic neuropathic pain in double blind, placebo controlled trials.

Contrary to the assumption of the initial trials, pain relief and relief of depression are independent effects.

Other adjuvant therapies for pain may include anti-seizure medications (gabapentin, pregabalin, topiramate for example); muscle relaxants (baclofen, cyclobenzaprine, methocarbamol, and diazepam ); sedatives/anti-anxiety medications, and spasm medication (botulinum toxin).

Who? Anyone.

What are the symptoms? Pain in one or more sites in the body.

How long has the patient had the symptoms? If the pain lasts longer than three months it is considered chronic.

Action already taken? The patient may have already used OTC pain relief.

Medication? Opioids to be used sparingly due to addictive properties.

12

How often should I use Stérimar?

same concentration of salts as the cells in the human body. As such, irritation is highly unlikely. Stérimar Hypertonic has a higher salt content than Stérimar Isotonic but the solution is still less salty than sea water. A sensation of dryness may occur and should disappear within a few days.

Always follow instructions and/or doctor’s recommendations.

Can I use Stérimar if I am pregnant, diabetic or suffer from high blood pressure?

We recommend using Stérimar Isotonic and Stérimar Baby two to six times a day (or more) in each nostril for as long as you need it or as long as and as often as your doctor recommends.

Stérimar Hypertonic is recommended for a short period. Use two to four times a day in each nostril for light congestion and up to six times a day for severe congestion.

Can Stérimar be used with other medication?

Yes. Stérimar is drug-free and doesn’t contain preservatives so there is no known risk of interaction with any other medication. However, in all cases it is best to check with your doctor.

Am I likely to experience any irritation from using Stérimar?

Yes, Stérimar is completely safe to use with these conditions, but it is always a good idea to check with your doctor.

Can I use Stérimar for my three year old?

Yes, Stérimar Isotonic is suitable for the whole of the family, even babies from 3 months old. Stérimar Hypertonic is suitable for all adults and children over three years of age and Stérimar Baby can be used with babies from birth to 3 years old.

Is the nozzle safe to use?

Yes. The Stérimar nozzle has been specifically designed to fit any shape and size of nostrils.

Stérimar Baby has a specific nozzle with a protective flange. The nozzle cannot be pushed too far into the nose to avoid any risks of injury.

Stérimar Isotonic and Stérimar Baby are purified sea water solutions with the

Please contact your Pemberton Rep to place your order on 01 4632424

How long will Stérimar keep?

Stérimar products can be kept for a maximum of three years after manufacture or until all solution has been used. The expiry date can be found at the bottom of the can and carton. Each dose of Stérimar delivered is aseptic.

The valve on top of the can prevents air from entering. Also, because the solution is kept in a sterilised pouch it never comes into contact with either the aluminium can or the non-flammable nitrogen gas within.

Why is it important to clean the nozzle after each use?

You must clean the nozzle in soapy water to remove any microorganisms left after use to help avoid any cross-contamination.

What does micro-diffusion mean?

The unique Stérimar micro-diffusion system produces a fine spray of sea water. As the droplets produced by Stérimar are microfine, they remain in contact with the walls of the nasal passages for longer, making Stérimar even more effective.

Why are the copper and manganese in Stérimar Hypertonic important?

Copper and manganese are found in very small amounts in the human body.

They stimulate the body’s self defense mechanisms and help keep it healthy.

ALLERGIES

13

ALLERGIES An allergy is a reaction the body has to a particular food or substance. Allergies are very common. They’re thought to affect more than one in four people at some point in their lives.

They are particularly common in children.

Some allergies go away as a child gets older, although many are life-long. Adults can develop allergies to things they weren’t previously allergic to.

Having an allergy can be a nuisance and affect your everyday activities, but most allergic reactions are mild and can be largely kept under control. Severe reactions can occasionally occur, but these are uncommon.

Common causes of indoor allergies House dust - although many allergens in the environment can trigger allergic symptoms, house dust is the main culprit in indoor allergies. House dust is an airborne mixture that might contain fine particles of soil and plant material from indoors or outdoors, particles of human and animal skin dander and hair, fabric fibres, mould spores, dust mites, fragments of insects that have died and their waste, food particles, and other debris. Some dust is present in every home, regardless of how often or how thoroughly the house is cleaned.

Dust mites - often, when people believe they are sensitive to dust, they are in fact sensitive to the dust mites and their waste particles that are found in household dust. Dust mites can be found in most homes, usually in beds and bed covers, upholstered furniture and fabrics.

Preventative measures include: using a dehumidifier or air conditioner, washing bedding on a hot cycle (non-washable bedding can be frozen overnight to kill dust mites), replacing wool or feathered bedding with synthetic materials or allergen-proof bedding, using a vacuum cleaner with a HEPA filter and avoiding the vacuumed area for 20 minutes to allow any dust and allergens to settle.

Pet dander - the allergic reaction to an animal is not caused by the animal’s hair.

It is caused by substances in the animal’s saliva, urine, and especially dander (dead skin flakes that become loosened from the animal’s skin). The allergens become crusted on the animal’s fur and skin from urination or the animal licking or scratching itself; once dry, the allergens are released into the air, where they join the other components of house dust. Cats and dogs are most likely to cause allergic reactions.

Moulds - moulds generally live outdoors but can normally be found in almost any indoor environment. They easily pass through open doors and windows and settle indoors, especially where there is

excess heat and humidity. They grow and produce mildew which thrives in places like shower cubicles. Non-visible moulds can grow in unseen areas of the house, such as under flooring materials and behind walls. To grow, mould requires water; for example, from a leaking pipe or roof, or condensation. As it grows, mould releases more spores, many of which become part of house dust. While moulds can trigger allergic symptoms, like any other allergen, they rarely cause serious health problems, except in people who are seriously immune-compromised or on chemotherapy.

Symptoms of indoor allergies • Itchy, congested nose • Clear nasal discharge • Itchy, watery, swollen or red eyes • Sneezing • Tickly, swollen throat • Coughing or wheezing • Tightness in the chest • Reactions to animal allergens may be very mild or quite severe. Symptoms may occur immediately after exposure to the allergen, or they may build gradually for 8-12 hours after exposure or become persistent.

Self-Care Treatment Options First generation antihistamines are more likely to cause drowsiness. Depending on the product, the duration of action is often shorter than newer antihistamines and may necessitate taking the drug three to four times each day.

Secondgeneration antihistamines can be taken over the long term with minimal side effects and are unlikely to cause sleepiness.

The non-sedating antihistamines are convenient to take since they are taken once or twice daily. Saline nasal rinses reduce the symptoms of nasal allergies and can offer relief in conjunction with conventional treatment.

Maintaining clear and nasal pages is important - the tiny hairs (cilia) inside the nasal passage work to carry dust, pollution and allergens to the back of the throat where they are swallowed and destroyed, before they can multiply and cause harm. If the nasal passages are dry or blocked, they become less efficient.

Who is the patient? Sensitivity to indoor allergens is very common and occurs at every age.

What are the Symptoms? Itchy, congested nose, clear nasal discharge, irritated eyes, sneezing, tickly throat, coughing or wheezing.

How long have the symptoms been present? Indoor allergies tend to be at their worst in the late summer, when dust mites are at most prevalent.

Action already taken? Patients may have tried antihistamines but not be aware of the benefits of nasal hygiene.

Medication? Saline nasal rinses and sprays are drug free and do not contain preservatives, so will not interact with other medication.

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Contains Lutein, Zeaxanthin and Astaxanthin

Added vitamins and minerals

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EYE HEALTH

15

AMD EYE HEALTH Eye health can easily be overlooked because eye conditions often don’t present symptoms early on Encouraging customers to have regular eye tests, at least every two years, will mean any general health problems and signs of eye conditions are picked up.

Take the opportunity to talk about specific eye health issues. For example, ensure customers who have a positive diabetes screening test result are made aware of the importance of annual screening to prevent diabetic retinopathy.

Dry Eye An estimated 10% to 30% of the population older than 40 years suffers from some degree of dry eye disease (DED). The condition tends to affect people above 60, and it is more common in women than men.

Around one in 13 people who are in their fifties experience dry eye syndrome, and the condition becomes more common with age. Up to a third of people age 65 or older may have dry eye syndrome.

DED, which is also sometimes referred to as dry eye syndrome or keratoconjunctivitis sicca, is considered the most prevalent ophthalmic disorder that affects the anterior eye and is For more information: most often associated with the aging process, UK: 0800 270 0253 especially Freephone in postmenopausal women.

Freephone IRL: 1800 816 005 Email: info@scopeophthalmics.com The symptoms of dry eye syndrome usually Visit: www.scopeophthalmics.com

affect both eyes and may include:

• feelings of dryness, grittiness or soreness, which get worse throughout the day • redness of the eyes • watering eyes, particularly when exposed to wind

glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces.

Conjunctivitis is one of the most common causes of ‘red eye’ and one that presents very often in the pharmacy. The term ‘conjunctivitis’ refers to an inflammatory condition that affects the conjunctiva, which is the thin transparent mucous membrane covering the white of the eye. It can become inflamed due to a variety of reasons and is normally subdivided into origins that are either infective or non-infective in nature. This can be further divided into acute or chronic conjunctivitis.

Red and watering eyes are the main symptoms of conjunctivitis. Others are: • a burning sensation in your eyes • a feeling of grit in your eyes • a sticky coating on the eyelashes

• eyelids that stick together when waking up

• an enlarged lymph node in front of the ear

These symptoms may get worse in smoky or hot environments.

Contact dermatoconjunctivitis and giant papillary conjunctivitis are frequently caused by contact lenses and lubricating eye drops.

Eye drops that contain a preservative agent, commonly benzalkonium chloride, are long established irritants. Hence, patients that present with symptoms of irritation that can be linked to onset of use of eye drops should be advised to switch to preservative-free formulations.

When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors.

Briefly, this should include details of the signs and symptoms, duration of symptoms and exacerbating factors, such as the environment, changes in humidity or computer use. Topical ocular lubricants are the mainstay of dry eye treatment, with the choice of tear substitute depending on the severity of the condition.

Pharmacological interventions in all forms of dry eye conditions range in formulation, such as drops, sprays, gels and ointments.

For occasional or mild dry eye symptoms, OTC eyedrops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing

Once the cause of the allergic symptoms has been identified, patients should be advised to avoid the allergen to control symptoms and avoid future flare-ups.

Blepaharitis Most people with dry eye syndrome also have blepharitis, which is a common and usually mild condition that causes inflammation (redness and swelling) of the rims of the eyelids. Patients with blepharitis may present with eyelash changes, watering, crusting and mattering around the lashes and canthus, photophobia, pain, and vision changes. The symptoms are

usually worse in the morning, after a night of closed eyes has kept eyelids in contact with the ocular surface.

Patients’ visual function may decline pursuant to corneal damage and inflammation, scar formation, loss of surface smoothness, and clouded corneas. If severe inflammation develops, corneal perforation can occur. The normal progression may include eyelid damage to the lids with trichiasis, or entropion and ectropion (respectively, inward or outward turning lids that cannot close properly).

Pharmacists should keep certain tips in mind when helping patients who have blepharitis.

First, pharmaceutical preparations like ointments and gels will stay in contact with the lid margin longer than solutions. These are usually preferred for blepharitis, but drops are preferred for corneal disease because they spread evenly.

Pharmacists need to repeat one message to patients at every visit: when applying any ointment to lid margins, using a clean application device, such as a cotton swab or a clean fingertip, is critical, as is gentle eyelid handling.

Who? Dry eye is usually older people; red eye, anyone What are the symptoms? dry, gritty eye for dry eye; grit and stick eye for conjunctivitis How long have they had the symptoms? If this persists for longer than a few weeks or is a particularly severe case, refer to GP Action already taken? Customers may have already tried eye drops Medication? check the medication of patients with dry eye as it may be causing it, check if patients are contact lens wearers and what lubricants they use.

BABY SKINCARE

17

BABY SKINCARE Babies are a customers most prized possession, and therefore any signs of in their child can be worrying – and their concern is not helped by the alarmist information that can be found on the internet. One of the most important things pharmacy teams can do is provide reassurance.

Eczema Atopic eczema is a very common skin condition, affecting one in five children.

Atopic dermatitis is the most common form of eczema affecting young children.

For most children affected, the disease is mild. However, often those who have seemingly outgrown the condition will continue to have life-long sensitive skin and may have recurrences of eczema following long symptom-free spells.

An intense itch is the major symptom of atopic eczema. Scratching only provides momentary relief, and leads to more itching (the itch-scratch cycle). Scratching worsens eczema and can make the skin more vulnerable to infection. The intense itch is very uncomfortable, can disrupt sleep and negatively impact on the child’s quality of life, as well as that of his/her parents and the wider family. Some children with more pronounced eczema can also experience social embarrassment due to the visibility of their condition.

In infancy, the first noticeable signs of atopic eczema may be skin dryness and roughness, but other symptoms (e.g. red itchy skin which can affect the cheeks and forehead, and/or the trunk and outer aspects of arms and legs) do not usually occur before two months of age.

In older children, from about 1-2 years onwards, atopic eczema is most often seen on the inner sides of the arms at the elbow creases, behind the knees, and on the face and neck.

Emollients can be used for daily use on dry skin – including bath soap substitutes that are free of sodium lauryl sulphate; topical corticosteroids during flare-ups. Advise parents to try and encourage their child not to scratch and help them avoid triggers.

Recommend a GP if you notice very red and weepy eczema with small blisters, as this could signal an infection. Similarly, if the skin is cracked or the problem is persistent or worsening.

Cradle Cap Cradle cap is the name given to the yellowish, greasy scaly patches that appear on the scalp of young babies. It is a very common, harmless condition that does not

usually itch or cause any discomfort to the baby.

Cradle cap usually begins in babies during their first three months and tends to last a few weeks or months. It usually clears up by the time the child is two years old, although in rare cases children can have cradle cap for a lot longer.

The cause of cradle cap is not clear, although it may be linked to overactive sebaceous glands, which are glands in the skin that produce an oily substance called sebum.

Pharmacists can advise that cradle cap requires no specific treatment, although gently washing the baby’s hair and scalp may prevent a build-up of the scale.

Chickenpox Also known as varicella zoster virus, chickenpox is often seen in children under eight years of age. Symptoms include an itchy rash (mainly on the chest and back) comprising of spots that resemble blisters.

Discomfort is notably worse if the skin is too warm.

Chickenpox tends to last between 7-21 days. Paracetamol should be given in the case of fever and cooler baths. Calamine lotion is the traditional option for topical use but is drying in nature. Newer cooling gels/ sprays are available to reduce itching and limit any potential scarring.

Advise parents to keep their child away from others – especially pregnant women or immunosuppressed individuals.

Ibuprofen is no longer advocated as it can make the lesions worse.

Recommend a GP if the child appears to be very unwell.

Prickly heat Prickly heat is a skin irritation that occurs when the sweat glands are blocked. Babies and children are more at risk because of their under-developed sweat glands.

Symptoms include a rash made up of tiny spots, bumps or sometimes blisters, surrounded by a patch of red skin. The symptoms can be accompanied by mild swelling, itching, and a stinging or prickling sensation. It is commonly found on the face, back, neck, chest and thighs.

Treatments include hydrocortisone cream (but not to the face), calamine lotion, antihistamines (where appropriate); wearing cotton clothing, avoiding excessive heat and humidity, and keeping skin cool.

Advise parents to call a health professional urgently if a rash does not fade when the skin is pressed with the side of a glass.

Who? Babies and children aged under 8.

Symptoms? Skin dryness, red itchy skin; greasy scaly patches on the scalp; itchy rash of spots resembling blisters on chest and back; rash made up of tiny spots surrounded by patch of red skin.

How long have they had the symptoms?

Action already taken. Avoiding itch, bathing hair and scalp.

Medication? Emollients, topical corticosteroids, calamine lotion, antihistamines.

BABY HEALTH - VITAMIN D

19

BABY HEALTH - VITAMIN D Babies need vitamin D for healthy growth and development. It helps them build strong, healthy bones and teeth.

Babies who don’t get enough vitamin D are said to have a deficiency. If the levels are low enough, they are at risk of getting rickets, a disease that affects the way bones grow and develop.

The recent re-emergence of rickets (a severe form of vitamin D deficiency causing deformity of the bones) amongst infants in Ireland indicated the widespread low levels of vitamin D in the Irish population.

Vitamin D deficiency was thought to have been eradicated in Ireland after the Second World War, due to better nutrition.

However, over 20 cases of rickets in infants and toddlers have been reported at two Dublin hospitals in the last four to five years. Further evidence is emerging that there is widespread low levels of vitamin D in the general population in Ireland.

There are several factors which have contributed to this.

• Vitamin D is mainly produced in the body by exposure of the skin to sunlight. However, because of Ireland’s northerly latitude, in the months between November and March there is inadequate quality and quantity of sunlight to enable sufficient production of vitamin D by the body (the current recommended dietary daily amount of vitamin D is 5 µg). Even on sunny days in the winter, the sun’s rays are of the wrong type for the production of vitamin D. In addition, with more people working indoors and using sunscreen when outside, vitamin D from sunlight exposure has decreased.

• Darker skinned people living in Ireland are particularly at risk as they require more sunlight to produce vitamin D (10 to 50 times more exposure to sunlight required). Also, some religious practices preclude any skin exposure.

• Dietary sources of vitamin D are not consumed in sufficient quantities to counter the lack of sunlight exposure and do not form part of the weaning diet for infants. Examples of dietary sources of vitamin D include oily fish (e.g. salmon, mackerel, sardines), egg yolks and fortified foods such as milk and breakfast cereals. In addition, offal meat such as liver and kidney are a good source of Vitamin D but these foods are not suitable for infants and pregnant women because they provide too much Vitamin A.

What are the dietary sources of vitamin D? Vitamin D is found in a small range of foods including oily fish, egg yolks and fortified foods such as milk, breakfast cereals and infant formula. In addition, offal meat such as liver and kidney are a good source of Vitamin D but these foods are not suitable for infants and pregnant women because they provide too much Vitamin A.

2. Supplements that provide only vitamin D and are in a suitable form to be given to infants should be used to supplement infants in Ireland. The daily amount of vitamin D provided by such supplements should be 5µg per day.

3. Health professionals and parents need to be made aware that vitamin D deficiency is prevalent in Ireland, particularly among dark-skinned infants and young children.

Recently updated dietary guidelines in North America recommend an intake of 5µg of vitamin D per day for infants and young children up to 3 years of age. In Canada, which is at a similar northerly latitude to Ireland, all babies taking less than 500ml of infant formula are supplemented with 10µg of vitamin D.

Who? All babies living in Ireland

FSAI recommendations

Medication: All babies living in Ireland should be given a vitamin D only supplement providing 5µg Vitamin D from birth; Supplements that provide only vitamin D and are in a suitable form to be given to infants should be used to supplement infants in Ireland. The daily amount of vitamin D provided by such supplements should be 5µg per day.

The recommendations are as follows: 1. All babies living in Ireland should be given a vitamin D only supplement providing 5µg Vitamin D from birth.

This is necessary because babies aged 0-12 months are at high risk of vitamin D deficiency, due to their rapid growth rates during this period.

What are the symptoms? N/A How long has the patient had the symptoms? N/A Action already taken?

A HEALTHY VAGINA

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A HEALTHY VAGINA

Bacterial Vaginosis:

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that lactic acid treatment in combination with antibiotics has the least recurrence episodes and has a better long 1. BASHH Hay P. et al (2012) National guideline for lactic the management Relactagel contains acidof bacterial whichvaginosis restores 7. Association for Sexual Health and HIV. 2012.treatment Clinical Effectiveness British term effectGroup. on BV References:

maintains the natural acidity providing an environm favourable to the growth of lactobacilli. Relactagel contains glycogen which provides nutrients for la acid bacteria.

2. Andersch, B et al (1990) Bacterial Vaginosis and the Effect of Intermittent Prophylactic Treatment with an Acid Lactate Gel. Gynecologic and Obstetric Investigation (30): 114-119 3. Hay P.E. Ugwumada A. Chowns J. (1997) Sex, Thrush and Bacterial Vaginosis.

International Journal of STD and AIDS 8; 603-608.

4. RCGP, Sexually Transmitted Infections in Primary Care (2013 Edition) 18/10/2017 12:00 5. Andersch, B et al (1986) Treatment of Bacterial Vaginosis with an Acid Cream: A Comparison between the Effect of Lactate-Gel and Metronidazole. Gynecologic and Obstetric Investigation (21):19-25 6. Bradshaw, C. SRelactagel et al (2006) High coats Recurrance rates of Bacterial Vaginosis over the the course of 12 Months after Oral Metronidazole Therapy and Factors Associated with vagina RecurrenceJ Indect Dis (11): 1478-86 .

7. Decena DC, Co JT, Manalastas RM Jr, Palaypayon EP, Padolina CS, Sison JM, Dancel LA and Lelis MA. (2006) Metronidazole with Lactacyd vaginal gel in bacterial vaginosis.

Journal of Obstetrics and Gynaecology Research, 32(2),243-251.

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23

CBD OIL IN PHARMACY In July of this year, Minister for Health Simon Harris TD signed legislation which will allow for the operation of the Medical Cannabis Access Programme on a pilot basis for five years. The Programme will facilitate access to cannabisbased products for medical use in line with legislation. This new law means that pharmacists are now also able to dispense cannabis for medical use to patients.

CBD stands for Cannabidiol. CBD is one of the many compounds found in the hemp plant. Unlike THC (tetrahydrocannabinol),CBD is not a controlled substance.

With the emergence and rapid growth of CBD product offerings in the Irish market over the past few years, there has also been a rise in misleading information about these products, the potential benefits they can offer and how the various products differ.

How does CBD Work?

CBD interacts with the bodies endocannabinoid system (ECS). The ECS is a regulatory system made up of endocannabinoids (the body’s own cannabinoids) which shuttle messages around the body to help maintain homeostasis, or simply, they aid the body in keeping itself in balance. These hemp-like molecules interact with various receptors (CB1 and CB2) which can be found in the brain, immune and central nervous system. Cannabinoids from plants, such as CBD, interact with this same system.

Sometimes the body’s demand on the ECS increases, or a consumer’s diet may not always be able to make sufficient endocannabinoids to meet the demand from the body. By taking an exogenous CBD it helps work with the body’s endocannabinoid system (ECS).

What are phytocannabinoids?

Cannabinoids are found in plants such as marijuana and hemp. Cannabinoids found in the cannabis plant are also known as phytocannabinoids. Phytocannabinoids occur naturally in the cannabis plant.

Several hundred compounds have been found in the cannabis plant and of those, many have been identified as cannabinoids. The most high-profile of these are CBD, THC and cannabinol (CBN). The most abundant cannabinoid found in the hemp plant is CBD.

cannabinoids stay mainly in their native form e.g. CBD stays in the form of CBDa. The cannabinoids are lipophilic i.e. they are soluble in oil. Therefore, CBDa will naturally reside in the oil of the plant.

Cold pressed products are always classified as Full Spectrum as they contain all the cannabinoids available from within the plant.

There are various extraction methods with the most common being alcohol extraction or super critical CO2. Depending on the extraction method the CBD can be extracted with a lot of other cannabinoids from the plant, this is referred to as Broad Spectrum or only a few other cannabinoids, this is referred to as Narrow Spectrum. These are sometimes incorrectly termed Full Spectrum. Due to processing, the CBD is usually in the non native form. The extract can be purified further to become an isolate i.e. only CBD is in the product. These products can usually be termed “THC Free”.

Is CBD legal in Ireland?

Yes. Under current European legislation Cannabis can be grown if the THC content is below 0.2%. The Misuse of Drugs Act 1977 in Ireland defines certain compounds of the cannabis plant including the psychoactive compound THC under schedule 1 and therefore a special licence is required where these compounds are present in the product. CBD is not included in the schedule 1 list of controlled substances as it is not psychoactive. CBD is considered a food supplement under the European Directive 2002/46/EC as it is a substance providing a nutritional physiological effect in concentrated small quantities.

What medical conditions will CBD help with?

Many companies claim that their CBD range will help with specific conditions.

The truth is, while many scientific studies show potential therapeutic effects of CBD, very few products will have gone through

the necessary clinical trials to allow them to make these claims. Always be wary of CBD providers making claims as they may give false hope to those with medical conditions. It is recommended that anyone considering taking CBD oil speaks with a pharmacist before taking CBD. CBD oil is sold as a food supplement and should not replace a balanced diet.

Is CBD suitable for pregnant or breastfeeding mothers?

Because of the minimal evidence of the potential effects on the developing foetus or new-borns, CBD oil is not recommended during pregnancy or breastfeeding.

Taking medicines with CBD oil?

At the recommended maximum daily dose there are no serious interactions with medicines reported. However, it is known that CBD is metabolised via the Cytochrome P450 CYP3A4 enzyme and therefore its elimination could be delayed when taking medicines that inhibit this enzyme such as medicines to treat AIDS or antifungals such as ketoconazole.

Conversely, there are medicines that promote this enzyme activity such as antiepileptics such as phenobarbital and carbamazepine and this will reduce the bioavailability of metabolised CBD. Therefore, it is advised that consumers taking other medicines should talk to their doctor or pharmacist beforehand.

What are the potential side effects of CBD oil?

Sometimes taking too much of a supplement can be linked to undesired side effects, therefore GreenLight have reviewed the potential side effects of a CBD oil food supplement. A review of CBD use reports that the most commonly reported side effects were tiredness, diarrhoea, and changes in appetite and/or weight.1 Further Education www.greenlightsupplements.com/ cannabinoids-cpd-training-course/ 1. Iffland K, Grotenhermen F. An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies. Cannabis Cannabinoid Res. 2017 Jun 1;2(1):139-154.

What is CBD oil?

CBD is either pressed from the plant i.e. cold pressed or extracted from the plant.

When the plants are cold pressed the

Supplements

COLD SORES

25

COLD SORES Cold sores are small blisters that develop on the lips or around the mouth. They’re caused by the herpes simplex virus and usually clear up without treatment within seven to 10 days.

Sufferers may not have any symptoms when they first become infected with the herpes simplex virus. An outbreak of cold sores may happen some time later.

Cold sores often start with a tingling, itching or burning sensation around the mouth. Small fluid-filled sores then appear, usually on the edges of your lower lip. Those affected can seek a number of treatments from pharmacists that reduce the duration of cold sores when used at first sign of a break out.

Causes Cold sores are caused by a form of the herpes simplex virus. Once infected, the virus never leaves the body. The virus is usually first contracted in early childhood where it may not appear as a visible cold sore.

The herpes simplex virus has two distinct types: HSV-1 and HSV-2. Both types can cause sores around the mouth (herpes labialis) and on the genitals (genital herpes). Up to 80% of the global population has the HSV-1 virus because it’s so contagious.

Damaging the skin as it reproduces itself and creating cold sores, the virus enters the body initially through a break in the skin around or inside the mouth. HSV invades the cells of the epidermis, the outer layer of the skin, causing fluid-filled blisters to appear.

The virus travels from the epidermis along the nerve paths to the roots of the nerves where it becomes inactive. The virus is extremely contagious, and spreads when a person has interaction a cold sore. They can also spread when a person has interaction with infected fluid such as saliva.

Examples of way that the virus can spread in this way include through the sharing eating utensils or razors or kissing an infected person.

Cold sores can also be spread to other areas of the body such as the nose or chin.

There are other triggers for people who get cold sores such as sunlight, fever, stress and menstruation. Most people will have come into contact with the virus at an early age (between the ages of three and five) but will often not show any symptoms until after puberty.

Around one in three people will experience recurrent infections. The HSV-1 virus ‘wakes up’, infects the cells in or around the lip or mouth and causes a visible and contagious sore.

Symptoms Symptoms of cold sores usually occur after something has triggered the virus, like a rundown immune system or cold, dry weather leading to dry, chapped lips.

Prior to a breakout, there are certain sign to look out for such as:

• Tingling lips

• Sore mouth that makes eating, and drinking uncomfortable • Fever • Sore throat • Swollen lymph nodes in the neck At break out of a cold sore, the skin around the blister is often red, swollen, and sore.

Blisters usually open, leak a clear fluid, and scab over after a few days. Without treatment, these cold sores can heal themselves within 10 days.

Treatment Nothing can prevent an outbreak, however there are a number of treatments that work to reduce the duration of cold sore symptoms such as:

• OTC antiviral creams can speed up the healing process • Cold sore patches containing hydrocolloid gel that ordinarily treats skin wounds. The patch is placed over the cold sore while it heals • In severe cases, the patient should be referred to their GP so that antiviral tablets may be prescribed General Advice on management

• Avoid triggers such as stress and colds • Avoid too much direct exposure to sunlight as it can cause cold sores to flare • Drink plenty of fluids to avoid dehydration • Try to avoid acidic or salty foods and eat cool, soft foods • If brushing teeth is painful, use an antiseptic mouthwash • Dab creams on to sores – avoid rubbing them

• Wash hands regularly using soap and water before and after applying cold sore creams Possible Complications

• Cold sores can become infected by bacteria • Dehydration can occur if the lesions are so painful as to discourage drinking.

Young children in particular may be at risk of dehydration • Herpetic whitlow (whitlow finger). Should the cold sore virus spread to another part of the body it may cause a secondary infection. The whitlow finger is such an infection, when the virus has come into contact with a graze or cut on the skin • If the condition spreads to the eyes, a secondary infection of the cold sore virus (herpetic keratoconjunctivitis) can occur.

It is easily treated, but if left untreated it can damage vision Who? Anyone infected with the herpes simplex virus, but predominantly HSV1.

What are the symptoms? Tingling, swollen lip, pain, blisters.

How long have they had the symptoms? Cold sores should clear within two weeks, but a patient may need referred to a GP if symptoms persist.

Action already taken? Customers may already have purchased cream to speed up the healing process.

Medication: Caution should be taken with patients who have existing skin conditions and are applying creams or treatments to skin.

N EW

To Relieve ANY Cough 1

For children from 1 year 1

Associated with a cold.

IRE/NHCPT/BRO/19-015

COUGH

27

COUGH Cold and flu season is the time of the year when pharmacists are more likely to see patients scanning the pharmacy shelves in search of the perfect remedy to manage a cough. Patients may be overwhelmed by the numerous OTC cough products, but pharmacists are in an ideal position to evaluate and aid patients in selecting a cough product for self-treatment, as well as to encourage patients to seek further medical care when warranted.

During winter, most coughs are caused by viruses such as colds and flu and can be safely managed at home using OTC remedies. Coughs are classified as “acute” or “chronic”. An acute cough is most common and lasts up to three weeks. It’s usually caused by a cold or flu virus and most improve after one to two weeks.

Chronic cough lasts for eight or more weeks.

The most common causes include acid reflux, asthma, TB, COPD, bronchitis and smoker’s cough. Red-flag signs include: • Coughing up blood • Unexplained weight loss • Night sweats • Cough worsening after three weeks • Shortness of breath • Voice changes • Lumps/swellings in neck • Chest pain Dry or chesty cough?

A dry cough is caused by inflamed airways due to a viral infection such as a cold or flu.

A chesty cough produces phlegm. This is caused by the lungs producing extra fluid due to an infection.

It is important to get a detailed overview of the patient’s symptoms. Is their cough productive? How long have they had the cough and what action has been taken?

Pharmacists should ask if a patient has any medical conditions that may affect any treatment or product you recommend.

The Right Medicine The role of cough medicine is to ease symptoms while the body heals. There are many brands of OTC cough medicines. But there are only three basic types: Expectorants help thin mucus, making

it easier to cough up. The ingredient is guaifenesin.

Suppressants help cut the number of times someone coughs. The active ingredient listed is usually dextromethorphan (DM).

Other cough suppressants include camphor, eucalyptus oil, and menthol.

Combination cough products have more than one active ingredient. They have both guaifenesin and dextromethorphan. Cough medicines may also contain ingredients to help coat and soothe the throat.

Combination products may have medicines to ease other symptoms, that may include decongestants for stuffy nose, antihistamines for allergies or a runny nose, or painkillers.

dehydration. Children suffering with the cold or flu may not feel as thirsty as they normally would, and they may be uncomfortable when drinking, so it’s important to encourage them to drink plenty of fluids.

Medicated nasal sprays aren’t recommended for young children. Fortunately, there are several easy ways to clear up a stuffy nose without medication.

Use a cool-mist humidifier in the child’s room. This will help break up mucus.

Another option is using a saline nasal spray or drops, which makes thin mucus easier to blow out or remove with a bulb syringe. This is especially helpful before feeding and bedtime.

Cough drops can also help relieve a cough and may ease a sore throat

Who? Anyone can be affected

The Paediatric Patient

What are the symptoms? Depend on type of cough to suggest if it is allergic or viral

When temperatures start turning colder and kids are inside and interacting with each other in greater numbers, cold and flu season inevitably follows.

Children under the age of 6, and particularly under age 2, are at an especially high risk during cold and flu season. Whilst it is known that antibiotics won’t help when it comes to clearing up an infection, there are steps pharmacists can advise parents to take to help their child feel better while their immune system battles the virus.

Advise on keeping the child hydrated to help reduce cold and flu symptoms and make them feel better. Fevers can result in

How long have they had the symptoms? Coughs should clear after 3 weeks, is it short or persistent?

Action already taken? Customers may already have purchased cough medicines.

Medication? Some of the ingredients in cough medicines should not be given to children such as opioids.

Antacids may interfere with other medicines.

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FOR HEALTHCARE PROFESSIONAL USE ONLY. FOR HEALTHCARE FOR HEALTHCARE PROFESSIONAL PROFESSIONAL USE ONLY. USE ONLY.

COWS’ MILK ALLERGY

29

COWS’ MILK ALLERGY Cows’ milk allergy (CMA), also called cows’ milk protein allergy, is one of the most common childhood food allergies. It is estimated to affect between 2% and 7.5% of babies under one, though most children grow out of it by the age of five.

CMA typically develops when cows’ milk is first introduced into a baby’s diet either in formula or when a baby starts eating solids.

More rarely, it can affect babies who are exclusively breastfed because of cows’ milk from the mother’s diet passing to the baby through breast milk.

There are two main types of CMA: • immediate CMA – where symptoms typically begin within minutes of having cows’ milk • delayed CMA – where symptoms typically begin several hours, or even days, after having cows’ milk Babies can either be allergic or intolerant to milk. Because some of the symptoms of milk allergy and milk intolerance are similar, they are difficult to diagnose. A milk allergy involves an immune reaction to one or more of the proteins present in milk, whereas an intolerance does not involve the immune system.

An intolerance is caused by an inability to deal with certain substances in milk, such as lactose. Lactose intolerance is when some individuals don’t produce any or enough of the enzyme lactase which breaks down lactose. Undigested lactose causes symptoms like diarrhoea, bloating and wind.

Recognising milk allergy If a baby is allergic to milk, they will react to infant formula which is based on cows’ milk and sometimes, but very rarely, to breast milk the mother recently consumed dairy products. Symptoms include stomach cramps, vomiting, diarrhoea, rashes, hives, eczema, and difficulty breathing. Individual symptoms can sometimes be related to a bug, but if the baby is affected in two separate areas of the body – for example, the stomach (vomiting) and skin (hives), parents should ask their health visitor or doctor for advice.

It’s common for babies who are allergic to cows’ milk to be allergic to goats’ milk and sheeps’ milk too, as they contain similar proteins. Unfortunately, there is no single diagnostic test for cows’ milk allergy and a combination of tests and a series of elimination and reintroduction diets are often necessary.

Giving the doctor as much detail about the baby’s symptoms as possible can help speed up the diagnosis process. By keeping

a diary of their symptoms, including when they occur and how long they last for, can help the doctor identify or rule out cows’ milk allergy. Taking photos of any skin reactions, such as a rash, can be helpful too. They should advise the doctor if there is a history of allergy in the family.

Feeding and milk allergies Managing a cows’ milk allergy involves removing all cows’ milk from the baby’s diet, so parents should always read ingredients on food labels. Common allergens, like milk, must be declared on pre-packaged foods.

If a baby is being formula fed and has been diagnosed with cows’ milk allergy, The doctor may prescribe an extensively hydrolysed formula. The protein in these formulae has been broken down into smaller pieces so that the baby’s immune system does not recognise it as an allergen – a process which does not affect the nutritional value of the formula.

Soya formulae are not recommended before six months as they contain phytoestrogens (plant-based compounds with oestrogen-like properties), and infants who react to cows’ milk-based formulae often also react to soyabased formulae.

In rare cases, the baby may be reacting to the milk proteins passing from the mothers’ diet into breast milk. If a breastfeeding mothers’ baby is diagnosed with cows’ milk allergy, she may have to change her diet but this is quite rare.

Identifying Lactose Intolerance A baby with lactose intolerance usually experiences less severe reactions than one with an allergy. As with a milk allergy, symptoms of lactose intolerance can include diarrhoea, vomiting, and stomach cramps but not usually hives or breathing difficulties.

Another difference is that lactose intolerance will not show up in a blood or skin-prick test. However, the baby’s reaction will be noticeable, if not as severe as that of an allergy.

There are two main types of lactose intolerance. The first is primary lactose intolerance, and is caused by a deficiency in the enzyme lactase. It normally affects Hispanic, Asian and American Indian populations, but is uncommon in Europeans.

Primary lactose intolerance doesn’t mean that lactose must be removed from the diet entirely: depending on the individual, those with primary lactose intolerance can often tolerate a certain amount of lactose.

Secondary lactose intolerance is usually caused by damage to the gut, after a severe stomach bug, for example. But this form of the condition is usually temporary, until the gut heals. In very severe cases, lactose may need to be removed from the diet for a few weeks.

Who? Babies and infants.

What are the symptoms? Stomach cramps, vomiting, diarrhoea, rashes, hives, eczema, and difficulty breathing.

How long has the patient had the symptoms? Only around 2–7.5% of babies under one year old are allergic to cows’ milk. By the age of three most children will have grown out of cows’ milk allergies.

Action already taken? If a baby is being formula fed and has been diagnosed with cows’ milk allergy, the doctor may have prescribed an extensively hydrolysed formula.

Medication? Parents may be using creams or emollients to treat the symptoms affecting their baby’s skin.

NEW Relizema™ ECZEMA DRY & SENSITIVE SKIN BABY CARE

A unique range of Italian emollients and cleansers, which includes products developed for eczema, dermatitis, baby care, dry and sensitive skin.

ORDER NOW OMAURA CRONIN

086 – 8198271 Maura.Cronin@united-drug.com

MERVYN CONNAUGHTON

086 – 8198271 Mervyn.Connaughton@united-drug.com

YVONNE QUIGLEY

087 - 0524507 Yvonne.Quigley@united-drug.com

All products are dermatologically tested

Distributed by: A.Menarini Pharmaceuticals Ireland Ltd, Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin.

www.relife.ie

IE19031 IR-REL-49-2019 Date of item August 2019

DRY SKIN

31

DRY SKIN Dry skin occurs when the epidermis does not hold on to sufficient moisture, so skin can feel tight, rough, flaky and itchy. A number of things can contribute to its development, for example; too frequent bathing, use of harsh drying soaps, the ageing process (the production of natural oils in the skin slows as we age, and sun damage is cumulative so a lifetime of sun exposure and sun damage can result in thinner skin that doesn’t retain moisture so well), or certain conditions such as eczema or psoriasis.

The average skincare category accounts for 5 per cent of total OTC shelf space. It is important this space works hard for you and the range stocked provides maximum return in terms of profitability as well as offering customers the right range of specialist skincare treatments to meet their needs.

Moisturisers People suffering from dry skin, shouldn’t use harsh, alcohol-based products as these can irritate skin and dry it out. People who have oily skin should avoid oil-based products and choose water-based ones instead. A good moisturiser is not necessarily an expensive one. Deciding what is best for skin depends on ingredients. There are various ingredients that provide different functions including: • Ceramides. Ceramides help the skin hold water and soothe dry skin. Synthetic ceramides may mimic the natural substances in the outermost layer of skin that help keep moisture in.

• Dimethicone and glycerin. These draw water to the skin and keep it there.

• Hyaluronic acid. Like ceramides, hyaluronic acid helps skin hold water.

• Lanolin, mineral oil, and petroleum jelly (petrolatum). These help skin hold on to water absorbed during bathing.

Washing Dry Skin In addition to moisturising, dry skin needs to be washed appropriately. This includes: • Skipping long, hot showers: hot water strips oils from the skin faster than warm water.

Long showers or baths actually dry out the skin. Anyone suffering from dry skin should limit themselves to a single 5- or 10-minute warm shower or bath a day.

• Using a gentle cleanser or shower gel with moisturizer. Instead of harsh cleansers, suggest unscented, soap-free, or mild soap cleansers.

• Moisturising while skin is still moist. Patting skin with a towel after a shower or washing the face or hands, leaving it damp. Apply a moisturiser within three to five minutes of washing to lock moisture in.

Self Care Tips Here are 6 tips pharmacists and pharmacy staff can advise sufferers on as efficient self-care management: 1: More moisturiser - Emollients are moisturisers that are used in two ways: applied directly to the skin as a leave on moisturiser, and as a soap substitute instead of soap and shower gel. Dry skin itches. Moisturising

rehydrates the epidermis, seals in moisture, and soothes dry, itchy skin. In winter, sufferers may need to moisturise more frequently and/or use a ‘heavier’ moisturiser such as an ointment rather than a cream or lotion; ointments tend to work better when the skin is very dry.

2: Choose products that are bland, unfragranced and preservative free 3: One quick daily dip! Staying in the bath or shower too long can be dehydrating, so keep the duration short (5-10minutes) and the water temperature should be lukewarm rather than hot.

4: Avoid harsh soaps - Ordinary soaps and bubble baths can dry out the skin by stripping away its natural oils. Skin pH is a measure of acidity and alkalinity, ranging on a scale form 0 (most acidic) to 14 (the most alkaline). Healthy skin is naturally acidic, with a pH of around 5.5. This acidity plays an important role in skin barrier function and skin health. Soaps and detergents raise skin pH which disrupts this delicate balance.

Use emollient wash products (soap substitutes) when hand-washing, bathing or showering, which leave the skin coated with a protective film afterwards.

After bathing or showering, gently pat the skin dry. This is a great time to apply emollient all over as it helps to seal in moisture while skin is still damp.

5: Wear sunscreen 6: Consider using a humidifier - Humidifiers moisten the air to increase the level of humidity.

To combat the drying effects of central heating and lower humidity during winter, some may

want to consider using a humidifier indoors when the heating is on.

Applying moisturiser • Apply a 50p piece-sized amount of moisturiser to the face and neck, from the chest upwards.

• Application should be even, across the whole area, especially when using a day cream with in-built sun protection.

Moisturisers can be applied immediately after a serum or, if not using a serum, directly after cleansing, to help trap essential moisture inside the skin.

• Advise customers not to apply face cream to the eye area, as this requires a specific eye cream. Many moisturisers may be too rich in oils for the eye area and cause puffiness, or contain high levels of hydroxy acids, which may cause irritation.

Who? Anyone What are the symptoms? Red and inflamed skin.

How long has the patient had the symptoms? Dry skin is particularly prevalent in the winter months.

Action already taken? Patients may already be using moisturisers.

Medication: If the patient has other skin conditions refer them to a GP so they can provide the appropriate topical cream.

NEW Relizema™ ECZEMA DRY & SENSITIVE SKIN BABY CARE

A unique range of Italian emollients and cleansers, which includes products developed for eczema, dermatitis, baby care, dry and sensitive skin.

ORDER NOW OMAURA CRONIN

086 – 8198271 Maura.Cronin@united-drug.com

MERVYN CONNAUGHTON

086 – 8198271 Mervyn.Connaughton@united-drug.com

YVONNE QUIGLEY

087 - 0524507 Yvonne.Quigley@united-drug.com

All products are dermatologically tested

Distributed by: A.Menarini Pharmaceuticals Ireland Ltd, Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin.

www.relife.ie

IE19031 IR-REL-49-2019 Date of item August 2019

ECZEMA

33

ECZEMA Eczema (or atopic dermatitis) is a common, inflammatory skin condition characterised by red, dry, itchy skin. Those with eczema can experience acute worsening of their condition, which are referred to as flares.

During flares the skin becomes red which can sometimes weep, become blistered, crusted and thickened.

The symptoms of this skin disorder can range from mild to severe, and all forms of eczema can have a significant impact on the quality of life for the person with eczema, caregivers and their loved ones.

One area for which there is a considerable demand in primary care for advice and support is dermatology and some evidence suggests that many people with skin problems manage their condition t hrough self-care.

Eczema affects approximately 1 in 5 children and 1 in 12 adults in Ireland.

While the exact cause of eczema is not known, certain factors are thought to be important in its development, these include an inherited (genetic) predisposition to have a weakened skin barrier, as well as altered inflammatory and allergy responses.

Atopic eczema can run in families and frequently occurs alongside other atopic conditions, including hayfever and asthma.

Although there is no cure for eczema yet, treatment are available to manage the condition.

Eczema is recognizable by the presence of red, dry, itchy skin, which can sometimes weep, become blistered, crusted and thickened. However, the appearance of eczema, and the locations of the body affected, can vary greatly depending on the age of the person.

Irritants and allergens Atopic eczema can be triggered or aggravated by exposure to a number of environmental irritants or allergens.

Common irritants include soap, bubble bath, shampoo, laundry detergents, fragrances, clothing that feels ‘itchy’ next to the skin (e.g. wool), changes in temperature, or allergens like animal dander, the house dust mite or pollen, but sometimes no cause can be identified.

Stress Emotional stress can aggravate eczema.

Finding ways to reduce stress may lessen the frequency and, hopefully, the intensity of the flare-ups. Whilst stress is associated with flares of atopic eczema, it is not yet fully understood.

Infection Atopic skin is more vulnerable to infection and infection is often associated with a worsening of eczema. Advise customers to seek medical attention if skin becomes:

• Wet or weepy, with yellow/brownish crusts • Very sore, with clusters of painful itchy blisters, particularly if there has been contact with someone who has a cold sore.

Emollients Atopic eczema and dry skin go hand-inhand; medical moisturisers / emollients have been used for managing eczema for many years and are still the recommended first-line treatment.

Emollients are an essential part of daily care, even when skin is clear. Emollients are moisturisers that are used in two ways – applied directly to the skin as a leaveon moisturiser, and as a soap substitute instead of soap or shower gel.

Used several times a day, emollients help to soothe dry, itchy skin and repair the skin’s barrier, thereby preventing entry of irritants and allergens, which can trigger eczema flares.

Soap substitutes/emollient wash products Ordinary soaps, bubble baths and shower gels should be avoided as they dry out the skin by stripping away its natural oils.

Instead, advise customers to choose emollient wash products when bathing which leave the skin coated with a protective film afterwards.

Emollients come as lotions, creams and ointments. Finding the right emollient is often a matter of trial and error but the best emollients are ones that the sufferer prefers to use and will continue to use every day.

Sodium lauryl sulfate (SLS) and Aqueous cream One common emollient, Aqueous cream, has been on the market for decades but

according to some studies the negative effects on the skin barrier are thought to be related to a particular ingredient: sodium lauryl sulfate (SLS) 1%.

Reports of skin reactions such as burning, stinging, itching and redness after using Aqueous cream have been highlighted over a number of years.

SLS is a component of emulsifying wax and is a detergent and surfactant – which means it breaks surface tension and separates molecules – and allows products to lather (causing bubbles and suds). It helps to maintain the creamy consistency of emollients.

Clothing & Wet Wraps Sometimes it can be difficult for children or indeed anyone who suffers with eczema to find comfortable clothing, particularly when there has been a flare up of the condition.

Clothing can aggravate eczema as skin can be very hot and heat increases itch.

Who? Anyone, some babies may outgrow it What are the symptoms? Itch, rash, skin pigmentation How long has the patient had the symptoms? The patient may need prescription corticosteroids if other treatments are not helping with flareups Action already taken? The patient may already be using topical creams Medication? Corticosteroids should only be taken after other eczema treatments have failed in adults and children over age 2. Younger children should not take these medications.

Embrace Your Moment

HOW PERSPIREX WORKS

MODE OF ACTION SUPERIOR PROTECTION Controls excessive sweat and odour EFFECTIVE FOR 3-5 DAYS Ensures maximum dryness for days 1 Perspirex containing the active ingredient aluminium chloride is applied on the skin at night.

ACTIVE SKIN CARE SYSTEM* 2

The Perspirex formulation is activated in theProvides a comfortable skin feel sweat duct.

The aluminium forms a temporary gel-plug when it comes into contact with water and protein contained HOW UNCOMFORTABLE within the sweat duct. In this process Hydrochloric ISAcid YOUR SKIN TYPEacidTHE SOLUTION isSWEATING formed (HCl). HCI is a strong andPERSPIREX could PROBLEM? cause irritation on the skin due to low pH. The Perspirex skin care system balances the pH and Perspirex Comfort Mythereby sweating from the reduces potentialSENSITIVE skin irritation. roll-on, 20ml underarms is BARELY 4TOLERABLE The gel-plug is dispelled over the course of a few days and Perspirex FREQUENTLY interferes - normally 3-5 days - with the natural shedding ofOriginal dead / NORMAL For Men Regular with my daily activities. skin cells. roll on 20ml

1 2 3 4

2 This reacts with the water in your sweat duct, 3 temporarily forming a gel-plug preventing the sweat from reaching the surface of the skin.

HOW TO APPLY PERSPIREX 4 few days with the natural shedding of dead The gel-plug is dispelled over the course of a skin cells.

3

1

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Perspirex Original PERSPIREX My sweating from SENSITIVE roll-on, 20ml the underarms is SKIN CARE INTOLERABLE and SYSTEM

Perpirex Strong / ALWAYS interferes with The and patented formulations* Perspirex NORMAL ofFor Men Maximum my unique daily activities. contains a skin care system that provides a comfortable roll on 20ml skin feel. Thus the irritation that is commonly associated with other aluminium chloride-based antiperspirants is minimised.

1 Perspirex works so effectively thanks to aluminium chloride in an alcohol-base.

3

1 APPLY TO DRY AND UNBROKEN SKIN Apply at night before going to bed, when the sweat glands are less active. Allow to dry fully after application.

2 APPLY AT NIGHT Wash off in the morning with soap and water. Do not re-apply after showering, as soap and water do not affect the antiperspirant’s performance. You can still use your scented deodorant or fragrance.

3 WASH OFF IN THE MORNING

NO PERSPIREX SKIN CARE SYSTEM When the antiperspirant is applied, the formulation can 1 cause irritation and pain to the skin due to low pH value.

1

PERSPIREX SKIN CARE SYSTEM The skin care system has been added to the formulation to counteract the low pH. The skin care system consists 2 of a weak acid which is a moisturising agent, and is part of the NMF (Natural Moisturising Factor**). The skin care system balances the pH and thereby reduces potential skin irritation.

2

* Perspirex Original and Perspirex Comfort roll-on ** Natural Moisturising Factors are elements that ensure an intact structure of the outer layer of the skin (epidermis)

Maintain sweat and odour control by applying Perspirex 1-3 nights per week, or as often as needed.

EYE HEALTH IN THE ELDERLY

37

EYE HEALTH IN THE ELDERLY

Eye Health in Older Patients There are several eye problems that become more common among people as they age, although they can affect anyone at any age.

Many of them while bothersome are not particularly serious such as presbyopia (loss of ability to see close objects or small print), dry eyes, and tearing (having too many tears from light sensitivity). Others however can be both serious and have a huge impact on a patient’s life. Sensitivity to the patient is extremely important as is offering help to aid the symptoms. The most serious of these conditions are macular degeneration, glaucoma and cataracts.

Macular Degeneration Macular degeneration is the leading cause of severe vision loss in people over age 60. It occurs when the small central portion of the retina, known as the macula, deteriorates. The retina is the light-sensing nerve tissue at the back of the eye. Because the disease develops as a person ages, it is often referred to as agerelated macular degeneration (AMD). Although macular degeneration is almost never a totally blinding condition, it can be a source of significant visual disability.

There are two main types of age-related macular degeneration: Dry Form Most patents are affected by this form and it is characterised by the presence of yellow deposits (called drusen) in the macula. A few small drusen should not cause changes in vision; however, as they grow in size and increase in number, they may lead to a dimming or distortion of vision that people find most noticeable when they read. In the advanced stages, patients lose central vision.

Wet Form The “wet” form of macular degeneration is characterized by the growth of abnormal blood vessels from the choroid underneath the

macula. These blood vessels leak blood and fluid into the retina, causing distortion of vision that makes straight lines look wavy, as well as blind spots and loss of central vision. These abnormal blood vessels and their bleeding eventually form a scar, leading to permanent loss of central vision.

Treatment There is currently no cure for macular degeneration, but treatments may prevent severe vision loss or slow the progression of the disease considerably. Several options are available, including: • Anti-angiogenesis drugs: These medications block the development of new blood vessels and leakage from the abnormal vessels within the eye that cause wet macular degeneration. This treatment has been a major change in the treatment of this condition and many patients have actually regained vision that was lost.

• Vitamins: A large study performed in America by the National Eye Institute of the National Institutes of Health, called AREDS (Age-Related Eye Disease Study), showed that vitamins C, E, beta-carotene, zinc and copper can decrease the risk of vision loss in patients with intermediate to advanced dry macular degeneration Cataracts Cataracts are cloudy areas that cover part of or the entire lens inside the eye. In a healthy eye, the lens is clear like a camera lens. This means that light has no problem passing through it to the back of the eye to the retina where images are processed. When a cataract is present, the light cannot get through the lens as easily and, as a result, vision can be impaired. Cataracts often form slowly, and normally without pain, redness, or tearing in the eye. Some stay small and do not alter eyesight. But, if they become large or thick, cataracts can usually be removed by surgery. Surgery is often not needed or can

be delayed for months or years. Many people with cataracts treat the symptoms with the help of glasses, contact lenses, and other vision aids.

Glaucoma This condition develops when there is too much fluid pressure inside the eye. It occurs when the normal flow of the watery fluid between the cornea and the lens of the eye is blocked. If not treated early, this can lead to permanent vision loss and blindness. Glaucoma is less commonly caused by other factors such as injury to the eye, severe eye infection, blockage of blood vessels, or inflammatory disorders of the eye.

Because most people with glaucoma have no early symptoms or pain, it is very important to get your eyes checked by an eye doctor regularly. Treatment may include prescription eye drops, oral medications, or surgery.

Who? In all three cases mostly older people.

What are the symptoms? Distortion of vision in all three cases.

How long has the patient had the symptoms? If symptoms worsen with cataracts or glaucoma, surgery should be suggested.

Action already taken? The patient may already be using glasses or contacts.

Medication? If patient wears contact lenses and has been prescribed eye drops, they may need to stop wearing lenses as medication in the eye drops can build up in the lenses and damage the eye.

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HAEMORRHOIDS

39

HAEMORRHOIDS Haemorrhoids are one of the most common ano-rectal ailments. More than half of people will develop haemorrhoids, usually after the age of 30. A HTA on referral thresholds for haemorrhoid procedures has shown that half the Irish population “experience symptomatic haemorrhoid disease at some point in their lives, with the peak incidence of symptomatic disease between the ages of 45 and 65 years.”

Also known as piles, these are swellings that contain enlarged blood vessels that are found inside or around the bottom (the rectum and anus).

Most haemorrhoids are mild and sometimes don’t even cause symptoms. When there are symptoms, these usually include: • bleeding after passing a stool (the blood will be bright red) • itchy bottom • a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool

• a persistent cough or repeated vomiting • sitting down for long periods of time Supportive care strategies may include lifestyle changes, such as adopting a highfibre diet, increasing fluid intake, avoiding straining during defecation, and using topical products for symptom relief.

Symptoms may include rectal bleeding resulting from irritation of internal haemorrhoids, with bleeding usually occurring immediately after defecation.

Other symptoms may include itching, perianal discomfort, and soiling.

As haemorrhoidal tissues are inflamed, topical vasoconstrictors are commonly used to shrink blood vessels in the anorectal area and temporarily relieve swelling. Topical analgesics may also be used to relieve pain, itch, and irritation.

Constipation, pregnancy, heavy lifting, or strenuous exercise may exacerbate these symptoms. Prolonged sitting, obesity, and low-fibre diets are other possible contributing factors.

Medication and treatments

What causes haemorrhoids?

The exact cause of haemorrhoids is unclear, but they’re associated with increased pressure in the blood vessels in and around the anus. This pressure can cause the blood vessels in the back passage to become swollen and inflamed.

Many cases are thought to be caused by too much straining on the toilet, due to prolonged constipation – this is often due to a lack of fibre in a person’s diet.

Chronic (long-term) diarrhoea can also make sufferers more vulnerable to getting haemorrhoids.

Other factors that might increase the risk of developing haemorrhoids include: • being overweight or obese • age – as a person get older, the body’s supporting tissues get weaker, increasing the risk of haemorrhoids • being pregnant – which can place increased pressure on your pelvic blood vessels, causing them to enlarge • having a family history of haemorrhoids • regularly lifting heavy objects

OTC treatments - various creams, ointments and suppositories are available from pharmacies without a prescription.

They can be used to relieve any swelling and discomfort. These medicines should only be used for five to seven days at a time. They may irritate the sensitive skin around your anus if you use them longer than this.

Any medication should be combined with the diet and self-care advice discussed above. Pharmacists can advise about which product is most suitable.

Corticosteroid cream - a GP may prescribe corticosteroid cream, which contains steroids, if there is severe inflammation in and around the back passage.

Painkillers - common painkilling medication, such as paracetamol, can help relieve the pain of haemorrhoids. But if a sufferer has excessive bleeding, they should avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, as they can make rectal bleeding worse. They should also avoid using codeine painkillers as they can cause constipation.

Banding - carried out as a day procedure, this involves placing a very tight elastic band around the base of the haemorrhoids to cut off their blood supply. The haemorrhoids

should then fall off within about a week of having the treatment. Banding is usually a day procedure that doesn’t need an anaesthetic, and most people can get back to their normal activities the next day.

Sclerotherapy - may be used as an alternative to banding.During sclerotherapy, a chemical solution is injected into the blood vessels in the back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so a scar is formed. After about four to six weeks, the haemorrhoid should decrease in size or shrivel up.

Surgery - although most haemorrhoids can be treated using the methods described above, around one in every 10 people will eventually need surgery.Surgery is particularly useful for haemorrhoids that have developed below the dentate line – unlike non-surgical treatments, anaesthetic is used to ensure sufferers don’t feel any pain.

Who? The risk of haemorrhoids increases as a person gets older.

What are the symptoms? Pain or discomfort, especially when sitting, pain during bowel movements, itching or irritation around the anal region, bright red blood on stools, swelling around the anus.

How long have they had the symptoms? If OTC products have not helped the symptoms within a week they sufferer should be referred to a doctor.

Action already taken? Sufferer can be advised of a number of lifestyle changes which can lessen the symptoms or reduce the risk of haemorrhoids returning.

Medication? A number of OTC treatments are available. Sufferers should avoid ibuprofen and codeine.

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HAIR LOSS

41

HAIR LOSS Losing hair isn’t usually anything to be worried about but it can be upsetting. Treatment may help with some types of hair loss.It’s normal to lose hair. Most people can lose between 50 and 100 hairs a day, often without noticing. Occasionally it can be a sign of a medical condition.

Some types of hair loss are permanent, like male and female pattern baldness. This type of hair loss usually runs in the family.Other types of hair loss may be temporary. They can be caused by an illness, stress, cancer treatment, weight loss, iron deficiency.

Which vitamins may help thinning hair?

The quality of hair growth can be influenced by diet, so supplements that include minerals needed to stimulate hair growth are often advised for thinning hair and hair loss. The quality of diet can be reflected in the quality of hair so it pays to eat a balanced diet and include foods such as oily fish, spinach and eggs.

The most common supplements advised for hair growth are: Iron: People who are anaemic, can start to see hair loss. If you believe that a patient may be anaemic, they should be referred to a GP. Zinc: It’s thought that this mineral is useful for hair growth because people who are deficient in it due to other medical conditions can often have dry, brittle hair.

Zinc is a vital mineral for healthy hair, skin and nails. A zinc supplement for hair loss will supply a good amount of the mineral, as well as other key hair nutrients such as biotin, vitamin C and iron.

Some experts believe that zinc deficiency actually can lead to deterioration of the protein structure that makes up the hair follicle. This weakening of follicles can in turn cause hair shedding and hair loss.Zinc is also believed to play a crucial role in DNA and RNA production.

This is required for the normal division of hair follicle cells, leading to healthier hair growth.

Zinc also may help keep hormone levels balanced. As a bonus, zinc for hair growth may help eliminate dandruff on the scalp as well.

Biotin: A B vitamin often recommended for hair health. Since biotin deficiency can lead to thinning of the hair, proponents claim that taking biotin supplements (in pill or tablet form) or using biotin-enriched shampoo and hair products can thicken hair and stimulate hair and nail growth.

Hair loss is a symptom of biotin deficiency, so biotin supplementation is thought to benefit people with hair loss or thinning hair who have a biotin deficiency.

Male pattern baldness Androgenetic alopecia, commonly known as male-pattern baldness, is the most common form of hair loss for both men and women.

It can be caused by either hormonal or hereditary factors.

Androgenetic alopecia is an androgendependent hereditary disorder in which dihydrotestosterone is a significant contributing factor. The condition affects Caucasian men more than men of other ethnicities. It can start at any age, but approximately 30% of men will experience some hair loss by the age of 30 years, 50% by the age of 50 years, and 80% by the age of 70 years.

In addition, up to 13% of premenopausal women experience some degree of androgeneticalopecia, and the incidence may increase significantly after menopause. By the age of 70 years, approximately 40% to 50% of women experience hair loss.

Alopecia areata is another type of hair loss, involving patches of baldness that may come and go. It can occur at any age, but mostly affects teenagers and young adults. Six of 10 people who are affected develop their first bald patch before they are 20 years old.

Causes: Hair loss – in the form of male pattern baldness – is often a genetic disorder.

Male pattern baldness occurs when hair follicles convert testosterone into another hormone called dihydrotestosterone (DHT).

Affected hair follicles (typically at the sides and the top of the head) become more sensitive to DHT, which causes the hair follicles to shrink, weaken, and eventually die. This slows down hair production and can stop hair growth altogether.

Treatments: Minoxidil is available as a lotion that you rub on your scalp every day.

It is available from pharmacies without a prescription. It is not clear how minoxidil works, but evidence suggests that it can cause hair regrowth in some men.

Minoxidil usually needs to be used for at least four months before any effect is seen. The balding process will usually resume if treatment with minoxidil is stopped. Any new hair that regrows will fall out two months after treatment is stopped. Side effects are uncommon.

Finasteride is a medicine that is used in the UK for treating male pattern baldness. It is also used for treating Benign Prostatic Hypertrophy (BPH). It is only licensed in Ireland for BPH.

Who? Both men and women can be affected by thinning hair due to a number of factors.Androgenetic alopecia will affect 30% of men will by the age of 30 years, 50% by the age of 50 years, and 80% by the age of 70 years. In addition, up to 13% of premenopausal women experience some degree of androgenetic alopecia.

What are the symptoms? Most people will lose some hair every day.

Patients with androgenetic alopecia experience hair loss with no signs of inflammation or scarring.

How long has the patient had the symptoms? If a patient develops sudden hair loss they should be referred to a GP. Action already taken? Eating a balanced diet can aid hair health.

Medications?Finasteride is only licensed in Ireland for BPH.

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HEALTHY SKIN

43

HEALTHY SKIN Community pharmacy teams play a significant role in helping patients to maintain the health of their skin. From reducing the risk of sun exposure by recommending appropriate sunscreens to advising patients on the use of OTC acne medications, pharmacists and their staff frequently are the frontline health care professional for what is the body’s largest organ.

Pharmacists are ideally positioned to counsel patients about the importance of appropriate skin care. It is important for community pharmacy teams to be aware of skin disorders and cancer risks so they are able to help their patients by providing preventive and early-stage care.

Because many medications can compromise skin health, brown bag sessions are ideal not only for reviewing patient medications, but also the risks of developing preventable conditions.

Counseling patients can also help to prepare them for serious or cosmetic adverse effects that include rash, itching, redness, or discoloration.

Pharmacy staff should have a thorough knowledge of the products available and which skin conditions most customers want advice and products for. With the increasing trend for natural products, a good category should include some newer natural remedies alongside familiar brands.

Customers need to be urged to use emollients regularly, particularly once symptoms are brought under control. Your range of products should be extensive as there is no-one-size-fits-all remedy.

Consider incorporating regime into your category display. Regime is encouraged to help reduce and relieve symptoms on a long-term basis.

Use health promotion displays that focus on a specific skin condition and are linked to a national promotion, such as National Eczema Week.

Sun protection is essential to skin cancer prevention – about 90 percent of nonmelanoma skin cancers and about 86 percent of melanomas are associated with exposure to UV radiation from the sun. Key to staying healthy is protecting yourself from the sun. Pharmacies play an important role through education. When customers purchase sun cream, engage them in conversation and explain about the purchase they are buying as well as offering advice on staying safe in the sun.

Keeping Safe in the Sun In addition to providing advice on sun cream, there are other ways to prevent sun damage. These include:

• Avoiding the sun at its most powerful between 11am and 3pm • Trying not to burn • Covering up with a T-shirt, hat and sunglasses • Reporting mole changes or unusual skin Sun Cream There are various things you sun cream needs to do to protect skin, so it is important that the customer is aware of what to look for. There are many sun creams out there, but to provide adequate protection, the customer needs to: • Find a sunscreen formula that fits their life and lifestyle: if the sun cream is too sticky, heavy or expensive, the customer may not wear it • Scan the label for active ingredients.

Good choices include the highly effective sun blocks titanium dioxide and zinc oxide, and the chemical sunscreen avobenzone • Look for “broad-spectrum”, “complete” or “total protection” on the bottle. This means that the wearer is protected against UVB and UVA rays. Sunlight emits up to 95 percent UVA (the rays that penetrate deeply into skin, causing wrinkles, spots, and skin cancer) and around 5 percent UVB (the more energetic rays that cause sunburn and can also contribute to skin cancer). If the sun cream is not broad- spectrum,

the wearer may be exposed to massive doses of UVA. • Use an SPF (Sun protection factor) no lower than 15. The SPF theoretically means that the wearer is 15 times more protected by wearing the cream, but since most people apply less than half the amount of sunscreen used in lab tests, they get only about half the protection. Most dermatologists suggest using an SPF 30.

• That does not mean that higher is better, however, as really high SPFs do not offer that much more protection. An SPF of 30 absorbs about 96 percent of UVB rays, but a 45 is only about one percentage point better.

• People with fair skin that burns in strong sun, red or fair hair, a lot of moles or freckles, or a personal or family history of skin cancer should use higher SPFs.

Who: Everyone.

What are the symptoms? N/A How long have they had symptoms?

These will probably be seasonal.

Action already taken? Customers may already be using sun creams.

Medication: Do not apply sun cream to children under 6 months.

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TREATS HEARTBURN AND ACID REFLUX. ONE TABLET PER DAY. LASTS 24 HOURS. AVAILABLE IN PACKS OF 7s AND 14s.

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CCF:22656 Date of preparation: (10-19)

ABBREVIATED PRESCRIBING INFORMATION Product Name: Emazole Control 20 mg Gastro-Resistant Tablets Composition: Each tablet contains 20 mg esomeprazole (as magnesium dihydrate).

Description: Light pink oval film coated tablet.

Indication(s): Proton Pump Inhibitor (PPI): Short-term treatment of reflux symptoms (e.g. heartburn and acid regurgitation) in adults. Dosage: Swallow tablets whole with liquid, do not chew or crush. Disperse in half a glass of non-carbonated water if difficulty in swallowing. Stir until tablets disintegrate, drink liquid with pellets immediately or within 15 min, or administer through a gastric tube. Do not chew or crush pellets. Adults: The recommended dose is 20 mg esomeprazole (one tablet) per day. It might be necessary to take the tablets for 2-3 consecutive days to achieve improvement of symptoms. Duration of treatment is up to 2 weeks. Once complete relief of symptoms has occurred, treatment should be discontinued. If no symptom relief is obtained within 2 weeks of continuous treatment, the patient should be instructed to consult a doctor. Elderly (≥ 65 years old): As per adults. Paediatric population (< 18 years): Not recommended. No relevant use in this group in the indication: “short-term treatment of reflux symptoms (e.g., heartburn and acid regurgitation)”. Severe impaired renal function: Caution. Severe liver impairment: 20 mg max daily dose.

Contraindications: Hypersensitivity to esomeprazole, substituted benzimidazoles or any of the excipients. Not with nelfinavir. Warnings and Precautions for Use: On demand treatment: Contact a physician if symptoms change in character. In the presence of any alarm symptom (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded, as treatment with esomeprazole may alleviate symptoms and delay diagnosis. Treatment with proton pump inhibitors (PPIs) may lead to a slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and in hospitalised patients, also possibly Clostridium difficile. Patients should consult their doctor before taking this medicinal product if they are due to have an endoscopy or urea breath test. Absorption of vitamin B12 may be reduced due to hypo- or achlorhydria. Not recommended for long-term use as the following may also occur: Hypomagnesaemia; Risk of fracture. Consider stopping Emazole Control in cases of Subacute cutaneous lupus erythematosus (SCLE) accompanied by arthralgia. Interference with laboratory tests: Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours. To avoid this interference, Emazole Control treatment should be stopped for at least 5 days before CgA measurements. If CgA and gastrin levels have not returned to reference range after initial measurement, measurements should be repeated 14 days after cessation of PPI treatment. Contains glucose and sucrose.

Interactions: Effect of esomeprazole on other drugs: Co-administration with atazanavir is not recommended. If the combination of atazanavir with a PPI is judged unavoidable, close clinical monitoring is recommended in combination with an increase in the dose of atazanavir to 400 mg with 100 mg of ritonavir; esomeprazole 20 mg should not be exceeded. Esomeprazole is a CYP2C19 inhibitor. When starting or ending treatment with esomeprazole, the potential for interactions with drugs metabolised through CYP2C19 should be considered. Serum levels of cilostazol, cisapride, tacrolimus, methotrexate may be increased. An interaction is observed between clopidogrel and esomeprazole, but the clinical relevance is uncertain. As a precaution, concomitant use of esomeprazole and clopidogrel should be discouraged. Gastric acid suppression by PPIs increase or decrease absorption of drugs with pH dependent absorption (decreased absorption of ketoconazole, itraconazole); esomeprazole inhibits CYP2C19 metabolising enzyme and could increase plasma concentrations of diazepam, citalopram, imipramine, clomipramine, phenytoin (monitor plasma levels of phenytoin), etc. resulting in need of a dose reduction; monitor INR when given with warfarin or similar. Caution as absorption of digoxin can increase. Effect of other drugs on esomeprazole: CYP2C19 and CYP3A4 inhibitors (clarithromycin, voriconazole) may increase the esomeprazole exposure. Dose adjustment not regularly required, except in severe hepatic impairment and long-term use. CYP2C19 and/or CYP3A4 inducers (rifampicin and St. John’s wort) may lead to decreased esomeprazole serum levels by increasing the esomeprazole metabolism.

Pregnancy and Lactation: Caution in pregnancy due to lack of clinical data. No studies in lactating women, therefore, not recommended during breast-feeding. Ability to Drive and Use Machinery: Minor influence on the ability to drive or use machines. Adverse reactions such as dizziness (uncommon) and blurred vision (rare) have been reported. If affected, patients should not drive or use machines.

Undesirable Effects: Common: Headache, abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting, fundic gland polyps (benign). Uncommon: Peripheral oedema, insomnia, dizziness, paraesthesia, somnolence, vertigo, dry mouth, increased liver enzymes, dermatitis, pruritis, rash, urticaria, fracture of the hip, wrist or spine. For other side effects refer to the SPC. Marketing Authorisation Holder: IQ Pharmatek Ltd., Gurtnafleur, Old Waterford Road, Clonmel, Co. Tipperary. Marketing Authorisation Number: PA 22777/001/001. Further information and SPC are available from: Rowex Ltd, Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417. E-mail rowex@rowa-pharma.ie Legal Category: Not subject to medical prescription.

Date of Preparation: September 2019 Adverse events should be reported. Reporting forms and information can be found on the HPRA website (www.hpra.ie) or by emailing medsafety@hpra.ie or by emailing Rowex pv@rowa-pharma.ie

HEARTBURN AND DYSPEPSIA

45

HEARTBURN AND DYSPEPSIA People often confuse the symptoms of upper gastrointestinal (GI) disorders, but in the main, indigestion or dyspepsia refers to pain or discomfort in the upper abdominal area after eating, while heartburn refers to the burning pain felt behind the sternum associated with acid reflux, which is often accompanied by nausea, water brash or regurgitation of acid or bile.

Dyspepsia usually occurs when stomach acid irritates the stomach lining, oesophagus or top part of the bowel, perhaps after a heavy meal, whereas most cases of acid reflux or gastro-oesophageal reflux disease (GORD) occur due to weakening of the lower oesophageal sphincter.

For anyone experiencing the discomfort associated with heartburn and dyspepsia, finding rapid relief is a top priority. Heartburn and dyspepsia are common gastrointestinal (GI) complaints that, if left unresolved, may negatively affect an individual’s overall quality of life and restrict or limit activities or ingestion of certain foods.

Because many patients elect to self-treat mild to moderate cases of heartburn and dyspepsia, pharmacists are likely to encounter patients seeking advice on the various non-prescription products available for the prevention and treatment of both conditions. Pharmacists also are instrumental in identifying patients at increased risk for developing heartburn and dyspepsia because of certain medications, medical conditions, or lifestyle habits.

Heartburn, or pyrosis, is characterised as a burning sensation arising from the substernal area and moving toward the neck or throat.

There are 2 main types: postprandial heartburn occurs within 2 hours after a meal, when bending over, or when lying down, and nocturnal heartburn occurs during sleep and often is responsible for interrupting it.

Pharmacists should ask open-ended questions about concurrent medications and supplements, such as NSAIDs, aspirin, glucosamine, and others, that may list heartburn among their side effects.

Sometimes pointed questions about lifestyle can help patients select appropriate lifestyle modifications. Pharmacists should remember that for gastrointestinal reflux, certain symptoms should raise an alarm. If patients report any symptom indicative of one of these, referral to a physician is warranted.

Refer those who have been self-treating unsuccessfully continuously for ≥4 weeks; are ≥45 years old with new or recently changed indigestion symptoms; have unintended weight loss in association with indigestion.

Dyspepsia is pain that manifests in the gastroduodenal region. Symptoms may include postprandial fullness, epigastric pain, and burning.

GORD is caused by acid leaking up from the stomach and coming into contact with the oesophagus. While the stomach is able to withstand litres of acid without pain, the gullet is not. GORD has a significant impact on quality of life and productivity, with sufferers reporting impaired sleep and interference with social activities and work.

Incidence of GORD is certainly rising as obesity rates accelerate. People are also binge drinking and eating more fatty or calorific food, which increases acidity levels and contributes to poorer digestive health.

Lifestyle Issues Lifestyle modifications can help to ease the severity of symptoms of GORD and dyspepsia, although many patients will also need to take medication. For example, eating smaller, more frequent meals can help to control reflux and indigestion by reducing pressure on the abdomen, as can avoiding dietary triggers, such as coffee, alcohol, citrus fruits, chocolate and fatty foods. These may relax the lower oesophageal sphincter and/or delay gastric emptying.

Giving up smoking may also help, as smoking can exacerbate GORD symptoms by relaxing the lower oesophageal sphincter. Losing weight, if overweight or obese, should also help to control symptoms, but sufferers should avoid over-exertion and exercises like sit-ups, as these can provoke acid reflux.

The symptoms of GORD are often worse at night, especially for overweight individuals, but raising the head of the bed by 20cm by placing blocks underneath it may help. Propping the head up with pillows is not advisable as this may put extra pressure on the abdomen. It may also be beneficial to avoid wearing tight clothes, stooping or bending forwards.

Treatment Options Alongside lifestyle measures and reviewing medication, the first-line treatment options for mild to moderate GORD and dyspepsia are antacids and alginates.

Antacids are alkali liquids or tablets that provide immediate relief by neutralising excess stomach acid, although the effects are often short-lived so extra doses may be needed. Care should be taken to avoid taking antacids alongside other medicines, as they can interfere with absorption or damage the coating of certain tablets.

Alginates protect the oesophagus by forming a barrier or ‘raft’ over the top of the stomach contents, helping to suppress the backflow of acid.

Antacids and alginates are available in combination to provide dual action relief against both heartburn and indigestion.

For patients with persistent symptoms that

are not relieved by antacids or alginates, acid suppressants are available, including histamine H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs).

H2 blockers, such as cimetidine, famotidine, nizatidine and ranitidine, prevent the parietal cells in the stomach from responding to histamine by releasing acid.

PPIs, such as lansoprazole, omeprazole, pantoprazole, rabeprazole and esomeprazole, are more commonly prescribed or recommended for managing GORD than H2 antagonists, and are also used to treat H. pylori infections. They work by reducing the production of stomach acid by inhibiting the hydrogen-potassium adenosine triphosphatase enzyme system, otherwise known as the ‘proton pump’. This reduction in acid reduces reflux symptoms, helping to heal the oesophagus as well as ulcers in the stomach or duodenum.

Who? 73% of people can experience indigestion and heartburn interchangeably. As many as eight out of 10 women experience indigestion at some point during their pregnancy.

What are the symptoms? Pain in the lower chest, abdomen or top of the stomach, feeling bloated, needing to burp or pass wind, nausea or vomiting and loss of appetite.

How long have they had the symptoms? The symptoms are usually experienced after eating or drinking, but there can sometimes be a delay between eating a meal and developing indigestion. Women may experience indigestion at any point during their pregnancy. Symptoms may be more frequent and severe during the third trimester.

Action already taken? People may have taken antacids but not be aware how to eliminate triggers until they start to keep a food diary Medication? Antacids can be taken safely during pregnancy to treat indigestion.

46

CHILD HEALTH CONSULATATION: PHARMACY ASSISTANTS Q & A SESSION ON INFANTILE COLIC Infantile Colic is a common ailment which can affect the whole family.

The intense crying that defines the condition makes it highly distressing for both baby and parents and can have a major impact on family life.

The aim of this training guide is to provide information and reassurance about the condition and offer practical advice on a non-medicinal solution.

Explain what Colic is Colic is the name given to excessive, frequent crying in a baby who appears to be otherwise healthy. It’s a common problem with almost half of babies in the UK developing Colic*.

Colic is very distressing for both baby and parent!

Reassure parents as to what the signs and symptoms of Colic are Colic is defined by:

3) Gastro-Oesophageal Reflux Disease (GORD)

• Intense crying bouts

Reassure parents that Colic will not harm baby?

• Crying in the late afternoon or evening that lasts at least 3 hours a day, 3 days per week.

• Baby’s face may become red and flushed when they cry • Baby will tend to clench their fists, draw their knees up to their tummy, and arch their back while crying Caring for a baby with colic can be very difficult for parents, particularly first-time parents.

Explain the common causes of Infantile Colic 1) 78% of Healthcare Professionals agree that the most common cause of colic in young babies is caused by digestive or feeding problems, including swallowing air and trapped wind* 2) Temporary gut sensitivity to certain proteins and sugars found in breast milk and formula milk, such as Lactose Intolerance.

Explain that a baby suffering from colic may appear to be in pain but the condition is not harmful to baby’s health in the long term, as long as baby continues to feed and gain weight normally.

• Bath baby in a warm bath • Gently massaging baby’s tummy Product Options: There is a natural solution – suggest to parents to change their baby bottle to Dr Brown’s Options+ bottles or recommend they use Dr Brown’s from day one as prevention is better than cure!

Practical Advice for Parents?

Preventing baby from swallowing air is extremely important in helping to avoid wind related colic and choosing the right baby bottle can help.

Traditional and restrictive vented bottles tend to develop vacuums because babies have to suck progressively harder on the one hole in the bottle to obtain the liquid.

This causes teat collapse and baby has to stop feeding. Air enters the bottle when the teat reinflates; the air is ingested which can cause the colic symptoms.

There are also a number of techniques you can advise parents to try that can help alleviate the symptoms of windy colic: • Burp baby after feeds • Gently rock baby over your shoulder

Dr Brown’s Options+ Baby Bottles feature a unique system with a removable green vent designed to create a “vacuum free” environment. Dr Brown’s is clinically proven to help reduce wind related colic by removing the air bubbles in the feed*.

As baby becomes more developed and no longer experiences feeding issues parents now have the convenient option to remove the vent. Without the vent Dr Brown’s Options+ provides a feeding experience

Dr Brown’s Options+ bottles offer the complete feeding system that grows with baby and helps alleviate symptoms of windy colic.

47 Other useful information sources you can offer to parents.

Cry-sis - the only UK charity offering help and support to parents with babies who cry excessively or have sleeping problems - https://www.cry-sis.org.uk/ NCT - https://www.nct.org.uk/parenting/ coping-colic NHS - https://www.nhs.uk/conditions/ colic/ Article sponsored by:

similar to most teat-vented bottles. The teat venting creates a controlled flow, offering babies an easy and convenient way to feed at their own pace.

Explanation as to how a Dr Brown’s Options+ bottle works?

Parents can see a fully animated explanation on www.drbrowns.co.uk Dr Brown’s is the most recommended baby bottle for the relief of wind related colic*.

When can parents expect their baby to stop suffering from Colic?

Thankfully babies tend to grow out of Colic between four and six months, as baby’s feeding become more developed.

Dr Brown’s availability: Dr Brown’s Options+ bottles and feeding accessories are available for pharmacies to purchase from http://www.murrayshealthandbeauty.com/ References: Results from a HCP Colic Survey carried out by Consumer Analysis – May 2010 and research conducted by Mustard Research Ltd amongst a sample of 200 UK Health Care Professionals during May 2017.

DON’T GET FLATTENED

BY Migraine

EXCLUSIVE OTC PRODUCT FOR PHARMACIES ONLY* *Sumatran Relief is a non-prescription migraine treatment, containing sumatriptan. Sales must be referred to the pharmacist. Please use your consultation aid. Medicinal product not subject to medical prescription.

Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork, P75 V009. Freephone: 1800 304 400 Fax: 027 50417 E-mail: rowex@rowa-pharma.ie. Date of preparation (09-19) CCF No:22529

ABBREVIATED PRESCRIBING INFORMATION Product Name: Sumatran Relief 50 mg Tablets. Composition: Each tablet contains 50 mg sumatriptan (as sumatriptan succinate). Description: Pink, biconvex, oblong tablet with a break-line on both sides. Indication(s): The acute treatment of migraine attacks with or without aura. Only to be used where there is a clear diagnosis of migraine. Dosage: Only in Adults aged 18 to 65 years: Recommended adult dose is a single 50 mg tablet.

If a patient responds to the first dose of sumatriptan, but the symptoms recur a second dose may be taken for the same attack but no sooner than 2 hours after the first tablet was taken. If a patient does not respond to the first dose, a second dose should not be taken for the same attack (in these cases the attack can be treated with paracetamol, acetylsalicylic acid, or non-steroidal anti-inflammatory drugs). No more than 100 mg (2 tablets) should be taken in 24 hrs. The recommended dose should not be exceeded. Contraindications: Hypersensitivity to the active substance or to any of the excipients or sulphonamides; Should not be used prophylactically; A history of myocardial infarction, ischaemic heart disease or coronary vasospasm (Prinzmetal’s angina;) Peripheral vascular disease; Symptoms or signs consistent with ischaemic heart disease; A history of stroke (cerebrovascular accident (CVA)) or transient ischaemic attack (TIA) or cardiac arrhythmia; Renal or hepatic impairment; Hypertension or a history of hypertension; History of seizures or other risk factors which lower the threshold; Concomitant administration of preparations containing ergotamine or ergotamine derivatives (including methysergide) or any triptan/5-hydroxytryptamine 1 (5-HT1) receptor agonist; Concomitant use of monoamine oxidase inhibitors and the use of sumatriptan within 2 weeks after discontinuation of therapy with monoamine oxidase inhibitors; Management of basilar, hemiplegic or ophthalmoplegic migraine. Warnings and Precautions for Use: Only for use where a clear diagnosis of “migraine” has been made by a doctor initally. For pharmacy supply, patients should have an established pattern of migraine (a history of five or more migraine attacks occurring over a period of at least 1 year). Migraineurs whose typical headaches persist for longer than 24 hours, who experience four or more migraine attacks per month, or in whom the pattern of symptoms has changed or whose attacks have become more frequent, more persistant, or more severe, or who do not recover completely between attacks, should seek advice from their doctor. Following administration, sumatriptan can be associated with transient symptoms including chest pain and tightness, which may be intense and involve the throat. Where such symptoms are thought to indicate ischaemic heart disease, no further doses of sumatriptan should be given. A medical evaluation should be obtained immediately.

Note that migraineurs may be at increased risk of certain cerebrovascular events (e.g. CVA, TIA). Medication should be stopped if they experience atypical symptoms (i.e. unilateral motor weakness, double vision, ataxia etc.) and they should seek medical advice. Not to be used in migraineurs without a prior cardiac risk assessment by a doctor or pharmacist. As migraine is a chronic condition, cardiovascular risk should be evaluated

regularly in patients who use sumatriptan intermittently, over the longer term. Sumatriptan is effective for migraine occurring during menstruation, but women with migraine who are taking the combined oral contraceptive have an increased risk of stroke and should seek advice from their doctor if migraine attacks started recently (within the last 3 months), migraine symptoms have worsened, or they have migraine with aura. Not to be given to patients (especially postmenopausal women and males over 40 years of age) with risk factors for ischaemic heart disease, including those patients who are heavy smokers or users of nicotine substitution therapies, without prior cardiovascular evaluation. Risk factors for heart disease include hypercholesterolaemia, regular smoking, marked obesity, diabetes or a family history of early heart disease (father/brother developed heart disease before the age of 55, mother/sister developed heart disease before the age of 65). The diagnosis of medication overuse headache (MOH) should be suspected in patients who have frequent or daily headaches despite (or because of) the regular use of headache medications (e.g. triptans, opioids, ergotamine or combination of these drugs for 10 days or more per month). Patients with headache present on more than or 15 days per month for three months whose headache has developed or markedly worsened during medication overuse should be referred to their doctor for further management. Contains lactose monohydrate. Interactions: There have been rare post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the use of SSRIs and sumatriptan.

Serotonin syndrome has also been reported following concomitant treatment with triptans and SNRIs and is also a risk with concomitant use with lithium. Undesirable effects may be more common during concomitant use with herbal preparations containing St John’s Wort (Hypericum perforatum). Pregnancy and Lactation: Not to be used during pregnancy or breast-feeding unless on the advice of their doctor. Ability to Drive and Use Machinery: Drowsiness, dizziness and weakness may occur as a result of migraine or its treatment with sumatriptan. This may influence the ability to drive and to operate machinery. Undesirable Effects: Common: Dizziness, drowsiness, sensory disturbance including paraesthesia and hypoaesthesia. Transient increases in blood pressure arising soon after treatment, flushing. Dyspnoea. Nausea and vomiting occurred in some patients, but it is unclear if this is related to sumatriptan or the underlying condition. Sensations of heaviness (usually transient and may be intense and can affect any part of the body including the chest and throat), myalgia. Pain, sensations of heat or cold, pressure or tightness (these events are usually transient and may be intense and can affect any part of the body including the chest and throat); feelings of weakness, fatigue (both events are mostly mild to moderate in intensity and transient). Marketing Authorisation Holder: Rowex Ltd., Bantry, Co. Cork. Marketing Authorisation Number: PA 711/272/1. Further information and SPC are available from: Rowex Ltd., Bantry, Co. Cork. Freephone: 1800 304 400 Fax: 027 50417 E-mail rowex@rowa-pharma.ie Legal Category: Not Subject to medical prescription. Date of Preparation: April 2018

MIGRAINE

49

MIGRAINE Migraine is the most common headache disorder seen by pharmacists and their teams.

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

Migraine patients may experience episodic or chronic symptoms, and the latter is usually associated with the most significant disability.

There is often a component of overuse of painkillers or analgesics (medication overuse) in patients with more chronic symptoms.

Furthermore, there is an increased risk of certain medical co-morbidities in patients with chronic migraine including depression, anxiety, fibromyalgia and obesity.

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

• Associated with other symptoms such as sensitivity to light/sound, nausea, vomiting, diarrhoea, disequilibrium, neck pain

As migraine is most often seen in females of childbearing ages, most pharmacists will have seen women who relate their migraine to their menstrual cycle. Most will also have many children with infantile colic. In such cases, it is now considered important to ask if there is a family history of migraine.

Warning signs

Emphasise the importance of regular lifestyle, diet, exercise, avoidance of stress, alcohol, smoking and other stimulants.

Confirmation of the diagnosis of migraine is a very important part of the consultation. In children and adolescents, migraine attacks are generally of shorter duration than those seen in adults. Children often give a history of travel sickness and recurrent abdominal pain or cyclical vomiting syndrome, prior to the development of headaches in their late teens or adulthood.

Diagnosis Summary • Unilateral or bilateral, typically lasts 4 to 72 hours • Pulsating or throbbing pain, moderate or severe

• Aura can occur with or without headache - Typical aura symptoms include visual, sensory, speech disturbance and occasionally motor symptoms which are reversible • Frequency < 15 days per month = EPISODIC MIGRAINE +/- aura ≥ 15 days per month = CHRONIC MIGRAINE +/aura

Many migraine sufferers report experiencing prodrome — early symptoms that can serve as a warning sign of an impending migraine.

These premonitory symptoms can take place anywhere from days to hours prior to a migraine, and their frequency and severity can vary depending on many different variables. People may experience irritability, restlessness, depression or a combination of these feelings right before a migraine begins.

• Sensitivity to light, sounds and smells – which becomes even more heightened during the migraine – is a common premonitory symptom, while others are impacted by things like excessive thirst, lethargy and constipation or diarrhoea.

Some migraine sufferers experience vision impairment or temporary loss (most commonly in aura migraines).

The duration of a migraine can be excruciating, but even once the worst of the attack has passed, there’s often aftereffects to deal with for up to 24 hours later.

Following the headache, sufferers often feel depleted of energy and can face a shift

in mood (irritability is frequently reported), though for some the opposite happens and they get a surge of energy afterwards.

Muscle weakness accompanied by tiredness is also a common post-migraine complaint, with many sufferers needing to sleep following an attack.

In the hopes of helping to prevent future migraines, keeping track of potential triggers and pre-headache symptoms is recommended – as each individual person might experience a different set. People can track any triggers and possible patterns in their migraines by keeping a migraine headache diary. Understanding each individual’s own personal migraine patterns and symptoms will be key to controlling them.

Who? Anyone - there are half a million migraine sufferers in Ireland.

What are the symptoms? Severe head pain that generally has throbbing or pulsating peaks, often on one side of the head, nausea and vomiting.

How long have they had the symptoms? Migraines are best controlled as soon as the warning signs appear. After-effects can last up to 24 hours.

Action already taken?Paracetamol, aspirin or ibuprofen can be effective for patients with mild-moderate migraine although the data suggests that their efficacy is limited to about one third of patients.

Medication? Codeine is a major cause of rebound headache.

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References: 1. Merry A, et AFT-MX-1, a prospective group, double-blind ofthethe References: 1. Merry A, et al. AFT-MX-1, a prospective parallel group,al. double-blind comparison of the analgesic effect of a combination parallel inhibiting drug, an anti-inflammatory drug and thiazide diureticcomparison at the same time increases risk of analgesic renal impairment. Bloodeff paracetamol and paracetamol alone, or ibuprofen alone patients withtherapy post-operative pain.

Departmen of of paracetamol and ibuprofen, paracetamol alone,ibuprofen, or ibuprofen alone in patients with post-operative pain. Department of Anaesthesiology, dyscrasias have been rarelyin reported.

Patients on long-term with ibuprofen should have regular haematological monitoring.

University Auckland, New 2008. with the same daily dose of standard University of Auckland, Newof Zealand 2008. *compared with the same Zealand daily dose of standard paracetamol or*compared ibuprofen alone.

Like other NSAIDs, ibuprofen can inhibit platelet aggregation.

GI bleeding, ulcerationparacetamol or perforation, which can beor fatal,ibupro has been reported with all NSAIDs at anytime during treatment. Combination therapy with protective agents (e.g. misoprostol or proton pump be considered.

Use with contains concomitant NSAIDs including cyclooxygenase-2 selective inhibitors mg should be and avoided.

Easolief Duo 500 tablets mg/150 mg film-coated tablets Each tablet paracetamol 500 Easolief Duo 500 mg/150 mg film-coated Each tablet contains paracetamol 500 mg and ibuprofen 150 mg. inhibitors) should NSAIDs may lead to on onset ofone new hypertension worseningplain of pre-existing hypertension patients taking antihypertensive Presentation: Atablet White, shaped tablet side or and on the and other side.

Indic Presentation: A White, capsule shaped with breaklinecapsule on one side and plain on the other side.

Indications:with Short-termbreakline NSAIDs may have an impaired anti-hypertensive response. Fluiddosage retention and oedema been to observed in symptomatic mild The tousual moderate The usual is have one two symptomatic treatment of mild to treatment moderate pain. Dosage:of Adults/elderly: dosage is one to two pain. tablets takenDosage: every medicines withAdults/elderly: taking NSAIDs. NSAIDs may very rarely cause serious is cutaneous adverse events such as exfoliative in dermatitis, toxic hours up maximum ofDuosix tablets in under 2418 hours.

Children: Easolief Duo contraindicated childr sixsix hours up to a maximum of sixto tabletsain 24 hours. Children: Easolief is contraindicated in children years. some patients syndrome. Products containing ibuprofen, ibuprofen should not be administered with Contraindications: Severeto paracetamol, heart ibuprofen, failure, known to paracetamol, otherto patients NSAIDs Contraindications: Severe heart failure, known hypersensitivity other NSAIDs or to any of hypersensitivity the epidermal necrolysis and Stevens-Johnson acetylsalicylic acid sensitive asthma and should after be used with taking caution in patients with pre-existing asthma. Adverseacid ophthalmological excipients, alcoholism, urticaria, or history allergic-type reactions acetylsalicylic or ot excipients, active alcoholism,active asthma, urticaria, or allergic-type reactions asthma, after taking acetylsalicylic acid or other NSAIDs, have been observed with NSAIDs. For products containingactive ibuprofen asepticor meningitis has been reported rarely. NSAIDs gastrointestinal bleeding related to effects previous NSAID therapy, history of onlyrecurren ofof gastrointestinal bleeding or perforation related to previous NSAID or therapy,perforation active or history of recurrent peptic ulceration/ may mask symptoms of infection and fever. Interactions: Warfarin, medicines to treat epilepsy, chloramphenicol, probenecid, haemorrhage, severe hepatic failure severe renal failure, cerebrovascular or other active bleeding, blood-form haemorrhage, severe hepatic failure or severe renal failure, cerebrovascular or other activeor bleeding, blood-formation disturbances, medicines used to treat tuberculosis as isoniazid, acetylsalicylic acid,short other NSAIDs,term medicines to treat high blood i during theof third trimester of pregnancy.

Warnings andzidovudine, precautions: This such medicine is for use and during the third trimester pregnancy. Warnings and precautions: This medicine is for short term use and is not recommended pressureof or other heart conditions, diuretics, lithium, methotrexate, corticosteroids.

Refer to summary of product characteristics for use beyond 3 days. studies that ibuprofen, particularly at a high dose may be asso forfor use beyond 3 days.

Clinical studies suggest that use of Clinical ibuprofen, particularly at a high dose suggest may be associated with a smalluse other interactions.

Fertility, pregnancy and lactation: Easolief Duo congestive is contraindicated during the third trimester of pregnancy.es increased risk events. of arterial thrombotic events. with uncontrolled hypertension, heart failure, increased risk of arterial thrombotic Patients with uncontrolled hypertension, congestive heart failure,Patients established ischaemic Driving and operation of machinery: Dizziness, drowsiness, fatigue and visual disturbances are possible afterwith taking NSAIDs. heart disease, peripheral disease cerebrovascular disease should only be treated ibup heart disease, peripheral arterial disease and/or cerebrovasculararterial disease should only be treated with and/or ibuprofen after careful If affectedconsideration patients should not drive or operate machinery.be Undesirable effects: Dizziness, headache, nervousness, tinnitus, l consideration high dosesshould should avoided.

Careful should exercised before initiating consideration and high doses shouldand be avoided.

Careful consideration be exercised be before initiating long-term treatment fluid retention, pain, diarrhoea, dyspepsia, nausea, discomfort, vomiting, flrecommended atulence, constipation, slight patients with risk factors for cardiovascular The use abdominal of paracetamol at stomach higher than ofof patients with risk factors for cardiovascular events.

The use of paracetamol at higher than recommended dosesevents. can lead to oedema, blood loss, rash, pruritus, alanine aminotransferase gamma-glutamyltransferase increased, abnormal liverwh hepatotoxicity, hepatic failure and death.

Patients with impaired liver function or a increased, history of liver disease or hepatotoxicity, hepatic failure and death.

Patients with impaired liver function or a history of liver disease or who are on long term gastrointestinal tests, blood creatinine increased and blood increased. Refer to Summary of Product Severe Characteristics forhepatic other adverse ibuprofen or paracetamol therapy hepatic function monitored aturearegular intervals. ibuprofen or paracetamol therapy should have hepatic function monitored at regularshould intervals. Severe have hepatic reactions, including function Pack size: reported 24 tablets. Marketing authorisation holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. jaundice and cases fatal though with ibuprofen.

Paracetamol canMarketing be us jaundice and cases of fatal hepatitis, though rare, of have been reportedhepatitis, with ibuprofen. Paracetamol can be usedrare, in patients have with effects.been number: PA0126/294/1. product not subject to medicaltoxicity prescription. For retail through pharmacywith only. chronic disease adjustment. is minimal riskMedicinal of paracetamol in sale patients chronic renal diseaserenal without dosage adjustment. Therewithout is minimal risk of dosage paracetamol toxicity in patients with moderate toThere severe authorisation copy of the summary of with product characteristics is available upon Date prepared:with October 2019.

2019/ADV/EAS/120H. renal failure.

Caution should be inused initiating ibuprofen inrequest. patients dehydration. renal failure. Caution should be used when initiating treatment with ibuprofen patients withwhen dehydration. The use of an ACE Atreatment

MILD TO MODERATE PAIN

51

MILD TO MODERATE PAIN Painful conditions are among the most commonly presenting minor ailments in general practice, and the scope for pharmacy input into self-care for painful minor ailments is evident. It is imperative that pharmacists and pharmacy support staff have relevant and evidence-based knowledge to inform their practice.

Pain is one of the most common symptoms presented to pharmacists and its presence is almost ubiquitous in all diseases and injuries.

Pain can be mild, moderate or severe. It can be treated using different strengths of painkiller, depending on the level of pain. A pharmacist can assess a patient’s pain before prescribing the best painkillers to help control it.

Effective assessment is the keystone of pain management and it is important to focus on the patient’s experiences and circumstances. Acute pain is short-term and usually follows an injury, such as an operation, fracture or infection.

Acute pain is usually self-limiting, resolves once the underlying problem is treated or heals – which generally takes days or weeks – and typically responds well to analgesics, including those available OTC from pharmacies.

Acute pain is often treated with non-opioid drugs and anti-inflammatory drugs. Sometimes opioids are used to treat mild pain.A patient’s description of pain should be considered the most reliable indicator of suffering.

On the whole, pains encountered in community pharmacies will be mild to moderate and selflimiting (less than one week), and will generally respond to any one of the wide range of over-the-counter analgesic products available.

Typical conditions presented include toothache, headache, dysmenorrhoea and musculoskeletal injuries.

Non-opiod drugs Mild pain is often successfully treated with painkillers such as paracetamol and antiinflammatory drugs.

Paracetamol can be used for most types of mild pain. It can be bought it from a pharmacy or supermarket. It has few side effects, but it is very important not to take more than the recommended dose. Higher doses can damage the liver. Paracetamol does not reduce inflammation.

Anti-inflammatory drugs such as ibuprofen help reduce inflammation and swelling. They are good for treating pain in the skin, muscle or bone. These can be bought from a pharmacy or supermarket. Other anti-inflammatory medicines need to be prescribed by a doctor.

Advice should be given by a medical professional before these types of medicines are taken. They do not always work for everyone and may not mix well with other medicines you’re taking.

Anti-inflammatory drugs can cause indigestion and may irritate the lining of the stomach, so it’s important to take them after a meal or snack.

A doctor may prescribe another medicine to help protect the stomach. If a patient has had problems with stomach ulcers before, a doctor may suggest they don’t take anti-inflammatory drugs at all. Or they may suggest they use an

anti-inflammatory gel, which you can rub onto the skin.

• Toothache

When taking these drugs, always check the recommended dose on the packet and never take a higher dose.

• Minor injuries, strains and sprains

Other medicines or tablets that are sold from a pharmacy or supermarket, such as cold and flu remedies, may also contain paracetamol or anti-inflammatory drugs. If a person is taking painkillers, they should be careful which other medicines they take, so that they don’t take more than the recommended doses. A pharmacist can give advice about over-thecounter medicines.

Topical OTC treatments

Compound analgesics Compound analgesics are made from a combination of two different drugs.New combination painkillers combining full strength paracetamol and ibuprofen are available and suitable for the treatment of mild to moderate pain.

Compound analgesics containing low doses of codeine are available over the counter from pharmacists, but stronger ones are only available on prescription. They can be used for moderate pain.

• Period pain

• Backache, muscle aches, joint pains

Topical OTC treatments broadly divide into those with active ingredients and those that are drug-free.

Formats available include gels, creams, ointments, sprays, patches and wraps. Patients will often use OTC topical analgesics for the treatment and management of musculoskeletal injuries and disorders.

These products may have local analgesic, anesthetic, antipruritic, and/or counterirritant effects.

Topical analgesics for musculoskeletal pain can be used alone or in conjunction with oral analgesics when appropriate and warranted.

External analgesic products may contain one or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsicum, and trolamine salicylate.

Other ways to manage pain A number of other methods can be recommended for managing pain

Who? Anyone suffering mild to moderate pain.

• Applying heat to the skin can help some types of pain. Use compresses or products such as sprays, creams, ointments, gels and patches to help swelling and inflammation.

What are the symptoms? Persistent and nagging pain.

• Support from bandages or compression hosiery can help with sprains and strains.

• Acupuncture or Transcutaneous Electrical Nerve • Stimulation (TENS) are alternatives to medication for pain control • Rest • Exercise (if the patient is able to) What kinds of pain can be helped by OTC medicines?

• Headache, migraine

How long have they had the symptoms? If the symptoms persist after taking OTC medication further advice should be offered.

Action already taken? Rest and exercise can help with managing mild to moderate pain.

Medication? A number of painkillers are available OTC. Stronger painkillers are available with prescription.

CaldeSpray from the makers of Caldesene.

Contains Zinc Oxide. ALWAYS READ THE LABEL. For cutaneous use only.

Date prepared: July 2017. 2017/ADV/CAL/033

NAPPY RASH

53

NAPPY RASH Nappy rash is one of the most common skin conditions in babies and it is also the most common skin problem in early childhood.

Most children aged 0-3 years old develop nappy rash in some way and it is usually presents in babies from 6-8 months.

Nappy rash can be caused by a number of factors including a combination of excess moisture, warmth, urine, faeces and friction in a baby’s nappy. It is a difficult environment for baby skin.

The nappy rash creates an enclosed area around the bottom and this increases warmth, moisture and encourages the growth of micro-organisms that can cause infection.

Chafing, due either to skin rubbing against the nappy, or from skin folds, can damage and irritate the skin and ongoing contact of the skin with urine, faeces or both, can lead to a formation of ammonia which can irritate a baby’s skin.

There is also a common link made between nappy rash and teething, as well as the transition to solid foods.

Causes and Symptoms There are various causes of a nappy rash.

Examine the rash and explain what type it is, and how to treat it most effectively.

Nappy rash can occur a baby soils or wets itself and the nappy is left on for a longer time than usual, the urine and faeces can encourage the production of the chemical ammonia, which can irritate the baby’s skin, causing it to become sore and inflamed.

Where there has been close contact with the nappy, the baby’s skin will look red and inflamed. Most affected will be the genitals, the outer skin on the folds of thighs, and the bottom. The affected areas can appear either dry or moist, and look shiny or pimply.

The best way to treat this is to keep the bottom as clean and dry as possible and change nappies often. It’s also a good idea to apply a barrier ointment/cream or medicated powder after every change.

Fungal Nappy Rash Fungal nappy rash is often a complication of initial nappy rashand looks different. If the baby’s skin is warm and damp for long periods of time, it can cause the fungus ‘candida’, to grow. Like ammonia, candida can irritate the baby’s skin. The area of skin will be inflamed, with spots around the edges. The infection will be bright red and also present in the folds of the skin.

To treat a fungal infection, the parent should apply a barrier cream every time the baby’s nappy is changed. Zinc cream, zinc oxide ointment and petroleum jelly are all suitable barrier creams.

Prevention Ultimately, prevention is key and, in order to avoid painful nappy rashes, pharmacists should advise parents to follow the same steps involved in treating a mild nappy rash.

• Zinc Oxide works by providing a skin barrier to prevent and help heal skin irritation.

This involves:

• Matricaria Chamomilla (chamomile) is effective in that it is both a demulcent and antibacterial.

• Changing the nappy regularly.

• Dexpanthenol (pro-vitamin B5) is an advantageous ingredient in baby care products as it encourages the regeneration of the skin, is a demulcent, activates the lipid synthesis and strengthens the skin’s protective barrier.

Severe Nappy Rash If a patient’s baby has severe or reoccurring nappy rash, they should be advised to visit their GP as it will usually require prescribed medication. Nappy rash should clear up within a few days of over the counter treatment.

There are a number of treatments for severe nappy rash.

• Corticosteroids help to reduce the inflammation of the skin and relieve any itching and redness.

• Hydrocortisone cream, which should only be applied once a day should not be used for more than seven days • An anticandidal medicine helps to treat any fungal infection that may cause a rash. Some commonly prescribed anticandidal medicines include: Clotrimazole, econazole, ketoconazole, miconazole and nystatin.

• Leaving the nappy off for as long as possible.

• Using only water to wash the baby’s bottom.

• Applying a barrier cream after each nappy change.

• Tight-fitting plastic pants over nappies should not be used.

• Standard talcum powder should not be used when changing nappies.

Who? Predominantly newborn babies up to one year of age.

What are the symptoms? Nappy rash can affect the genitals, the outer skin on the folds of the thighs and the buttocks. The affected areas can appear either dry or moist and may sometimes look shiny or pimply.

How long has the patient had the symptoms? Severe nappy rash or recurring nappy rash should be referred.

Action already taken? Parents may already be following self-care tips such as leaving baby’snappy off and changing regularly.

Medication? If baby’s rash is caused by thrush, don’t use a barrier cream or ointment, as this can make the rash worse.

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SUSTAINABILITY MATTERS Protect our Oceans - Certified Friend of the Sea, it is Important to abide to strict regulations Certified Fisheries - Only use certified sustainable fisheries No Over-Fishing - Products only use sustainable small fish that are not over-exploited & no by-catch of endangered species.

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OMEGA FISH OILS

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OMEGA FISH OILS

Fish oils are sometimes called the beauty and brains supplement. The DHA ingredient in fish oils is known to be a building block for brain and nerve formation.1 It is added to baby formulas to support brain and nerve development.

Fish oil’s popularity has soared in recent years, propelled by research that suggests consuming omega-3 fatty acids can ward off heart disease. Community pharmacists play an important role in helping patients make informed decisions about fish oil and omega-3 supplementation.

But with hundreds of OTC options available (and labels claiming that the supplements treat everything from bipolar disorder to menstrual cramps) how can pharmacists distinguish between them to help patients make the best choice?

Fish oils are a type of polyunsaturated fatty acids (PUFAs). They are the omega-3 and omega-6 fatty acids. Regarding heart health, the active ingredients in fish oils are DHA and EPA. The hypothesis is that omega-3s offer protection from cardiovascular disease by reducing the heart’s susceptibility to arrhythmias, decreasing platelet aggregation and lowering blood pressure and triglyceride levels.

Sold by pharmacists since the early years of the 20th century, cod liver oil is one of the oldest and most well-known food supplements. The oil first gained its reputation as an effective preventative against rickets because of its high vitamin D content and it was taken by generations of children, decreasing in popularity only when, in the 1960s, the British government decided to phase it out as a welfare food. Fish oils are most commonly used in supplements

for conditions related to the heart and blood system. They may also be used for many kidney-related problems.

Importance of Fish Oils There is little doubt that n-3 fatty acids have an important role in nutrition. They are significant structural components of the phospholipid membranes of tissues throughout the body, particularly in the brain and retina.

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

Pharmacy team should be aware of, and understand, the following key points:

• Fish oil may have a role in various mental disorders, such as depression, schizophrenia and Alzheimer’s disease, but research in this area is in its infancy • Fish oil supplements appear, in general, to be safe. However, patients on anticoagulants or with blood clotting disorders should be monitored.

• Fish oil could have beneficial effects in inflammatory conditions such as rheumatoid arthritis, Crohn’s disease and ulcerative colitis, but evidence of any benefit in asthma and psoriasis is poor.

Who? Certain vitamins are recommended for specific patient groups. Keep educated on their target populations.

What are the symptoms? Take a full symptom and medical history in order to direct the customer to the most appropriate vitamin/ supplement How long have they had the symptoms? N/A

• Those who could benefit from an increased intake of n-3 fatty acids. The typical Irish diet contains relatively low amounts of these.

Action already taken? Some customers may have already commenced a more balanced and healthy approach to diet and lifestyle, recommend continuation of this to include exercise.

• Fish oil appears to reduce the risk of CHD. It may help to reduce the risk of thrombosis (by increasing bleeding tendency), reduce blood levels of triacylglycerols, prevent atherosclerosis and arrhythmias and reduce blood pressure

Medication: A full medication history is essential to ensure the right product is selected for the right customer as many vitamins and supplements can cause side effects if used inappropriately.

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ORAL HEALTH

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ORAL HEALTH Oral disease impacts on the vast majority of the population and despite advances in preventive dentistry the prevalence of dental decay and gum disease remains high.

be able to advise on brushing technique as well as the types of product available to manage specific oral health problems, such as acid erosion, staining and gum disease

At the frontline of healthcare, pharmacists and pharmacies have a substantial role to play in improving oral health. Many people visiting a pharmacy are looking for pain relief and medication to rid themselves of toothache, mouth ulcers and other areas of discomfort in the mouth and jaw.

It is important to brush twice daily for two minutes each time with a good toothbrush and a good whitening toothpaste, and to floss at least three times a week to prevent dark stains between the teeth.

Oral disease is one of the most common diseases in contemporary society. In spite of considerable advances in preventive dentistry, the vast majority of the population will have experienced both dental decay and gum disease by their early twenties.

Advances in the prevention and treatment of oral diseases mean that most children born in this century will keep their teeth into old age, and the condition of these teeth will depend on how well they are looked after over a lifetime.

High sugar intake, for example, is linked to obesity, heart disease, diabetes and dental decay. Smoking is linked to cardiovascular disease, respiratory disease, gum disease and cancer, including oral cancer. In addition to sharing common risk factors, poor oral health appears to impact on general health.

Routines and Products There is more to oral hygiene than a toothbrush and some toothpaste. Pharmacy teams need to

Reinforcing the message about twice-daily brushing remains the most important priority and is one of the most effective ways of preventing dental decay.

Lifestyle Good oral hygiene is the cornerstone of dental health, but there are other lifestyle factors that also have an effect, such as diet, smoking, smokeless tobacco and alcohol.

Most people don’t realise that their diet can have a significant impact on their oral health.

Crash dieting, fasting and low-carbohydrate diets can have nasty side-effects on breath due to acetone caused by ketosis, or an excess of protein in the diet producing volatile sulphur compounds in the breath.

Certain types of food can also feed the bacteria in the mouth that cause bad breath. Hard sweets are a major culprit. Similarly, ice lollies are known to stain the teeth because of the amount of sugar they contain.

For customers who do smoke but want to

Gingivitis Gingivitis is a form of periodontal disease. Periodontal disease is the inflammation and infection that destroys the tissues, such as the gums, ligaments and the tooth sockets, which support the teeth. This is caused by a build-up of plaque over periods of time and is caused by poor dental hygiene, undiagnosed diabetes or a poor diet.

The disease can often remain silent for many years and will only present itself when the gums become swollen or bleed. Gum disease can result in teeth loss.

Patients who smoke or suffer from diabetes are at a higher risk of developing the disease.

If a patient presents with symptoms of gingivitis, they should have their teeth professionally cleaned and they should also be advised to practice good oral hygiene. In order to prevent a build-up of plaque, toothbrushes or water irrigation devices can be advised, along with anti-bacterial mouthwashes and anti-plaque or anti-tartar toothpastes. Soft bristle brushes should be used and the recommended time for cleaning the teeth is two minutes.

Halitosis Halitosis or bad breath can be caused by excessive amounts of volatile sulphur compounds (VSCs) being produced by bacteria in the mouth. This can be influenced by any number of factors, such as eating, drinking, oral hygiene, sleeping and the effect that these activities have on saliva flow. Mouthwashes will reduce halitosis, due to the anti-microbial influences of the products.

mask bad breath, an alcohol-free mouthwash should be advised to kill bacteria. Alcohol is also a drying agent and will reduce saliva flow, in turn creating a perfect breeding ground for bacteria.

Mouth Ulcers Mouth ulcers affect up to 20% of the population, particularly women and young people. They are usually white, red, yellow or grey in colour and inflamed around the edge.

Mouth ulcers can be uncomfortable, especially when sufferers are eating, drinking or brushing their teeth, but they are usually harmless. Most mouth ulcers will clear up on their own within a week or two, but a GP or dentist should be consulted if the ulcer gets worse, lasts for longer than three weeks, or if the patient develops ulcers on a regular basis.

Who: Those suffering from mouth ulcers.

What are the symptoms? Ranging from burning and tingling before sores appear, pain in the mouth.

How long have they had symptoms?

Symptoms will usually clear up within 7 days of treatment.

Action already taken? Sufferers may already be aware of tell-tale signs.

Medication: If using Ibuprofen avoid smoking or drinking large amounts of alcohol.

Who? Adults are more likely to present to the pharmacy with gingivitis, especially smokers, those with a poor diet and some experts believe women on some of the contraceptive pills may be extrasusceptible.

What are the symptoms? Swollen or bleeding gums How long has the patient had the symptoms?

Gingivitis can be present for years without the patient knowing.

Actions already taken? Patients may have already attended their dentist and are looking for pharmacy over-the-counter solutions.

Medication:Customers who express concern about sensitive teeth should choose a product formulated to reduce this.

Who? People, who have poor oral hygiene. The problem can affect anyone of any age.

What are the symptoms? Bad breath How long has the patient had the symptoms? If the patient has persistent bad breath that cannot be resolved, it may be a symptom of another condition.

A referral should be made to a doctor, dentist or health hygienist.

Medication: Customers who express concern about sensitive teeth should choose a product formulated to reduce this.

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OSTEOARTHRITIS

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OSTEOARTHRITIS Osteoarthritis is caused by wear and tear of cartilage in the joints. It is the most common form of arthritis in Ireland. In osteoarthritis, the surface of a joint becomes damaged and the surrounding bone grows thicker.

There are many different types of osteoarthritis, which can affect a number of the body’s joints.

The knees are the most common sites for osteoarthritis. The hips, hands, spine and big toes are also often affected.

The pain and stiffness in the joints can make carrying out everyday activities difficult for some people with the condition.

The condition affects 400,000 people in Ireland.

There has been an increase in the number of people with osteoarthritis in Ireland for two reasons; our ageing population and more obese people putting an increased strain on their joints.

Osteoarthritis is more common and often more severe in women, especially in the knees and hands. It often starts after the menopause.

Osteoarthritis occurs when there is damage in and around the joints that the body cannot fully repair.It’s not clear exactly why this happens in some people, although the chances of developing the condition can be influenced by a number of factors, such as age and weight.

Osteoarthritis usually develops in people over 45 years of age, although younger people can also be affected.It is commonly thought that osteoarthritis is an inevitable part of getting older, but this is not quite true. People may in fact be able to reduce their chances of developing the condition by doing regular, gentle exercises and maintaining a healthy weight.

Symptoms Stiff and painful joints are the main symptoms.

Symptoms vary from one person to the next.

The level of physical activity can make a difference. The weather (especially damp and low pressure) may affect symptoms.

Pain tends to be worse on exercising the joint and at the end of the day. The joints do not move as freely as normal and may cause a ‘cracking’ sound when moved.

In osteoarthritis of the knee, pain is felt at the front and sides of the knee, and in severe causes it causes the legs to become bent (bow-legged). With hip joints, the pain is usually in the front of the groin, but can radiate around the side and front of the thigh, the buttock and even down to the knee. Sometimes when osteoarthritis is severe, the affected leg may shorten.

With knee and hip osteoarthritis, daily tasks such as going up or down stairs can become difficult to perform. Mobility can be affected due to pain and walking.

A complication of osteoarthritis, especially knee osteoarthritis, is calcification, which is when chalky deposits of calcium crystals form in the cartilage of joints. This process tends to make the osteoarthritis more severe and painful.

Most people with osteoarthritis can carry on

Treatments

Capsaicin cream - a GP may prescribe capsaicin cream if a patient has osteoarthritis in the hands or knees and topical NSAIDs haven’t been effective in easing the pain.Capsaicin cream works by blocking the nerves that send pain messages in the treated area. The patient may have to use it for a while before it has an effect.

There’s no cure for osteoarthritis, but the condition doesn’t necessarily get any worse over time and a number of treatments are available to help relieve the symptoms. One of the main treatments for osteoarthritis is changes to lifestyle – such as maintaining a healthy weight and exercising regularly

Steroid injections - steroids are a type of medication that contain manmade versions of the hormone cortisol, and are sometimes used to treat particularly painful musculoskeletal problems.Some people with osteoarthritis may be offered steroid injections when other treatments haven’t worked.

with a normal life. Symptoms can peak for a few years, and then subside. For others, one or more joints may worsen, causing pain and disability. Unfortunately, it is difficult to predict the outcome for a person affected with the condition.

Topical gel - pharmacists will be able to advise on the use of topically applied gel to ease joint pain associated with osteoarthritis. Gels work by delivering lubricating ingredients directly into joints that have become damaged due to osteoarthritis. By improving lubrication within the joints they can relieve pain and reduce joint stiffness. They can be used safely with other medicines.

Painkillers - the type of painkiller (analgesic) you may recommend will depend on the severity of the pain and other conditions or health problems the patient has. Paracetamol is often used in the first instance and sufferers can be advised to take it regularly rather than waiting until the pain becomes unbearable.

Opioids, such as codeine, are another type of painkiller that may ease pain if paracetamol does not work. Opioids can help relieve severe pain, but can also cause side effects such as drowsiness, nausea and constipation.

In some circumstances a non-steroidal antiinflammatory drug (NSAID) may be prescribed as a painkiller by a GP. NSAIDs are painkillers that work by reducing inflammation. Some NSAIDs are available as creams (topical NSAIDs) that you apply directly to the affected joints. Some topical NSAIDs are available without a prescription.

Who? Osteoarthritis usually develops over the age of 45. It is more common and severe in women than men.

What are the symptoms? Pain and stiffness in the joints, joint tenderness, increased pain and stiffness when a person has not moved their joints for a while, joints appearing slightly larger or more ‘knobbly’ than usual, a grating or crackling sound or sensation in the joints, limited range of movement in the joints.

How long have they had the symptoms? Medical help should be sought if a patient has persistent symptoms.

Action already taken? Lifestyle changes, such as exercise and losing weight, can help to relieve symptoms.

Medication?There’s no cure for osteoarthritis, but the condition doesn’t necessarily get any worse over time and a number of treatments are available to help relieve the symptoms.

HEADACHE PANADOL EXTRA SOLUBLE RELIEVES 5 TYPES OF TOUGH PAIN

Headaches Period pain Joint pain

Back pain Dental pain

Panadol Extra Soluble has a dual active formula which provides up to 30% more powerful pain relief than standard paracetamol.1

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paracetamol/caffeine

Reference. 1. Laska EM et al. JAMA. 1984; 251(13):1711-1718.

Panadol Extra 500mg/65mg Soluble Effervescent Tablets. Contain paracetamol. Always read the label/leaflet.

Product Information: Please consult the summary of product characteristics for full product information. Panadol Extra 500mg/65mg Soluble Effervescent Tablets, paracetamol 500mg, caffeine 65mg. Indications: Relief of mild to moderate pain including rheumatism, neuralgia, musculoskeletal disorders, headache, symptoms of colds and flu, fever, toothache and menstrual pain. Dosage: Adults and children 16 years and over: 2 tablets up to 4 times a day. Do not exceed 8 tablets in 24 hours. Children aged 12-15 years: 1 tablet up to 4 times a day. Do not exceed 4 tablets in 24 hours. Do not give to children under 12 years. Minimum dosing interval: 4 hours. Contraindications: Hypersensitivity to paracetamol, caffeine or any ingredients. Precautions: Avoid concurrent use with other paracetamol-containing products. Diagnosed liver of kidney impairment. Patients with depleted glutathione levels or chronic alcoholism or sepsis. Avoid excessive caffeine intake. Caution in those with hereditary sugar intolerance or on a low sodium diet. Should not be used in pregnancy or lactation without medical advice. Do not exceed the stated dose. Prolonged use except under medical supervision may be harmful. Side effects: See SPC for full details. All very rare: Thrombocytopenia, hypersensitivity reactions including anaphylaxis and skin rash, angioedema, Stevens-Johnson syndrome, bronchospasm, hepatic dysfunction. Frequency unknown: Nervousness, dizziness. When combined with dietary caffeine intake, higher doses of caffeine may increase potential for caffeine related adverse events such as insomnia, restlessness, anxiety, irritability, headaches, GI disturbances and palpitations. Overdose: Immediate medical advice should be sought in the event of an overdose, even if symptoms of overdose are not present. Legal Category: Supply through pharmacy only. MA Number: PA 678/39/10.

MA Holder: GlaxoSmithKline Consumer Healthcare (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24. Additional information is available upon request. Text prepared: November 2019. CHGBI/CHPAN/0107/19

PAIN RELIEF

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PAIN RELIEF Oral analgesics are used commonly for relieving pain such as headache, menstrual pain, toothache, back pain and arthritis.

Some analgesics work on the body’s peripheral and central nervous systems to block or decrease sensitivity to pain. Others act by inhibiting the formation of certain chemicals in the body that mediate pain.

They are available in various oral forms such as tablets, capsules, syrups, suspensions and powders. The analgesics market has experienced its fair share of ups and downs in recent years but is still growing and is likely to continue doing so.

Types There are two kinds of analgesics: Non-opioid: Non-opioid analgesics include paracetamol and non-steroid anti-inflammatory drugs (NSAIDs) such as Aspirin and Ibuprofen.Non-opioid analgesics are the first choice analgesics for treating mild to moderate pain and are also used in moderate to severe pain to potentiate the effects of opioids.

Opioid: Opioid analgesics block or decrease sensitivity to pain in the body’s peripheral and central nervous systems. Most of the opioid analgesics are prescription-only medicines and are suitable for moderate to severe pain, particularly of visceral origin. They can be further classified into two categories: mild and potent opioids. Mild opioid analgesics include codeine and tramadol. Strong opioid analgesics examples are morphine and methadone.

General Advice when taking Oral Analgesics • Always follow the dosage instructions on the packaging or as instructed by your doctor or pharmacist. Do not take more than the recommended dose as this will increase the risk of serious side effects.

• Painkillers should not be shared with anyone else, as different people may experience pain with different cause and severity.

• Avoid drinking alcohol if you are taking analgesics as it may increase the risk and severity of side effects of the medicines.

alcohol as these activities can increase the risk of developing a stomach ulcer Oral Pain Oral pain is a big market for analgesics.

Many common conditions cause oral pain or discomfort. Examples of these conditions include cold sores (see separate entry), toothaches; tooth sensitivity; teething; minor oral mucosal injury or irritation; oral mucosal disorders, such as recurrent aphthous stomatitis ([RAS]; and xerostomia (dry mouth). There are OTC products available for the self-treatment of each of these sources of oral pain and discomfort, including topical analgesics/anaesthetics, toothpastes formulated for sensitive teeth, artificial saliva products for dry mouth, and oral mucosal protectants, as well as products that provide treatment of and relief from pain due to cold sores.

Paracetamol: Taking excessive amounts can cause Liver damage and less frequently kidney damage following over doses. It should be used with caution for patients with impaired kidney or liver function, alcohol dependence, chronic malnutrition or dehydration

In general, the goals involved in the treatment of minor oral pain are to provide immediate symptomatic relief from discomfort and irritation and to promote healing. Patients should be assessed for the appropriateness of therapy and educated on the proper use of these products. Pharmacy teams should advise patients to seek medical care if their conditions worsen or show signs of infection.

NSAIDS: These should always be taken with food or milk. The medication should be stopped immediately and the patient referred to a GP if the patient has abnormal or black stools. Those taking NSAIDS should avoid smoking and drinking large amounts of

In an effort to self-medicate, some patients may try using analgesics to ward off pain caused by more serious health conditions and pharmacy staff are in an ideal position to monitor such situations without being too intrusive.

Warnings for Oral Analgesics

Dental Pain Toothache is pain in and around the teeth and jaws that is most often caused by tooth decay.The pain usually starts suddenly and it can vary from mild discomfort to a severe throbbing, which is often worse at night. The area of the jaw close to the infected tooth may also be sore and tender to the touch.

Toothache can either come and go or be constant. Eating or drinking can make the pain worse, particularly if the food or drink is hot or cold. Painkillers such as paracetamol and ibuprofen may help reduce pain and discomfort whilst sufferers are waiting for an appointment.

Who: Those suffering from pain such as dental pain.

What are the symptoms? Pain anywhere in the body.

How long have they had symptoms?

Symptoms will usually clear up within 7 days of treatment.

Action already taken? Sufferers may already have tried analgesics. If the pain persists longer than 2 weeks, the patient should be referred to a GP. Medication: check for underlying conditions before suggesting a specific pain relief, see the warning box above.

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PRE-PREGNANCY & FERTILITY

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PRE-PREGNANCY & FERTILITY Just over a third of couples will conceive in the first month of trying, while for others it can be a much longer road, with factors such as age, general health and reproductive health affecting how long it takes.

Around 1 in 6 couples in Ireland may experience issues with fertility.

The growing demands of a modern lifestyle are having a significant impact on our nutritional health. Stress, anxiety, lack of sleep, dieting and poor nutrition all impact the bodies ability to absorb the nutrition needed to optimise reproductive health.

Improving nutrition and lifestyle for as little as three months before trying to conceive can make a noticeable difference to both genders as both the male and female reproductive systems need adequate nutritional support to contribute to sperm and egg quality.

Factors Affecting Fertility Age: For women, the most fertile period is in their mid-twenties and fertility starts to decrease after the age of 35.For men, sperm is strongest in their mid-twenties and starts to decrease after the age of 40.

Smoking: Smoking can affect fertility in both men and women, it can affect the chances of conceiving for women and sperm quality in men.

Weight: A body mass index (BMI) of 30 or over is known to reduce fertility in men and women.

While, for women, being underweight (BMI less than 18) can also affect ovulation.

Alcohol: For women planning to get pregnant, the HSE recommend the safest approach is not to drink alcohol at all. While for men drinking too much alcohol can affect the quality of sperm.

Stress: Stress can affect your relationship and cause a loss of sex drive. In severe cases, stress may also affect ovulation and sperm production.

Diet & Lifestyle: The HSE recommends all women begin taking folic acid at least 3 months before conception. There are number of other vitamins, minerals and amino acids that are known to be beneficial to the reproductive system, however it can be difficult to get all of these nutrients in the diet in today’s busy world. This is where supplements can help, by providing extra support needed to support good pre-conception health.

How Do Fertility Supplements Work?

Supplements can help to correct nutritional deficiencies associated with the reproductive cycle by supplying the raw materials needed to support the reproductive system so it can function optimally.

For Women: Supplements can support the nutritional needs of the female reproductive system. Getting the environment right and developing good quality egg cells are key factors when trying for a baby.

Nutrients play an important role in the development of the egg, womb and the hormonal system. Each month, the reproductive and hormonal cycle develop an egg cell, prepare the womb and a myriad of other processes have to be performed to create the right fertile balance.

Egg quality can be enhanced if it is released into a healthy nutritious environment. Fostering a good diet and ensuring that you are taking the essential nutrients can positively effect the health of your eggs and subsequently the developing foetus.

For Men: Men have to produce between 40 and 300 million sperm cells to be fertile. This is an intensive process and the energy involved in creating these cells is significant. Getting the environment right and developing good quality sperm cells are key factors when trying for a baby. A deficiency in any nutrient may have an impact on male fertility.Improvements to both sperm quality and quantity can be made in as little as 3 months.

Vitamins are vital for the production of energy in the body. Sufficient energy production is required for reproductive health. Key reproductive vitamins are: Beta Carotene, Vitamin B1 (Thiamin), Vitamin B2 (Riboflavin), Vitamin B3 (Niacin), Vitamin B5 (pantothenic acid), Vitamin B6 (Pyridoxine), Folic acid, Inositol, Biotin, Vitamin C, Vitamin D, Vitamin E, Vitamin K1.

Amino acids are the building blocks of proteins necessary for growth and repair in the body. Look for: L’Arginine, L’Carnitine, L’Citruline, L’Glutamine, N-Acetyl-L-cysteine, Glycine, Taurine.

Antioxidants such as Co-Q10 are important for reproduction. Co-Q10 is a powerful antioxidant and energy power house. It is present in the membrane of almost every cell in the body.

Omega 3 DHA contributes to the maintenance of normal brain function and vision. During pregnancy, essential fatty acids are important to the baby’s brain and eye development.

Key Nutrients for Conception Look for a combination of Folic Acid, Vitamins, Minerals, Amino Acids, CO-Q10 & Omega 3 DHA. Folic acid contributes to normal maternal tissue growth during pregnancy. The HSE recommends all women begin taking 400ug folic acid at least 3 months before conception.

Minerals including Calcium, Magnesium, Iron, Zinc, Copper (gluconate), Manganese, Selenium, Chromium, Molybdenum, Iodine, Boron, are essential for both male and female reproductive health. Minerals work together creating a synergy. Multiple mineral deficiencies are common amongst many women particularly those who have been using hormonal contraception.

Who? Men and Women trying to conceive.

What are the symptoms? Those unable to conceive within first 6 months.

How long has the patient had the symptoms? N/A Action already taken? Ovulation kits and fertility lubricants may have been tried.

Medication: N/A

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IE19031 IR-REL-49-2019 Date of item August 2019

PSORIASIS

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PSORIASIS Psoriasis is a chronic, systemic, inflammatory skin disorder in which there is an increase in the rate at which skin cells are produced and shed from the skin. Psoriasis can affect any part of the skin surface, but most commonly involves the elbows, knees, scalp, and the sacrum (lower back).

Along with the physical burden of psoriasis, the often-visible nature of the disease means people living with the condition may have to cope with the reactions of others to the appearance of their skin. This can impact negatively on quality of life, self-esteem, social and personal relationships, which can then take an emotional, psychological and psychosocial toll on people with psoriasis.

Psoriasis is a common, non-contagious, longterm, immune-mediated inflammatory disease in which there is an increase in the rate at which skin cells are produced and shed from the skin. Psoriasis affects at least 100 million people worldwide, including upwards of 73,000 people in Ireland, suggesting a prevalence of close to 2% of the Irish population. It is estimated that around 9000 people in Ireland have severe psoriasis.

Psoriasis is a condition which tends to run in families. Several different genes have been identified but the exact way in which the disorder moves from generation to generation has not yet been established. What is known is that both the immune system and genetics are important in its development. So although the potential to develop psoriasis is genetically inherited, it is by no means certain that it will ever occur.

Psoriasis may seem only skin deep, but it begins inside the body within the immune system. The red, scaly, flaky, and itchy patches occur when the skin cells grow too quickly as a result of inflammation caused by the body’s immune system.

Triggers for this abnormal immune reaction can include physical injuries or infections (in particular, a streptococcal throat infection), certain medicines, and emotional stress.

Psoriasis varies in severity from person to person and can vary in severity in the same person at different times.

Occasionally psoriasis can disappear without treatment but more usually, it is a chronic disease that requires treatment. Patches (also called plaques or lesions) can occur on various parts of the body, including the scalp, elbows, and or knees.

Symptoms Red, scaly patches (also called plaques or lesions) with sharply defined edges, that occur most commonly on both elbows, both knees, the scalp, under arms, under breasts, natal cleft (groove between the buttocks) and genitalia, or at the site of an injury • If the scales are gently scraped off, a number of small, bleeding points can be seen underneath • Nail changes – loosened, thickened or pitted nails (pits are small dents/ice pick like depressions on the surface of the nails) People who have psoriasis are at risk of developing psoriatic arthritis, which commonly

affects the joints of the fingers, toes and spine. Psoriasis is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol, cardiovascular disease (angina, heart attack, stroke), and obesity.

There is also a strong association between psoriasis and depression.

Some symptoms that may be associated with psoriatic arthritis include; • Joint pain, especially with redness, swelling, and tenderness • Pain in the heel(s) or tennis elbow • A finger or toe that was completely swollen (sausage shaped) and painful for no apparent reason • Morning stiffness/pain in the back that improves with movement Those presenting into the pharmacy who suffer from psoriasis and exhibit any of these symptoms, should be referred to their local GP for follow-up.

Pregnancy and Psoriasis Over the last decade or so, research has provided greater insights about the course of psoriasis during pregnancy and the safety of newer treatments, particularly for moderateto-severe psoriasis. This is an evolving area and the science is complex, so it is important pharmacy tams are educated and knowledgeable so as to be able to effectively advise sufferers when considering planning a pregnancy.

Fifty percent of psoriasis patients are women and the majority of these are diagnosed with psoriasis during their reproductive years.

With this in mind, if a woman is considering becoming pregnant, it is important she has a conversation with her consultant.

Approximately 50% of women experience an improvement in their psoriasis symptoms during pregnancy, while others report no change or a worsening of their condition.

However, it is thought that good disease control during pregnancy may optimise the health of both the mother and the baby.

Psoriasis treatments Treatment can be divided into four main categories: Topical treatments: e.g. creams, ointments, lotions, gels, foam or mousse applied directly to the skin.

• Phototherapy: a form of artificial ultraviolet light, delivered in hospital dermatology departments.

• Systemic treatments: medications taken in the form of tablet, liquid or injection that work throughout the body to control the psoriasis.

• Biologic agents: targeted medicines used to inhibit part of the immune system that drive inflammation. These are mainly injections but some are now being developed in table form.

In recent years, the new biologic agents have significantly broadened the range and efficacy of treatment options available, revolutionising the care of psoriasis patients and have become the ‘mainstay treatment’ for many with moderate to severe psoriasis.

Who? The skin condition usually starts affecting people from the age of 15 and into their twenties.

What are the symptoms? Painful red, itchy raised patches with visible silvery scales, typically on the knees, scalp and elbows.

How long has the patient had the symptoms? Most psoriasis sufferers will have flare ups if they do not adhere to a good skin care routine or if they experience stress.

Action already taken? Patients may already be using a moisturiser to reduce dryness Medication: pustular psoriasis can be caused by cessation of topical or systemic medicine check with the patient about their medications.

HELP SCARS FADE WITH KELO-COTE

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For more information about Kelo-Cote, or to access Scar Management Training Modules, please visit www.kelo-cote.ie JB-000032

Date of Preparation: Oct 2019

SCARRING

69

SCARRING Most people will, at some time, have experienced a burn, cut, or surgery that has left a scar. When the scar is located in an inconspicuous place, it is not so bad. When an existing scar or a new injury occurs in a noticeable place, however, many consumers will turn to their community pharmacy team for advice and guidance, and will appreciate knowing that there are OTC products that can reduce scarring.

By ensuring the pharmacy team are trained and knowledgeable across all levels of primary care in minor skin conditions, those visiting the pharmacy for advice will be receiving the best support and care, both physically and emotionally.

Normal fine line scars A minor wound like a cut will usually heal to leave a red, raised line, which will gradually get paler and flatter over time. This process can take up to two years. The scar won’t disappear completely and the customer will be left with a visible mark or line.

Fine line scars are common following a wound or after surgery. They aren’t usually painful, but they may be itchy for a few months.

On darker skin types, the scar tissue may fade to leave a brown or white mark. A pale scar may be more obvious on tanned skin because scar tissue doesn’t tan.

Keloid scars A keloid scar is an overgrowth of tissue that occurs when too much collagen is produced at the site of the wound. The scar keeps growing, even after the wound has healed.

Keloid scars are raised above the skin and are red or purple when newly formed, before gradually becoming paler. They’re often itchy or painful, and can restrict movement if they’re tight and near a joint.

Hypertrophic scars Like keloid scars, hypertrophic scars are the result of excess collagen being produced at the site of a wound. But not as much collagen is produced in hypertrophic scars compared with keloid scars.

Also, unlike keloid scars, hypertrophic scars don’t extend beyond the boundary of the original wound, but they may continue to thicken for up to six months. Hypertrophic scars are red and raised to start with, before becoming flatter and paler over the course of several years.

Pitted or sunken scars Some scars caused by skin conditions, such as acne and chickenpox, can have a sunken or pitted appearance. Pitted scars, also known as atrophic or “ice-pick” scars, can also occur as a result of an injury that causes a loss of underlying fat.

If a wound takes 10 or more days to heal, this increases the risk of scarring. Once the wound is completely healed, lots of massage will help to break down scar tissue.

Customers can use a hand massager and an evidence-based silicone product as soon as possible. Some of these products are rubbed on the skin, normally twice a day. The sheets need to be applied to the skin for seven to 12 hours a day.

Silicone gels are the first line treatment for scars by healthcare professionals including plastic surgeons. This treatment forms an occlusive layer over the scar tissue to help create an optimal healing environment for scars to normalise collagen production and help improve the appearance of scars. It has a patented formulation which helps to soften and flatten raised scars as well as reducing discolouration and redness. It also relieves itching, discomfort and pain associated with scars.

• Stocking a range of products including dressings, surgical tape, antiseptic wipes, wound cleaners, spray skin, swabs, plasters, adhesive removers, bandages, massage oil (for aftercare), and antiseptic creams and ointments • Featuring the best sellers and sizes in each brand and focusing on a specific skin concern • Avoiding overstocking the category by focusing on the top two or three brands, including ones that pharmacy teams particularly advocate and use • Engaging with customers to research what they are looking for in a skincare range and whether anything is missing from a pharmacy’s skincare category • Setting up a campaign to support wound care, promoting good practice to customers.

Offering Advice Be sure to ask a patient what aspect of their scar or stretch marks is troubling them so you can advise them accordingly.

Who? Those who at some time, have experienced a burn, cut, or surgery that has left a scar.

Like any sensitive topic, asking questions can be a good way to initiate a positive discussion. Scars and stretch marks are extremely common – so reassure customers that it is something the pharmacy team is used to advising on. Ask a customer if they would prefer to talk in private and, if so, move the conversation to a consultation room.

What are the symptoms? The first sign is itchiness of the skin at the scar site.

• Considering the aspects of wound and skincare that they need to address, and keeping up-to-date with product developments and launches

How long have they had the symptoms? Some scars may continue to thicken after 6 months.

Action already taken? Many may already be moisturising with a regular lotion, but this won’t penetrate the skin deeply enough to keep it hydrated.

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For more details on opening an account or to place an order, please call +44 (0) 1442 821 419 or email enquiries4@solgar.com Food supplements should not be used instead of a varied balanced diet and a healthy lifestyle.

Solgar® is a registered trademark. BioCell Collagen II® is a registered trademark of BioCell Technology LLC.

SKINCARE: BEAUTY

71

SKINCARE: BEAUTY Physical appearance is very important for many people, and skin complaints can have a significant impact on confidence.

Problems such as ageing, dry and sun damaged skin tend to be very visible and can have a significant impact on confidence and lifestyle. When thinking of ways to address your customers’ skin issues an initial recommendation may be to try a range of topical creams and lotions.

As experts and trusted advisors to your customers it could enhance their experience to also advocate the use of supplements that can target specific beauty concerns, supporting the health and balance of the complexion from the inside out.

The skin is the largest organ of the human body, accounting for approximately 16% of total body weight. Skin is organised into two primary layers; the epidermis and the dermis, and plays a key role in protecting the body from the environmental threats including smoking, sun exposure and pollution.

Ageing The structural integrity of the dermis is vital for the normal function and youthful appearance of the skin, as this layer provides structural support for the epidermis.

As people age, the skin undergoes what is known as natural (chronological) ageing which is thought to occur as a result of the photoageing process (from exposure to UV light). This occurs primarily on the face and arms as they are the areas on the skin that are most exposed to the elements. Signs of photoageing include dryness, deep furrows, irregular pigmentation, elastosis and a leathery appearance.

Sun-damaged Skin Sun exposure is important as it allows the body to produce vitamin D. However, skin is vulnerable to photoageing and damage from overexposure to the sun and excessive exposure to UV carries health risks, including atrophy, pigmentary changes and wrinkling.

Ultraviolet B (UVB) is the primary component of sunlight that causes sunburn as well as UV light from tanning beds.

Atopic Dermatitis Atopic dermatitis (AD), commonly known as eczema, is an inflammatory condition characterised by skin dryness and intense itching. AD is associated with a reduction in the barrier function of the epidermis, and impacts up to 20% of children and 3% of adults.

Factors that can contribute to dry skin include the weather, chemicals and cosmetics.

There are several specific nutritional supplements available through pharmacy which can support beauty from the inside out, in addition to the usual skin creams and topical lotions.

While a healthy, balanced diet, which includes plenty of essential vitamins and minerals, is required for healthy skin, more and more people are using beauty supplements (nutraceuticals) to help add further benefit.

BioCell Collagen® - Biocell Collagen® is a healthy ageing ingredient containing a patented composition of naturally occurring hydrolysed collagen type II (60%), chondroitin sulfate (20%) and hyaluronic acid (HA)(10%) in a highly absorbable matrix form that has been the subject of numerous human clinical trials determining safety, efficacy and bioavailability.

Normally collagen in its unhydrolysed form has a large molecular structure making it difficult for the body to absorb and use. BioCell Collagen® undergoes patented manufacturing process which significantly reduces the molecular size allowing for easier absorption and quicker action.

Hydrolysed Collagen Type II - Hydrolysed collagen type II has a major role in the integrity of the dermis layer of the skin. Research shows that daily ingestion of BioCell Collagen Type II® over 3 months increased the collagen content in the facial skin leading to a significant reduction in skin dryness and wrinkles.

Fish oil - supplements are loaded with Omega-3 fatty acids. These fatty acids have a number of proven health benefits. They support collagen growth and promote skin moisture, both of which help to keep skin healthy.

GLA oils - also known as gamma-Linolenic acid oils, GLA oils are Omega-6 fatty acids.

Like their cousin, the Omega-3 fatty acids, Omega-6s are also intended to keep skin healthy. While they’re important for healthy skin, the body doesn’t produce them. GLA oils are found in vegetable oils. The most common GLA supplements are evening primrose oil (EPO), borage oil, and black currant seed oil.

All these varieties of GLA oil can be found in tablet form.

VITAMINS (A, C, D & E) - it’s widely knownthat vitamins are good for general health.

But it’s worth stressing how important these Vitamins A, C, and E are for skin health.

• Vitamin D also regulates sebum glands and without enough the glands can produce too much sebum, contributing to acne.

• Vitamin E is an antioxidant that protects skin cells and helps maintain moisture.

Coenzyme Q10 - commonly referred to as CoQ10, this antioxidant helps get rid of free radicals and other toxins in the body. Thus, it has the effect of promoting healthy skin and allowing the body to make as much collagen as possible.

Biotin - an essential B vitamin, also known as vitamin B7, that helps promote healthy skin, as well as healthy nails and hair. Researchers also think that Biotin works to reduce the death of skin cells. Biotin is found in foods like cheese, beans, eggs, and leafy greens.

People can add more of these foods to their diet to ensure they’re getting plenty of Biotin, or can take a tablet as a supplement. Hyaluronic acid – also known as sodium hyaluronate, has strong moisture-retaining properties, which benefits healthy skin. While this compound is an ingredient in many creams and serums, there’s little evidence to suggest hyaluronic acid is effective when applied topically. It’s best to ingest an oral tablet to receive maximum benefits from this skin supplement.

Who? Available to everyone, but women and older people purchase more supplements.

Symptoms? As a person ages the collagen and elastin in their skin begins to break down.

How long have they had the symptoms? Part of the natural ageing process.

• Vitamin A increases cell reproduction and stimulates collagen production.

Action already taken. A balanced diet is recommended to achieve necessary vitamins and minerals.

• Vitamin C helps prevent damage to cells, thus facilitating the production of elastin and collagen.

Medication? N/A

Clinically Proven to Help your patients quit for good

Nicorette® is the No.1 NRT Brand with the widest range of formats* *IMS OIRMTH MAT 11/2019 Nicorette Icy White 2mg Medicated Chewing Gums, Nicorette Invisi Extra Strength 25mg/16 hours Patch. Nicorette 15mg Inhaler, Nicorette Cools 2mg Lozenges, Nicorette Quickmist 1mg/spray Spray, Nicorette 15mg Inhaler: For the treatment of tobacco dependence by relieving nicotine craving and withdrawal symptoms, thereby facilitating smoking cessation in smokers motivated to quit. Helping smokers temporarily abstain from smoking (Gum and Inhaler only). In smokers currently unable or not ready to stop smoking abruptly. Gum, Inhaler and Lozenges may also be used as part of a programme to reduce smoking prior to stopping completely. 2mg Gum or Inhaler may be used in combination with Invisi 10mg and 15mg Patch for the treatment of tobacco dependence as part of a stop smoking programme. Dosage: Smoking cessation: Gum: The gum should be used whenever there is an urge to smoke. Not more than 15 pieces of the chewing gum may be used each day. Nicorette Gum may be used for up to 3 months during which time the habits associated with smoking will be lost. If not successful after 12 weeks the patient should be encouraged to make a fresh attempt to stop smoking. Inhaler: Inhaler should be used whenever the urge to smoke is felt, up to a maximum usage of 6 cartridges per day. In the treatment of nicotine dependence, a course not exceeding three months is suggested, the patient stopping smoking completely at the start of the course. Patch: Heavy smokers: start at Step 1 with the 25 mg/ 16 hours patch and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15 mg/16 hours patch should be used daily for 2 weeks followed by one 10 mg/16 hours patch daily for 2 weeks. Light smokers: start at Step 2 (15 mg) for 8 weeks and decrease the dose to Step 3 (10 mg) for the final 4 weeks. Lozenges: 2mg lozenge is suitable for smokers with low nicotine dependency e.g. those smoking their first cigarette of the day more than 30 minutes after waking up or those who smoke fewer than 20 cigarettes per day. 4mg Lozenges are suitable for smokers with high nicotine dependency e.g. those smoking their first cigarette of the day 30 minutes after waking up or those who smoke more than 20 cigarettes per day. Should not be used for more than 9 months. One lozenge should be placed in the mouth and allowed to dissolve. Periodically, the lozenge should be moved from one side of the mouth to the other, and repeated, until the lozenge is completely dissolved.

The lozenge should not be chewed or swallowed whole. Sufficient lozenges should be used each day and most smokers usually require 8 to 12, not to exceed 15 lozenges. The duration of treatment is individual, but up to six weeks treatment is recommended to break the habit of smoking.

The nicotine dose should then be gradually reduced, by decreasing the total number of lozenges used per day. The treatment should be stopped, when the daily consumption is down to 1-2 lozenges. Quickmist: Step I: Weeks 1-6: Use 1 or 2 sprays when cigarettes normally would have been smoked or if cravings emerge. If after a single spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour.

Step II: Weeks 7-9: Start reducing the number of sprays per day. By the end of week 9 subjects should be using half the average number of sprays per day that was used in Step I. Step III: Weeks 10-12: Continue reducing the number of sprays per day so that subjects are not using more than 4 sprays per day during week 12. When subjects have reduced to 2-4 sprays per day, the spray use should be discontinued. Temporary Abstinence: During periods of temporary abstinence, the patient should use Gum or Inhaler when required to relieve nicotine cravings and withdrawal symptoms. Gradual cessation: For smokers who are unwilling or unable to quit abruptly. Use the gum/inhaler/lozenge whenever there is a strong urge to smoke in order to reduce the number of cigarettes smoked as far as possible and to refrain from smoking as long as possible.

The number of cartridges/gums/lozenges is variable and depends on the patient’s needs. Not more than 15 pieces of the gum, 6 cartridges, 15 lozenges should be used per day. If a reduction in number of cigarettes per day has not been achieved after 6 weeks, professional advice should be sought. Reduced tobacco consumption should lead to complete cessation of smoking. A quit attempt should be made as soon as the number of cigarettes has been reduced to a level whereby the smoker feels ready to quit completely, then start as outlined for “smoking cessation” as given above. Combination therapy: Step 1: The 15mg Patch would be applied daily on waking for 16 hours and removed just before bedtime for a total of 8 weeks. The 2mg gum or Inhaler would be used ad libitum when the smoker felt an urge to smoke or in situations where he/she feels that breakthrough cravings may occur, up to a maximum of 15 pieces of gum per day or 6 cartridges per day. Step 2: After the initial 8 weeks the lower dose Invisi 10mg Patch should be used for a total of 4 weeks. The 2mg gum or Inhaler would be used ad libitum when the smoker felt an urge to smoke or in situations where he/she feels that breakthrough cravings may occur, up to a maximum of 15 pieces of gum per day or 6 cartridges per day. Step 3: Use of the Invisi Patch should be stopped after the 12 week treatment program. The Nicorette 2 mg gum or Inhaler can continue to be used for a further 3 months during which time the habits associated with smoking will be lost. Contraindications: Use in non-smokers, Use in persons hypersensitive to nicotine or any ingredient in the formulation. Children under the age of 12 years (Lozenges) or under 18 years (Quickmist). Special Warnings and Precautions: The benefits of quitting smoking outweigh any risks associated with correctly administered nicotine replacement therapy (NRT). A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions: - Cardiovascular disease: Dependent smokers with a recent myocardial infarction, unstable or worsening angina including Prinzmetal’s angina, severe cardiac arrhythmias, recent cerebrovascular accident, and/or who suffer with uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions (such as counselling). If this fails, Nicorette may be considered but as data on safety in this patient group are limited, initiation should only be under close medical supervision. Allergic reactions: Susceptibility to angioedema and urticaria. Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects.

Gastrointestinal Disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions. Phaeochromocytoma and uncontrolled hyperthyroidism: Nicotine, both from NRT and smoking, causes the release of catecholamines from the adrenal medulla. Therefore, Nicorette should be used with caution in patients with uncontrolled hyperthyroidism or pheochromocytoma. - Diabetes Mellitus:. Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when smoking is stopped and NRT is initiated, as reductions in nicotine-induced catecholamine release can affect carbohydrate metabolism. Patients with diabetes mellitus may require lower doses of insulin as a result of smoking cessation. - Smokers who wear dentures may experience difficulties in chewing Nicorette Gum. The chewing gum may stick to, and may in rare cases damage dentures. Transferred dependence: Nicotine in any dose form is capable of inducing a dependence syndrome after chronic use and is highly toxic after acute use. However, dependence with Nicorette Gum is a rare side-effect and is both less harmful and easier to break than smoking dependence. Danger in children: Doses of nicotine tolerated by smokers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be handled or ingested by children. Nicorette Inhaler should be used with caution in smokers with chronic throat diseases and bronchospastic disease. The spray contains small amounts of ethanol (alcohol), less than 100 mg per dose (1 or 2 sprays). This medicinal product contains less than 1 mmol sodium (23 mg) per spray, i.e. essentially ‘sodium- free’. This medicine contains 12 mg propylene glycol in each spray which is equivalent to 150 mg/mL. Due to the presence of butylated hydroxytoluene, Nicorette QuickMist may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes. Care should be taken not to spray the eyes whilst administering the spray. Inhaler should be used with caution in smokers with chronic throat diseases and bronchospastic disease Invisi Patch should be removed prior to undergoing any Magnetic Resonance Imaging (MRI) procedures to prevent the risk of burns. Undesirable Effects: Regardless of the means used, a variety of symptoms are known to be associated with quitting habitual tobacco use. These include emotional or cognitive effects such as dysphoria or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating, and restlessness or impatience. There may also be physical effects such as decreased heart rate; increased appetite or weight gain, dizziness or presyncopal symptoms, cough, constipation, gingival bleeding or aphthous ulceration or nasopharyngitis. In addition, and of clinical significance, nicotine cravings may result in profound urges to smoke. Adverse Drug Reactions: Nicorette may cause dose dependent adverse reactions similar to those associated with nicotine administered by other means and are dose dependent. Most of the undesirable effects reported by the subjects occur during the early phase of treatment. Gum: Immune System Disorders: Hypersensitivity - Common Anaphylactic reaction - Not known. Psychiatric Disorders – Abnormal Dreams – Uncommon. Nervous System Disorders: Headache - Very Common, Burning sensation, Dysgeusia, Paraesthesia – Common. Eye Disorders: Blurred Vision, Lacrimation increased – Common. Cardiac Disorders: Palpitations, Tachycardia - Not known. Vascular Disorders: Flushing, Hypertension – Uncommon. Respiratory, Thoracic and Mediastinal Disorders: Cough, Throat irritation - Very common. Bronchospasm, Dysphonia, Dyspnoea, Nasal Congestion, Sneezing, Throat tightness – Uncommon. Gastrointestinal Disorders: Hiccups, Nausea - Very common. Abdominal pain: Diarrhoea, Dry mouth, Dyspepsia, Flatulence, Salivary hypersecretion, Stomatitis, Vomiting – Common. Eructation Glossitis, Oral mucosal blistering and exfoliation, Paraesthesia oral – Uncommon. Dysphagia, Hypoaesthesia oral, Retching – Rare. Dry throat, Gastrointestinal discomfort Lip pain - Not known. Skin and Subcutaneous Tissue: Hyperhidrosis, Pruritus, Rash, Urticaria Disorders – Uncommon. Erythema - Not known. Musculoskeletal and Connective Tissue Disorders: Pain in jaw – Uncommon. Muscle tightness - Not known. General Disorders and Administration Site Conditions: Fatigue – Common. Asthenia, Chest discomfort and pain, Malaise – Uncommon. Allergic reactions including angioedema - Rare. Inhaler: Immune system disorders: Common – Hypersensitivity. Not known - Anaphylactic reaction.

Psychiatric Disorders – Abnormal Dreams – Uncommon. Nervous system disorders Very common Headache Common Burning sensation Dysgeusia Paraesthesia Eye disorders Not known Blurred vision Lacrimation increased Cardiac disorders Uncommon Palpitations Tachycardia Vascular disorders Uncommon Flushing Hypertension Respiratory, thoracic and mediastinal disorders Very common Cough Throat irritation Bronchospasm Dysphonia Dyspnoea Nasal congestion Sneezing Throat tightness Gastrointestinal disorders Very common Hiccups Nausea Common Abdominal pain Diarrhoea Dry mouth Dyspepsia Flatulence Salivary hypersecretion Stomatitis Vomiting Uncommon Eructation Glossitis Oral mucosal blistering and exfoliation. Paraesthesia oral Rare Dysphagia Hypoaesthesia oral Retching Not known Dry throat Gastrointestinal discomfort Lip pain Skin and subcutaneous disorder Uncommon Hyperhidrosis Pruritus Rash Urticaria Not known Angioedema Erythema Muscoskeletal and connective tissue disorders Uncommon Pain in jaw Not known Muscle tightness . General disorders and administration site conditions Common Fatigue Uncommon Asthenia Chest discomfort and pain Malaise. Patch: Immune system disorder Uncommon Hypersensitivity Rare Anaphylactic reaction Nervous system disorder Common Headache Uncommon Paraesthesia Cardiac disorders Uncommon Palpitations Tachycardia Vascular disorders Uncommon Flushing Hypertension Respiratory, Thoracic and Mediastinal Disorders Uncommon Dyspnoea Gastrointestinal disorders: Common Nausea Vomiting Rare Gastrointestinal discomfort and/or pain Skin and subcutaneous tissue disorders Very common Pruritus Common Rash Urticaria Uncommon Hyperhidrosis Rare Angioedema Erythema Musculoskeletal and Connective Tissue Disorders Uncommon Myalgia Rare Pain in extremity General disorders and administration site conditions: Uncommon Application site reactions Asthenia Chest discomfort and pain Malaise Fatigue. Lozenge: Immune System Disorders: Common - hypersensitivity Uncommon -allergic reactions including angioedema and anaphylaxis. Psychiatric disorders: Uncommon - abnormal dreams. Nervous system disorders: Very common – headache. Common - dysgeusia, paraesthesia. Eye disorders: Not known – blurred vision, lacrimation increased. Cardiac Disorders: Uncommon - palpitations, tachycardia, atrial fibrillation. Vascular disorders: Uncommon – flushing, hypertension. Respiratory, thoracic and mediastinal disorders: Very common - cough, hiccups, throat irritation. Uncommon - Bronchospasm, dysphonia, dyspnoea, nasal congestion, oropharyngeal pain, sneezing, throat tightness. Gastrointestinal disorders: Very common - nausea, mouth/throat and tongue irritation Common - Abdominal pain, dry mouth, diarrhoea, dyspepsia, flatulence, salivary hypersecretion, stomatitis, vomiting, heartburn. Uncommon - Eructation, glossitis, oral mucosal blistering and exfoliation, paresthesia oral. Rare - Dysphagia, hypoaesthesia oral, retching. Not known - Dry throat, gastrointestinal discomfort, lip pain. Skin and Subcutaneous Tissue Disorders: Uncommon - Hyperhidrosis, pruritus, rash, urticaria. Not known – Erythema. General Disorders and Administration Site Conditions: Common – burning sensation, fatigue. Uncommon - Asthenia, chest discomfort and pain, malaise QuickMist: Immune system disorders Common Hypersensitivity Not known Allergic reactions including angioedema and anaphylaxis Psychiatric disorders Uncommon Abnormal dream Nervous system disorders Very common Headache Common Dysgeusia, paraesthesia Eye disorders Not known Blurred vision, lacrimation increased Cardiac disorders Uncommon Palpitations, tachycardia, Atrial fibrillation Vascular disorders Uncommon Flushing, hypertension Respiratory, thoracic and mediastinal disorders Very common Hiccups, throat irritation Uncommon Bronchospasm, Rhinorrea, dysphonia, dyspnoea, nasal congestion, oropharyngeal pain, sneezing, throat tightness Gastrointestinal disorders Very common Nausea Common Abdominal pain, dry mouth, diarrhoea, dyspepsia, flatulence, salivary hypersecretion, stomatitis, vomiting Uncommon Eructation, gingival bleeding, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral Rare Dysphagia, hypoaesthesia oral, retching Not known Dry throat, gastrointestinal discomfort, lip pain Skin and subcutaneous tissue disorders Uncommon Hyperhidrosis, pruritus, rash, urticaria Not known Erythema General disorders and administration site conditions Common Burning sensation, fatigue Uncommon Asthenia, chest discomfort and pain, malaise MA Holder: Johnson & Johnson (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland. MA Number: Gum –PA 330/37/8. Patch – PA 330/37/7. Inhaler - PA 330/37/10.

Quickmist - PA 330/37/13. Lozenge – PA 330/37/11. Date of Revision of the Text: PA 330/17/10 - April 2018, PA 330/37/8 – April 2018. PA 330/37/7 – May 2019. PA 330/37/13 – May 2019, PA 330/37/11 – November 2019. Legal Category: Products not subject to medical prescription.

Further information available upon request from Johnson & Johnson (Ireland) Ltd., Airton Road, Tallaght, Dublin 24, Ireland

IRE/NI/19-3994

SMOKING CESSATION

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SMOKING CESSATION Smoking is the leading cause of preventable death in Ireland. Each week, over 100 people die from diseases caused by tobacco use; this represents almost one in five of all deaths. In addition, many people live with conditions related to smoking, with people who smoke, on average, losing at least 10 quality years of life.

Pharmacy teams are ideally placed to advise people on how to stop smoking and to provide information on the supply of medication. Many will also be able to provide treatment for smokers who want to stop.

Ireland is committed to becoming tobacco free by 2025. A range of policy measures are being taken by the Department of Health and the Health Service Executive (HSE) to achieve this goal by strengthening the prevention of initiation and through further promoting smoking cessation.

NRT Treatments Nicotine replacement therapy (NRT) increases the chance of quitting smoking.

But, the level of smoker and previous attempts at quitting should always be considered to suggest the right product.

The choice of therapy depends on patient’s preference; previous treatment should also be taken into account. Combination therapy may benefit some people who have a high level of nicotine dependence or who have tried previously to quit and failed.

Gum - for patients who smoke less than 20 cigarettes per day should use one piece of the 2mg strength gum when they get the urge to smoke. The gum should be chewed until the taste becomes strong and then placed between the cheek and gum, one piece generally lasts about 30 minutes.

For people smoking more than 20 cigarettes per day or those who require more than 15 pieces of the 2mg gum should use the 4mg strength.

Inhalation Cartridges - these can be used when the urge to smoke occurs and are generally ideal for patients who feel that they would miss the hand to mouth action of smoking. No more thansix of the 15mg inhalators should be used per day. An inhalation cartridge last 40 minutes of intense use.

Lozenges A lower strength lozenge should be used in patients who smoke less than 20 cigarettes per day, and the higher strength lozenge should be used in those who smoke more than 20 cigarettes per day.One lozenge can be used every one to two hours when the urge occurs.

Patches

It is suitable if your customer:

Nicotine patches are a prolonged release formulation that can be applied for 24 or 16 hours. Patients who experience cravings on waking should use a 24 hour patch. For those who smoke more than 10 cigarettes per day a high strength patch can be advised to be applied per day for six to eight weeks, followed by a medium strength patch for two weeks and then a low strength patch for two weeks.

• Is a heavy smoker

In those who smoke less than 10 cigarettes per day can start on a medium strength patch for six to eight weeks and then a low strength patch for two to four weeks.

Mouth Spray Nicotine mouth spray is a nicotine replacement therapy (NRT) product that looks a bit like breath freshener.It helps a smoker to quit by replacing some of the nicotine they would normally get from a cigarette. They may still get cravings but the nicotine mouth spray takes the edge off.

Using the mouth spray can help to reduce nicotine withdrawal symptoms after quitting, such as cravings, difficulty concentrating, frustration, restlessness and anxiety.

Combination Therapy Combination therapy is suitable for those smokers who are still experiencing significant cravings and nicotine withdrawal symptoms while using one form of NRT, or for those who have not been able to quit altogether using one form of NRT alone.

The usual combination therapy is the nicotine patch combined with oral nicotine replacement products. It is suitable for those smokers who are still experiencing significant cravings and nicotine withdrawal symptoms while using one form of NRT, or for those who have not been able to quit altogether using one form of NRT alone.

• Has failed to quit using NRT previously • Experiences acute breakthrough cravings Including combination therapy in a quit a smoking strategy means you can offer a patient a nicotine patch throughout the day but also provide an oral NRT product for use during the day when patients may find craving for cigarettes difficult to manage.

For example, sometimes a craving can be hard to manage early in the morning, before a nicotine patch has time to work. This is a situation where oral NRT can be very helpful.

Some people may have concerns that they may get too much nicotine with combination therapy. Research shows that, for a smoker who is suited to this kind of therapy, there is no increased risk of side effects from combination therapy. The amount of nicotine in all NRT products is typically lower than the amount a person receives from regular smoking.

Who? Any adults who smoke What? N/A How long have they had the symptoms? The length of time they have smoked and the volume is essential to determining what NRT to recommend Action already taken? Sufferers may already be trying to cut down or stop smoking all together.

Medication: No more than 15 of the higher strength NRT lozenges should be used per day. Inhalators should be used in caution with patients with COPD or chronic throat disease.

TOPICAL ANALGESICS

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TOPICAL ANALGESICS When patients experience muscle and joint pain, pharmacists can recommend topical analgesics (rubs, creams and sprays) to help provide relief for their symptoms.

Helping customers choose the right topical analgesic for their individual needs is key if they are to gain optimum benefit.

Musculoskeletal pain is likely to affect a significant percentage of the population and encompasses a huge range of conditions. Low back pain, for example, is acknowledged to be the leading cause of disability worldwide and osteoarthritis is purported to affect 60% of 60-year-olds.”

While musculoskeletal conditions and the pain, stiffness and immobility that go with them can compromise the lives of sufferers in many obvious physical ways, mental health and wellbeing is also affected.

Patients will often use OTC topical analgesics for the treatment and management of musculoskeletal injuries and disorders. These products may have local analgesic, anaesthetic, antipruritic, and/or counterirritant effects.

Topical analgesics for musculoskeletal pain can be used alone or in conjunction with oral analgesics when appropriate and warranted.

External analgesic products may contain one or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsicum, and trolamine salicylate.

Assisting Selection Patient confusion regarding the wide array of topical products and formats available can also hinder usage. Consumers want help and reassurance when it comes to self-treating.

They do not understand the difference between various types of topical – hot, cold and non-steroidal anti-inflammatory drugs – or how to use them.

Following the introduction of the codeine regulations, pharmacists now encourage the use of acetaminophen as first in line choice of pain relief, followed by ibuprofen, before codeine-based analgesics.

In addition, patients must be made aware of how to use the medication properly and must be informed by pharmacists of the possible side effects that can occur when a product is used after the recommended period of three days.

Products may have local analgesic, anaesthetic, antipruritic, and/or counterirritant effects. Topical pain killers, or analgesics, are sprayed on or rubbed into the skin over painful muscles or joints. Although all are designed to relieve pain, different products are made up different ingredients.

Counterirritants are approved for the topical treatment of minor aches and pains of muscles and joints. They are often employed for the treatment of acute musculoskeletal injuries and as an adjunct therapy in the treatment of chronic musculoskeletal disorders.

Counterirritants differ from other external analgesics in that pain relief results more from nerve stimulation than depression.

Topical analgesics for musculoskeletal pain can be used alone or in conjunction with oral analgesics when appropriate and warranted. External analgesic products may contain or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsicum, and trolamine salicylate.

Salicylates: These same ingredients that give aspirin its pain-relieving quality are found in some creams. When absorbed into the skin, they may help with pain, particularly in joints close to the skin, such as the fingers, knees, and elbows.

Capsaicin: The main ingredient of hot chilli peppers, capsaicin is also one of the most effective ingredients for topical pain relief.

When first applied, capsaicin creams cause a warm tingling or burning sensation. This gets better over time. Users may need to apply these creams for a few days up to a couple of weeks before they will notice relief from pain.

Topical analgesic products are available in a variety of formulations, including gels, ointments, creams, lotions, and patches in

single-entity or combination formulations.

Topical heat therapy patches are also available in various sizes for treating joint and muscle pain and provide eight to 12 hours of continual, portable heat therapy.

OTC topical analgesics are intended to be used for mild to-moderate pain for no longer than seven days. The factors that a pharmacist may consider when recommending a topical analgesic include dosage form, cost, ease of use of product, as well as the patient’s medical history, including possible allergies.

Who? Anyone suffering from pain, musculoskeletal problems or fever.

What are the symptoms? Dependent on the condition suffered.

How long has the patient had the symptoms? Dependent on the condition suffered.

Action already taken?Pain relief.

Medication? Apply topical products only to intact skin. Areas treated with counterirritants should not be covered with tight bandages or occlusive dressings. Patients on anticoagulation therapy should be advised not to use topical products that contain salicylates, because concomitant use has been associated with prolonged prothrombin time.

U

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VAGINAL DRYNESS

77

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

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

Symptoms Some women only have symptoms of vaginal dryness at certain times, such as during sex, while others have them all the time.Problems associated with having a dry vagina include: • vaginal irritation, discomfort, itchiness or a burning sensation • discomfort during sex • a reduced sex drive • difficulty getting aroused and reaching orgasm • the surface of the vagina looks pale and thin • narrowing or shortening of the vagina • needing to pass urine more often than usual • repeated urinary tract infections (UTIs) Causes Causes of a dry vagina include: • the menopause - decreased levels of the hormone oestrogen during the menopause can cause persistent vaginal dryness (also known as vaginal atrophy or atrophic vaginitis) • breastfeeding or childbirth oestrogen levels can temporarily decrease after giving birth and make the vagina feel drier than usual • not being aroused before sex - if a woman doesn’t feel aroused before having sex, her vagina may not produce natural lubricant and sex may be uncomfortable • some types of contraception the combined contraceptive pill and contraceptive injection can occasionally cause vaginal dryness, although this is uncommon • cancer treatment - radiotherapy to the pelvic area, hormonal cancer treatments, and sometimes chemotherapy can cause vaginal dryness Vaginal dryness is also sometimes caused by an underlying condition such as diabetes or Sjögren’s syndrome, where the

immune attacks the glands in the body that produce fluid.

Self-help Sufferers of vaginal dryness can be advised that it’s worth trying self-help options first. It can help to: • try using a lubricant or vaginal moisturiser – these can be bought without a prescription • give yourself enough time to become aroused before having sex – read more about female arousal and get good sex tips Treatments The most common treatment for vaginal dryness due to low estrogen levels is topical estrogen therapy. These replace some of the hormone the body is no longer making.

That helps relieve vaginal symptoms, but it doesn’t put as much estrogen in the bloodstream as the hormone therapy in pills.

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

Vaginal moisturisers - creams that are applied inside the vagina to keep it moist.

They may be better than lubricants if the dryness isn’t just causing problems during sex, as they tend to have a longer-lasting effect. They usually need to be applied every few days.

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

Vaginal oestrogen is available as pills that are placed in the vagina (pessaries), vaginal creams and vaginal rings. Oestrogen treatment can be more effective than lubricants and moisturisers for menopausal women, and it generally causes few side effects.

However, it can take a few weeks to start working, so the patient may want to use a lubricant or moisturiser as well to begin with.

Treatment usually needs to be continued indefinitely, as the dryness tends to return if treatment stops.

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

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

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

Who? All women, but more prevalent during the menopause.

What are the symptoms? Vaginal irritation, discomfort, itchiness or a burning sensation, discomfort during sex, a reduced sex drive, difficulty getting aroused and reaching orgasm, the surface of the vagina looks pale and thin, narrowing or shortening of the vagina, needing to pass urine more often than usual, repeated urinary tract infections (UTIs).

How long has the patient had the symptoms? Many women will delay seeking medical advise because they may be embarrassed about the symptoms.

Action already taken? A number of self-care treatments may already have been used by the sufferer.

Medication?Topical estrogen therapies replace some of the hormone the body is no longer making.

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WINTER AILMENTS

79

WINTER AILMENTS It’s no coincidence that more people get ill over the winter period than any other time of year. Parties, late nights, bad weather, overindulgence in food and drink, not to mention concerns about the bank balance, all take their toll on people’s bodies.

Cold/Flu: Adults in general suffer from cold approximately two to four times annually while children can contract the virus three to eight times as their immune systems aren’t as developed. Distinctive symptoms means that people often diagnose and treat themselves through a combination of self-care and OTC products, without needing to go to the doctor.

If there is no improvement then an appointment with a doctor should be arranged.

The flu is the big brother to the common cold and will generally have similar symptoms, but they will be more intense. Other groups are at-risk of harmful or even life-threatening complications from the flu, particularly those with compromised or developing immune systems, including pregnant women, the elderly, and young children.

Sore Throat: Sore throats are nearly always the result of a viral infection which means antibiotics won’t be of any use. There is usually no need to seek medical help, unless an individual is getting them very regularly and are taking a long time to recover, which may imply a weakened immune system. One of the easiest home remedies is to gargle warm salty water and take paracetamol to help relieve the pain. Over the counter medications such as throat lozenges will not cure the illness, but they can help with painful symptoms.

Nasal Congestion: Nasal congestion is a blocked, stuffy or bunged-up feeling in the nose. Depending on the cause, it can last a short while (a few days) or can be persistent.

In adults and children it is usually an annoying symptom rather than a serious one. In babies, however, a blocked-up nose may make it difficult to breathe or feed.

Sinusitis: The sinuses are small, air-filled spaces inside the cheekbones and forehead which drain into the nose. Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by an infection. Most cases of sinusitis are acute (lasting 1-4 weeks) but some may go on to a more persistent (chronic) sinusitis.

The symptoms of sinusitis are mainly nasal congestion, and pain in the area of the affected sinus. This is most commonly in the forehead or cheeks on one or both sides of the nose. The pain may be worse on bending down. Other symptoms which may occur are dizziness and fever.

Sinusitis is usually treated with painkillers and decongestants.

Decongestants - These help to reduce nasal congestion by constricting the dilated blood vessels in the nasal mucosa. This reduces swelling and oedema of the nasal mucosa, making it easier to breathe. Decongestants are not suitable for pregnant and breast-feeding women and patients with hypertension.

Nasal sprays and oral tablets should not be used concurrently.

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

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

Inhalants, vapour rubs and saline products Inhalants work by helping to clear the nasal passages, while steam inhalation will help ease nasal congestion by loosening mucus. Saline preparations relieve congestion by helping to liquefy mucous secretions. Inhalants, rubs and saline products can be used daily until symptoms are cleared.

Sore throat treatments - Most sore throats are caused by a viral rather than a bacterial infection, so don’t need antibiotics. Medicated lozenges or anaesthetic sprays can help relieve the symptoms of sore throat. Gargling regularly with an antibacterial mouthwash or warm, salty water can reduce any swelling and inflammation, while sucking pastilles or lozenges will stimulate saliva secretion to lubricate the throat and help relieve irritation.

SAD: Seasonal Affective Disorder has only recently been recognised as a genuine condition, characterised by ongoing feelings of depression during the winter months, irritability, lethargy and a craving for carbohydrates. Levels of serotonin, which affect moods, appetite and sleep, are thought to be lowered by the shorter sunlight hours, and this stops the hypothalamus from working properly. Advise sufferers to make a point of getting as much natural sunlight as they can. If this isn’t possible, light therapy boxes can simulate exposure to sunlight and

help raise seretonin levels. Those who are feeling really low should be referred, Key Points: • The importance in ensuring people have adequate supply of prescription medication for the holiday season • Educate the pharmacy team on the recommended daily alcohol intake for both men and women • Lifestyle and hygiene tips and advice on reducing infection • The different types of OTC medications available for sore throat and cough and their indications • Those who must be referred to the pharmacist such as those with regular indigestion accompanied by additional symptoms

Who? Anyone – the young and elderly are more susceptible to winter illness.

What are the symptoms? Cold, congestion, sore throat and cough.

How long have they had the symptoms? Symptoms of a cold generally only last a few days, flu symptoms can make people feel very unwell often leaving them unable to leave the house or go to work.

Action already taken? People may have tried pain relief – but may not be aware of combination products, for example ones containing combinations of antihistamine, analgesic and stimulant.

Medication? Pseudoephedrine is contraindicated in patients with diabetes mellitus, cardiovascular disease, severe or uncontrolled hypertension, severe coronary artery disease, prostatic hypertrophy, hyperthyroidism, closed angle glaucoma, and pregnant women.

Dec 2019/ Jan 2020 Week 1

30 Monday

31 Tuesday

1 Wednesday

December 2019 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

2 Thursday

January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

3 Friday

January 2020

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January 2020 Week 2

6 Monday

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8 Wednesday

December 2019 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

9 Thursday

January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

10 Friday

January 2020

11 Saturday

12 Sunday

January 2020 Week 3

13 Monday

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15 Wednesday

December 2019 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

16 Thursday

January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

17 Friday

January 2020

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January 2020 Week 4

20 Monday

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December 2019 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

23 Thursday

January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

24 Friday

January 2020

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January 2020 Week 5

27 Monday

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January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

30 Thursday

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

31 Friday

Jan/ February 2020

1 Saturday

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February 2020 Week 6

3 Monday

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January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

6 Thursday

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

7 Friday

February 2020

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January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

13 Thursday

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

14 Friday

February 2020

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February 2020 Week 8

17 Monday

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19 Wednesday

January 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

20 Thursday

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

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February 2020

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February 2020 Week 9

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February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

27 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

28 Friday

Feb/ March 2020

29 Saturday

1 Sunday

March 2020 Week 10

2 Monday

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February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

5 Thursday

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

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9 Monday

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February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

12 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

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March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

19 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

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23 Monday

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February 2020 3 10 17 24 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23

March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

26 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

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March/ April 2020 Week 14

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March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

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April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

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April 2020 Week 15

6 Monday

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March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

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April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

10 Friday

April 2020

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April 2020 Week 16

13 Monday

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March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

16 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

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20 Monday

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March 2020 2 9 16 23 30 M 3 10 17 24 31 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

23 Thursday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

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April 2020

25 Saturday

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27 Monday

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April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

30 Thursday

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

1 Friday

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3 Sunday

May 2020 Week 19

4 Monday

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6 Wednesday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

7 Thursday

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

8 Friday

May 2020

9 Saturday

10 Sunday

May 2020 Week 20

11 Monday

12 Tuesday

13 Wednesday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

14 Thursday

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

15 Friday

May 2020

16 Saturday

17 Sunday

May 2020 Week 21

18 Monday

19 Tuesday

20 Wednesday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

21 Thursday

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

22 Friday

May 2020

23 Saturday

24 Sunday

May 2020 Week 22

25 Monday

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27 Wednesday

April 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

28 Thursday

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

29 Friday

May 2020

30 Saturday

31 Sunday

June 2020 Week 23

1 Monday

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3 Wednesday

May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

4 Thursday

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

July 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

5 Friday

June 2020

6 Saturday

7 Sunday

June 2020 Week 24

8 Monday

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May 2020 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

June 2020 M 1 8 15 22 29 T 2 9 16 23 30 W 3 10 17 24 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 S 7 14 21 28

11 Thursday

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July 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

August 2020 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

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July 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

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July 2020 6 13 20 27 M 7 14 21 28 T W 1 8 15 22 29 T 2 9 16 23 30 F 3 10 17 24 31 S 4 11 18 25 S 5 12 19 26

August 2020 3 10 17 24 31 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F S 1 8 15 22 29 S 2 9 16 23 30

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October 2020 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

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October 2020 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

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November 2020 M 2 9 16 23 30 3 10 17 24 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

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November 2020 M 2 9 16 23 30 3 10 17 24 T 4 11 18 25 W 5 12 19 26 T 6 13 20 27 F 7 14 21 28 S S 1 8 15 22 29

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September 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

October 2020 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

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October 2020 5 12 19 26 M 6 13 20 27 T 7 14 21 28 W T 1 8 15 22 29 F 2 9 16 23 30 S 3 10 17 24 31 S 4 11 18 25

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January 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

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December 2020 7 14 21 28 M T 1 8 15 22 29 W 2 9 16 23 30 T 3 10 17 24 31 F 4 11 18 25 S 5 12 19 26 S 6 13 20 27

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January 2021 M 4 11 18 25 T 5 12 19 26 W 6 13 20 27 T 7 14 21 28 F 1 8 15 22 29 S 2 9 16 23 30 S 3 10 17 24 31

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COMPANY LISTINGS

Alliance Pharmaceuticals Ltd

United Drug House,Magna Business Park,City West Road, Dublin 24, Ireland Type of company: Healthcare group including prescription medicines, devices, OTC brands, cosmetics and herbal remedies.

Website: www.alliancepharmaceuticals.com Tel: +353 1463 7482 Alliance Pharma PLC Registered Office, Chippenham Registered in England Company Number 04241478 Please use the contacts on our global website.

Help Line Number: Phone +44 [0]1249 466966 Local Contacts: Business Manager Con Walshe +353 0872164446 Shula Gold +353 0876108058 Company Information: From its origins in the UK 20 years ago, Alliance has grown to become a significant international healthcare group, marketing over 90 products in over 100 countries world-wide and employing over 200 people.

Recent years have seen a broadening in the scope of Alliance’s product portfolio. In addition to the established niche prescription products which formed the original focus of the company’s activities, our portfolio now includes medical devices and consumer products, covering a wide range of therapy areas.

In addition to its UK presence, the Group now has eight further offices across Europe, the Far East and the US. This geographic presence is enhanced by a broad network of international distributors, covering more than 100 countries worldwide.

An acquisitive company by nature, we have completed more than 35 acquisition or in-licensing deals over the last 20 years, fuelling both our portfolio development and international expansion.

Local Brands in Ireland include: NuSeals®, MacuShield®, KeloCote®, Vamousse®, Opus® Stoma Accessories, Anbesol®, Gelclair®, Hydromol®, Aloclair®, Naseptinl®, Ametopl®, and Lypsyl®.

Aptami l

Ascension Healthcare

Block 1, Deansgrange Business Park, Deansgrange, Co. Dublin, Ireland

Amadeus House, 27B Floral Street, London WC2E 9DP United Kingdom

Type of company: Infant Nutrition Website: Website for parents: www.aptaclub.ie Website for Health Care Professionals: www.aptamilhcp.ie Helpline for parents: 1800 22 12 34 Helpline for healthcare professionals: 1800 22 12 34 Products: A range of booklets/ Information leaflets covering pregnancy through to toddler years Standard Range: Aptamil – First Milk (from birth to 12 months) Aptamil Profutura – First milk (from birth to 12 months) Aptamil – Hungry milk (for hungrier infants) Aptamil 2 - Follow on Milk (from 6 months+)

Type of company: Biopharma Website: www.flexiseq.ie Tel:1800939149 Help Line Number: 1800939149 Products: All FLEXISEQ® products contain Sequessome™ vesicles – the tiny lipid spheres that pass through the skin when the gel is applied topically. FLEXISEQ® (OA) contains the maximum concentration of these vesicles.

FLEXISEQ® Active contains a lower concentration of the vesicles, making it lighter and therefore suitable for the daily needs of joint pain and early stage arthritis sufferers, seeking a sustainable drug-free solution.

Local Contacts: enquiries@flexiseq.com Marketing Manager, Allie Forde Allie.forde@ascension.co.uk

Bayer Ltd Consumer Health

Consumer Health Products: Aspirin, Alka-Seltzer, Bepanthen, Bepantiseptic, Berocca, Canesten, Canespro, Canestest, Canesbalance, Clarityn, Cystopurin, Diprobase, Kwells, Losec Control, Redoxon, Rennie, Scheriproct Suppositries & Ointment, UItraproct Ointment, Skineron Gel 15’s and Travacort Cream Local contacts: Commercial Lead: Hayley Claassen, Pharmacy Channel Manager: Patricia Lawrence Animal Health Products: Advantage, Advantix, Advocate, Bayticol, Baytril, Baytril Max, Baycox Multi, Byemite, Drontal Plus Flavours, Drontal Cat, Profender, Veraflox, Seresto Local contacts: Veterinary Business Managers: Carol Griffin RVN and Melanie O’Donoghue RVN

Brandshapers Ltd

Ballytramon Business Park, Ardcavan, Castlebridge, Co Wexford Y35 Y19A Type of company: Wholesale Distribution Website: www.brandshapers.ie Tel: +353 53 9179007 Fax Number: +353 53 9159494

Aptamil Profutura 2 - Follow on Milk (from 6 months+)

Help Line Number: +353 53 9179007

Aptamil 3 – Growing up Milk (1-2 years)

Order Line: +353 53 9179007

Aptamil Profutura 3 – Growing up milk (1 year +) Aptamil 4 - Growing up Milk (from 2 year+) Specials Range: Aptamil Comfort* (from birth) - for the dietary management of colic and constipation Aptamil Anti Reflux* (from birth)- for the dietary management of reflux and regurgitation.

Aptamil Lactose Free* (from birth) – for the dietary management of lactose intolerance Aptamil Pepti 1* (from birth) – for the dietary management of cows milk allergy from birth Aptamil Pepti 2* (from 6 months) – for the dietary management of cows milk allergy from 6 months Aptamil Pepti-Junior* For the dietary management of malabsorption and multiple food intolerances. GMS Listed

The Atrium, Blackthorn Road, Sandyford, Dublin 18 Type of company: Life Science Website: www.bayer.ie Tel: 01 2999313 Bayer is a Life Sciences company with a presence in Ireland for over 50 years. Through our innovative products in the areas of pharmaceuticals; consumer health; crop science and animal health, we contribute to finding solutions to some of the major challenges of our time.

Pharmaceuticals: The Pharmaceuticals Division focuses on prescription drugs for the therapeutic areas of cardiology, ophthalmology, oncology, women’s health, haematology and neurology. The division also comprises Radiology.

Local contact: Managing Director, Itziar Canamasas

Products: Brilliant, IsaDora, Nailner, Real Techniques, Sculpted, Seabond, Seven Seas, TanTastic, Just for Men, Vagisil, Bull Dog, Happy Skin, Old Spice, LifeLine Hangover Defence, Human + Kind, Profusion, Nakd, Trek, V Comb, Vosene, Wartie.

Local Contacts: Liam Dooley, Commercial Manager, liamdooley@brandshapers.ie customerservice@brandshapers.ie

Calco Ireland Limited

Unit 1-1d Cork Airport Industrial Est., Ballygarvan, Co. Cork. Ireland T12 A470 Type of company: Wholesale Distributors to Pharmacy Website: www.calcoireland.ie

COMPANY LISTINGS

Tel: 353 21 4962511 Fax: 353 21 4962994 Help Line Number: 353 21 4962511 Order Line:1850 240 000 – Trade only Products: Demak’Up, White to Brown, Oh My Glam, Manicare, Dove, Sure, Lynx, Alberto, Imperial Leather, Brylcreem, Fish, Mitchum, Pears, Carmex, Radox, Impulse, V05, Badedas, Simple, St Ives, Toni&Guy, Tresemme, Vaseline, Jakemans, Lockets, Fishman Friends, Gillette, Wilkinson Sword, Braun, Colgate, Vicks, Listerine, Tepe, Water Wipes, Eylure, Elegant touch, Dimples, Jolen, Durex, Duracell, Sun Care Local Contacts: F. Callaghan, S. Callaghan

Clonmel Healthcare Ltd

Unit 20A, Second Floor, Beckett Way, Park West Business Park, Nangor Road, Dublin 12 Website: www.clonmel-health.ie Tel: 353 1 620 4000 Help Line: 353 1 620 4000 Order Line: 1800 26 26 26 Services: Distributors of Medicines and OTC Products direct to Pharmacies, Hospitals and via Wholesalers Ethical: Aceomel; Amidex; Amitriptyline; Amlotan; Amoxicillin Clonmel, Anxicalm; Apo-Go; Aspirin; Atenomel; Atorvastatin Clonmel, Axid; Azithromycin Clonmel; Binosto; Bisoprolol; Calvepen; Candist; Candist Plus; Casomide; Caspofungin; Cimeldine; Ciprotan; Clavamel; Clavamel Forte; Cleo Infusion Sets; Clonactil; Clonocid; Clopidogrel TAD; Cozatan; Cozatan Comp; Crystapen; Denzapine; Donesyn; Doxatan; Doxatan XL; Duloxetine; Efestad; Etalopro; Flucloxacillin; Folic Acid; Fungasil; Fungasil Cream; Furosemide; Grastofil; Ibandronic Acid; Imatinib; Irbesartan Clonmel; Isomel SR; Keflex; Lercanidipine Clonmel; Letrozole; Levetiracetam Clonmel; Linezolide; Losamel; Maxilief; Melfen; Memantine; Memantine Drops, Meroponia; Miramel; Montelair; Mycophenolate mofetil Clonmel; Nebimel; Nepramel; Nytamel; Olanzapine; Olanzapine ODT; Olmesartan; Olmesartan HCT; Osteomel; Pantium; Paracetamol; Perdamel; Phenobarbital;

Pipercin; Pravamel; Prednisolone; Pregabalin; Prindace; Profloxin; Prosentio; Prozamel; Ramitace; Rasagaline Clonmel; Rabeprazole; Rinozal; Risontel; Rosuvastatin; Serimel; Seropia, Seropia XR; Sildenafil Clonmel; Simtan; Tamnic; Tamnexyl XL; Telmisartan; Telmisartan HCT; Temozolomide; Tipuric; Toltertan SR; True Result Diabetes Monitor, True result Twist; Valtan; Valtan Comp; Venex XL; Xymel; Xymel SR; Xymel Comp; Zestan; Zomel; Zopitan; Zolendronic Acid.

OTC: Accurate; Acriflex; Anti-Hist Allergy; Caldease; Caldesene; Caldesene Adult; CaldeSpray; Caldesun; CaldeBaby Teething Gel; CaldeKids Travel Pops; Cerumol; Cerumol Olive Oil; Clonfolic; Clonfolic Multicare; Covonia; Desenex; Easofen for children strawberry oral suspension; Easofen; Easofen Max; Eucryl; Flexitol Heel Balm, Flexitol heel Balm Platinum, Flexitol Heel Magic, Flexitol Moisturising Foot Cream, Flexitol Hand Balm; Galfer Caps, Galfer FA Caps, Galfer Syrup; Gastrolief; Gloup Swallowing Gel; Hedrin Treat and Go Lotion Spray, Hedrin Treat and Go Mousse, Hedrin Protect and Go Spray, Hedrin Dual Pack, Hedrin ONCE; Joint Aid; Just a Drop; Maxilief, Nicochew 2mg Gum, Nicochew 4mg Gum; Paralief 500mg Tablets; Paralief Effervescent Tablets; Viralief 2g cream; ViraSoothe Gel, ViraSoothe Spray.

Eurosales International Ltd

Local Contacts: Sandra Cheung 01 405 0900 sandra@eurosalesinternational.ie Telesales: Grainne Maughan 086 253 9556 grainne@eurosalesinternational.ie Clare, Galway, Leitrim, Longford, Mayo, Roscommon, Sligo, Westmeath Mark Keane 086 234 4408 mark.keane@ eurosalesinternational.ie Cavan, North Dublin, West Dublin, Dublin City Centre, Louth, Monaghan, Meath Helen Fallon 087 961 6125 helen@eurosalesinternational.ie Carlow, Kildare, Laois, North Tipperary, Offaly, West Dublin, South Dublin Suzanne Cooney 087 210 5126 suzanne@eurosalesinternational.ie Kilkenny, Waterford, Wexford, Wicklow, South Tipperary, East Cork Eoin O’ Hagan 087 777 0882 eoin@eurosalesinternational.ie Cork, Kerry, Limerick Allyson White +44 074 07709109 Allyson@eurosalesinternational.ie Antrim, Armagh, Derry, Donegal, Down, Fermanagh, Tyrone

Fitzgerald Power, Chartered Accountants & Business Advisors

187

Carlow – John McHugh, 059 9141100, jmchugh@fitzgeraldpower.ie

GreenLight Supplements

Unit 2, Block E, Nutgrove Office Park, Dublin 14, Ireland Type of company: Food Supplements Website: www. greenlightsupplements.com Tel: 0035316908888 Help Line Number: 0035316908888 Email: hello@greenlightmedicines.com Products: PHYTALITY Range Peony Rose Root Tincture 100ml; Super Six Mushroom Extract Capsules 300mg GreenLight Range - 10% CBD Oil 500mg 5ml (THC FREE); 10% CBD Oil 1000mg 10ml (THC FREE); Cold Pressed CBD Oil 500mg 15ml (full spectrum); Cold Pressed CBD Oil 1000mg 30ml (full spectrum) Local Contacts: United Drug Tel: +353 1 463 2300 Email: Reception.UDW@uniteddrug.com Consumer Email: Consumer@ united-drug.com Distribution Email: Distribution@ united-drug.com

Unit 3/4, Ballymount Business Park, Ballymount Drive, Ballymount Industrial Estate, Walkinstown, Dublin 12, D12 F884 Type of company: Beauty, Cosmetics & Healthcare Distributor Website: www.eurosalesinternational.ie Tel: 00 353 1 450 7771 Fax: 00 353 1 450 7795 Order Line: 00 353 405 0900 Products: 1000 Hour, 7th Heaven, Bathefex, Broadway, Cuticura, Dentyl Active, e.l.f. Cosmetics, Egypt Wonder, HASK, Inecto, Kennedy & Co Grooming, KISS, Lip Smacker, Madison Makeup, MAM, NOTE Cosmetics, P20, Palmers, Perspirex, Shea Moisture, Soft & Gentle, Tangle Teezer, Touch of Silver, UltraDEX, Vintage Cosmetics, wet n wild, White Glo, Yes To

Head office: Greyfriars, Waterford Offices also in Dublin and Carlow Type of company: Accountancy and business advisory firm Website: www.fitzgeraldpower.ie Tel: 051 870152 Fax: 051 871214 Products: Financial health check; Pharmacy valuations; Pharmacy sale brokerage; VAT investigations; Pharmacy specific online management accounts; Year-end statutory accounts production; Outsourced bookkeeping, payroll and company secretarial services; Business advisory; Tax planning and compliance.

Local Contacts: Dublin – John O’Sullivan, 01 6794772, josullivan@fitzgeraldpower.ie Waterford – Stuart Fitzgerald, 051 870152, sfitzgerald@fitzgeraldpower.ie

Wholesale Email: Wholesale@united-drug.com Uniphar: Uniphar Retail Service Help Line 01-4687501 Orders: www.uniphar.ie Star Medical: 01 4688282 contactus@starmedical.ie

KBC Bank Ireland plc

The Bank of You and Your Business Hub We are not a traditional bank.

If you’ve been into one of our Hubs, you’ll know why. It’s set up differently – no counters, just comfy seats and booths.

You can charge your phone while

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sipping a decent cup of free coffee.

You can check your emails with our free Wi-Fi.

to podophyllin or carbon dioxide laser c) Subacute sclerosing panencephalitis (SSPE)

Help Line Number: +44 (0) 1442 890 355

Focused on your business, we know it’s not always easy to get to the bank in normal working hours. So our Hubs open late and on Saturday mornings to make it easier for you.

Local Contacts: Head Office: +353 1 890 0406 Fax: +353 1 890 3016 Ireland (freephone): 1800 42 62 82 UK: 0845 303 8631 Email: info@korahealthcare.com

Products: Vitamins, Minerals, Specialist Food Supplements

Your Business Partner will be available at the end of a mobile or email and keen to help. They will even come out to your office or meet you anywhere that suits you.

Your KBC Business Support team contact details Tel: 1 800 804 414 Tel: +353 1 664 6180 Business Support Team: 1 800 804 414 +353 1 664 6180 Business Internet Banking Support: 1 800 804 414 +353 1 664 6180 24 hour debit & credit card lost/stolen: 1800 93 62 87

Kora Healthcare

Any other info: Restoring Health Kora Healthcare is a fully integrated healthcare company with core competencies across Research, Development & Innovation, Scientific & Medical Affairs, Regulatory Affairs & Pharmacovigilance, Quality, Supply Chain, Marketing & Sales, Finance and Customer Services.

All departments are led from our headquarters in Dublin, Ireland with UK sales and marketing operations located in York, UK.

Murrays Health & Beauty

Order Line: +44 (0) 1442 821 419

Local Contacts: Regional Key Account Manager: Sara Gibson Mobile: +35386 0406686 Email: sgibson@nbty.com Territory Account Manager: John Kennedy (South Ireland) +353 86 7778771 Email: jkennedy@nbty.com Territory Account Manager: Lorna Kerr (Dublin & Northern Ireland) +353 86 0422500 Email: lkerr@nbty.com

Nova Laboratories Ltd.

Products: Alflorex, Thea Pharmaceuticals, Kin Dental Products, Bioxtra, Skin Republic, Carmex, Total Shaving Solution, Dermatonics Once Heel Balm, Mycosan

Type of company: Wholesaler

Website: www.korahealthcare.com

Website: www. murrayshealthandbeauty.com

Martin House, Gloucester Crescent, Wigston, Leicester LE18 4YL

Tel: UK +44 (0)23 8046 0600 or IRE +353 (1) 69 50724

Type of company: Full Line Specials Manufacturer

Fax: +44 (0) 2380 460 601

Nova Laboratories Limited was established in 1994 and has since gained a global reputation for manufacturing complex and innovative experimental medicines and delivery devices, for a wide range of pharmaceutical and biotechnology companies. Nova is a UK leading independent supplier of both ‘Specials’ and clinical trial medicines to healthcare professionals. Our state-of-the-art facilities allow us to provide virtually any pharmaceutical dosage form, including non-sterile cytotoxic formulations. Our highly skilled team of formulation pharmacists continue to develop and produce new formulations, with >10,000 available.

Order Line: Ire: 1800 42 62 82 UK: 0845 303 8631 Products: Regelle – Long-lasting vaginal moisturiser, Pharmacy Relactagel – Treats and Prevents Bacterial Vaginosis, Pharmacy - BabyD – Vitamin D3 supplment for infants, Pharmacy - LiquiD – Vitamin D3 supplement for adults, Pharmacy - Magnaspartate – 243mg POWDER for oral solution, treatment for magnesium depletion, POM - Catephen - Indicated for the cutaneous treatment of external genital and perianal warts (condylomataacuminata) in immunocompetent patients from the age of 18 years, POM Fluomizin - 10mg Vaginal Tablets (dequalinium chloride) for the treatment of Bacterial Vaginosis, POM - Imunovir – 500mg tablets inosine acedoben dimepranol.

Imunovir tablets are indicated in the management of: a) Mucocutaneous infections due to herpes simplex virus (type 1 and/or type II) b) Genital warts as adjunctive therapy

Help Line Number: +44 (0) 2380460600 Order Line: +44 (0) 2380460600 Any other info: Murray’s Health and Beauty are the Pharmacy and Independent Retailer distributor for Dr Brown’s Anti-colic baby bottles and accessories, plus Dreamgenii Pregnancy Support and Feeding Pillow.

The Nature’s Bounty Co.

Tel: +44 (0) 116 223 0100

Type of company: Food Supplements Website: www.solgar.co.uk www.naturesbounty.co.uk Tel: +44 (0) 1442 890 355

Type of company: Pharma Distribution Website: www.pamex.com Tel: 094 9024000

Local Contacts: Diarmuid Gavin 086 2205864

Website: www.novalabs.co.uk

Aldbury, Tring, HP23 5PT, United Kingdom

Pamex

Moneen Business Park, Castlebar, Co. Mayo

Type of company: Healthcare

Help Line Number: Ire: 1800 42 62 82 UK: 0845 303 8631

Dr Mike Edge - Head of Non-Sterile Manufacturing Tel: +44 (0) 116 223 0100

We offer in-depth training to staff on benefits of supplements.

Samples for some products available on request from your Territory Account Manager. Free marketing materials and support available on request.

Swords Business Park, Swords, Co. Dublin, K67K8Y2, Ireland

Fax: +353 (0)1 890 3016

Local Contact: Karen Cole, Group Sales & Marketing Manager Specials: 07944 450987

Category and Product Training Manager: Bethan Carr Email: bcarr@nbty.com

Paul Murray PLC, Wide Lane, Southampton, Hampshire, SO18 2FA, UK

Tel: +353 (0)1 890 0406

formulations available which include: Solutions; Suspensions; Creams; Ointments; Lotions; Capsules; Sachets; Suppositories; Enemas; Ear Drops; Nasal Drops; Cytotoxic Products; Pre-Filled Syringes; Mini Bags; Injectables

Help Line: (Customer Care Pharmacist) freephone number 0800 975 4840 Order Line: freephone number 0800 975 4840 Email: sales@novalabs.co.uk Products: We have over 10,000

Gerard Murphy 087 7015701 Any other info: Pamex Limited is a successful marketing company, specialising in the promotion of prescription pharmaceutical medicines and personal healthcare products to Irish consumers.

The personnel at Pamex Limited have many years’ experience in dealing with pharmacists and members of the medical and pharmaceutical professions, along with the key influencers and decision makers in the market.

Parle & Hickey Ltd

Beechwood Close, Boghall Road, Bray, Co Wicklow Type Of Company: Distributor Website: www.parleandhickey.com Tel: Freephone 1800 286552 Fax: 01 2865533 Help Line Number: Freephone 1800 286552 Order Line: Freephone 1800 286552

COMPANY LISTINGS

Local Contacts: Tena + 3,000 Lines Freephone 1800 286552 Any Other Info: Group Training Available

Pinewood Healthcare

Unit 1, M50 Business Park, Ballymount, Dublin 12, Ireland Accounts, Manufacturing and Marketing: Ballymacarbry, Clonmel, Co Tipperary, Ireland Tel: 00353 1 456 9123 (Dublin) 00353 52 61 86000 (Clonmel) Fax: 00353 1 456 9125 (Dublin) 00353 52 61 36311 (Clonmel) Email: customerservicem50@pinewood.ie

Mr Jurgen Wegner: 087 741 1411 Hospital Business Manager Mr Jeffrey Walsh: 087 669 4043 Commercial Development Manager Mr Peadar Flynn: 087 259 4129 Pharmacy Business Manager Mr Michael O’Halloran: 087 117 9979 Pharmacy Business Manager

Products: Bonjela, Dettol, Disprin, Durex, E45, Full Marks, Fybogel, Gaviscon, KY, Lemsip, Mega Red, Nurofen, Optrex, Scholl, Senokot Strepsils, Veet

Mr Michael Comerford: 087 226 6899 Biosimilar Key Account Manager

Local Contacts: Adrian McCourt, Senior National Account Manager Pharmacy

Pharmacy Sales Representatives: Mr Pat Ahern 087 131 6663 - South

Rowex Ltd

Mr David Brannigan - East Mr Ciaran Clarke 087 770 0086 Dublin / North East Mr Danny Lynskey 087 251 3239 Mid-West

Newtown, Bantry, Co Cork.

Ms Aoife McDonnell 087 624 0817 Dublin / East

Type of company: Pharmaceutical Marketing of Ethical Medicines and OTC Products

Web: www.pinewood.ie

Mr Tom O’ Brien 087 255 9950 South

Pharmaceutical Manufacturer and Distributor of Ethical and OTC Products

Hospital Representative Ms Katie Tobin 087 991 4404

Products: Ethical: Alendronic Acid, Amlodipine, Anastrozole, Aripiprazole, Atorvastatin, Bisopine, Calcium Acetate, Caprin, Cetirizine, Chlorpromazine, Clopidogrel, Co-Danthramer, Citric Acid, Citalopram, Clarithromycin, CoTipol Suppositories, Donepezil, Dalmapam, Diflazole, Entacapone, Escitalopram, Flucillin, Grepid, Imatinib, Kopen, Lansoprazole, Levetiracetam, Levothyroxine, Losartan, Metformin, Minosil, Mirtazapine, Memantine, Mobiglan, Nexazole, Olanzapine, Omeprazole, Ondran, Paroser, Pantoprazole, Pinadone, Pinamox, Pregabalin, Pravat, Primacine, Prozit, Ramic, Risedronate, Rosuvastatin, Sereflo Inhaler, Sertraline, Simvastatin, Tipol Suppositories, Tramapine, Venlablue XL, Zileze, Olanzapine Orodispersible.

OTC Confined: Acidex, Aqueous Cream, Calamine Lotion, Cetirizine, Chlorhexidine, Codinex, Cortopin, Dispensing Bottles, Emulsifying Ointment, Fenopine Suspension, Flamozil woundspray, Glycerine Honey & Lemon, Glycerine Suppositories, Laxose, Micolette, Paratabs, Parapaed Junior, Parapaed Six Plus, Pholcodex, Silcocks Base, Surgical Spirits, Tantum Verde Lozenges, Tefin Suppositories, Tipol Granules, Tipol Suppositories, Viscolex.

Website: www.rb.com Tel: 01 4689200 Fax: 01 4689299 Help Line: Healthcare 01 6305429 Consumer (Household) 01 667318 Order Line: 01 4689200

PPC Ltd.

Type of company: Sales and Marketing of OTC Natural Health Products Website: www,.eskimo3.ie www.zerochol.ie www.zincuflex.ie Tel: +353 91-753222 E-mail: info@ppcgalway.ie Order Line: Order all product lines through Wholefoods Wholesale, Dublin 01-6262315 Products: Eskimo-3 Omega-3 Oils, Zerochol Plant Sterols for cholesterol management and ZinCuFlex Ginger and Curcumin Complex Local Contacts: Sales Director Michael Donnellan 087-7995035 Munster Sales Manager: Sarah Nelan 086-1890767

RB Ireland

Devices: Early Bird Pregnancy Test Kits & Ovulation Kit, Salbutamol CFC-Free Inhaler, Vera Temp Thermometer, Distribution: Direct to Pharmacies, Hospital Pharmacies and via Wholesalers

Unit 7, Riverwalk, Citywest Business Campus, Dublin 24

Management: Mr Fergal Murphy: Company Director

Type of company: Consumer Health

Forte, Cetrine Allergy, Diclac Relief Gel, Domerid Relief, Lactulose Fresenius, Lanafine AFR, Ketozol, Lorat, Pantup Relief, Ranitic 75mg.

Brupro, Brupro Max, Carbosan Gel, Decavit Plus, Magnesium Verla, Olive Oil BP Local Contact: Mr Tom Egan Munster 087-289 6738 Mr Martin Rowe Leinster 087-982 1463 Mr Rodney McCullough Leinster 087-260 6016 Mr Chris Thompson Leinster 087-820 9011 Mr Peter Hughes Connacht 087-687 1407 Mr Pearse Timothy Connacht 087-289 3350

Sanofi-Aventis Ireland Limited

Website: www.rowex.ie Tel: 00 353 27 50077 Fax: 00 353 27 50417 Freephone: 1800 304 400 Order Line: 1800 304 400

27 Mulvoy Business Park, Sean Mulvoy Road, Galway

189

Products: ETHICAL - Alfu, Alopur, Amoclav, Amoclav Suspension, Amlode, Anastrazole, Atecor, Atecor-CT, Atorvas, Beta-Prograne andf Half Beta –Prograne, Biluta, Bisop, Bonefurbit, Capecitabine Sandoz, Captor, Captor-HCT, Catasart, Catasart Plus, Ceftal, Cetrine, Cifox, Citrol, Clorom, Clorom XL, Clodel, Co-Vatan, Dancex SR, Deslor, Dexketoprofen Rowex, Diclac, Diltam, Domerid, Doxane XL, Dozept, Emazole, Enap,Eplerenone Rowex, Esciprex, Fental Matrix, Fintrid, Flucol, Fluzac, Gabin, Irbesan, Isomonit Retard, Lanzol, Lanafine, Larig, Latop, Latop-Comp, Letzo, Leuprex 3, Leonore, Levocetirizine, Lispril, Lispril-Hydrochlorothiazide, Lorat, Lotanos, Lotanos Comp, Mefac, Melcam, Metocor, Methadone Hydrochloride, Memantine LEK, Metophage, Minox, Mirap, Mirap Distab, Mometasone, Montelukast Paediatric, Montelukast, Mycolat, Nebol, Ondansetron,Pantup, Parox, Pendrex, Pendrex Plus, Pravitin, Quetex, Quetex XR, Ramilo, Ranitic, Razole, Rispone, Ridate, Rivastigmine Sandoz, Rolyprexa, Rolyprexa Distab, Romax Once weekly, Romep, Rosuva, Salbul, Serlan, Sidena, Sivatin, Sumatran, Tamox, Tamsu, Telmisartan Rowex, Ternaf, Tolusitol, Tradol, Valotix, Vatan, Vedixal, Vedixal XL, Vensir XL, Verap, Zoledronic Acid Sandoz, ZolnodAirFluSal, Aripiprazole Sandoz, Celecoxib Rowex, Macrolief, Metidate XL, Metformin Aurobindo, Pregabalin Sandoz, Telmisartan HCT, Vertigon OTC: Acic Cold Sore, Calciup D3

18 Riverwalk Citywest Business Campus Dublin 24 Tel: + 353 (0)1 403 5600

Solvotrin Therapeutics

Hoffmann Park, Little Island, Cork, Co. Cork Tel: +353 (021) 4510220 Fax: +353 (021) 4510229 Email: info@solvotrin.com Products: Active Iron and Active Iron & B Complex Plus for Men and Women

Teva Pharmaceuticals

Digital Office Centre Swords, Suite 101 – 103, Balheary Demense, Balheary Road, Swords, Co. Dublin, K67E5AO Type of company: Global pharmaceutical company Website: www.Teva.ie Tel: 00353 1 9127700 Help Line Number: 1800201700 Local Contacts: Paul Neill, Director Generic Products Ireland Clodagh Kevans, Director Specialty Medicines Ireland Any other info: We offer highquality generic, specialty and OTC

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medicines to patients across a wide range of therapeutic areas.

And, we are continually expanding our range of products and services to better meet the needs of Irish patients and healthcare professionals.

Teva employs around 800 people in Ireland and has three sites in the Republic of Ireland and one site in Northern Ireland.

Commercial Division Teva’s commercial activities span the sales and support services for Teva’s large portfolio of medicines, both generics and branded innovative medicines, along with over-the-counter consumer health products.

We supply medicines to treat a wide range of diseases and conditions – from multiple sclerosis, asthma, cancer and Chronic Obstructive Pulmonary Disease, to pain relief, cholesterol reducers and antibiotics. Dosage forms include extended and immediate release tablets and capsules, injectables, creams, ointments, solutions, suspensions and inhalers.

Whether they’re used in hospitals or by GPs, nurses, or independent pharmacists, our medicines are supported by comprehensive advice and information from our Medical teams.

In additional to the field-based sales teams covering both primary and secondary care in Ireland; Teva’s commercial teams and support functions are based in Swords, near Dublin.

United Drug

Magna Drive, Magna Business Park, Citywest Road, Dublin 24, D24 XKE5, Ireland.

Tel: +353 1 463 2300 Fax: +353 1 463 2333 E: Reception.UDW@united-drug. com Consumer E: Consumer@united-drug.com Distribution E: Distribution@united-drug.com Wholesale E: Wholesale@united-drug.com

United Drug Wholesale (Ballina)

Crossmolina Road, Ballina, Mayo, F26 W6R6, Ireland.

Tel: +353 096 72555 Fax: +353 096 72400

United Drug Wholesale (Limerick)

Johnsgate House, Old Clare Street, Limerick, V94 E3F1, Ireland.

Tel: +353 061 315411 Fax: +353 061 315012 Products: Revlon, Mitchum, Cutex, John Frieda, Bondi Sands, Mavala, Brand Arkitechs, Fruit of the Earth, TLC Wipes, Eveready, Optima: Snowfire, Valderma, Reckitts:Scholl, Kora (Relactagel, Regelle & BabyD), Westlabs, Lucy Wolfe, Wisdom, Rockface, Nitty Gritty, Sterimar, St Tropez, Sanctuary, NUK, EllaOne, Compeed, Cleanse Off Mitt, Skingredients, He-Shi, Seavite, Childsfarm, Swedish Nutra, Babyliss, Remington, Viviscal, Batiste, Anusol, First Response, Arm and Hammer, Pearl Drops, Nair, Femfresh, Replens, PreSeed, Tan Organic, Anne French, Waterpik, Plantur, Alpecin, Bionsen, Vagisan

Wholefoods Wholesale

Unit 3 Kylemore Ind Estate, Killeen Road, Dublin 10 Tel: 01 626 2315 Fax: 01 626 1233 Email: info@wholefoods.ie Website: www.wholefoods.ie Types of Business: Agents and distributors of Herbal Remedies, Nutritional Supplements, Homeopathic Remedies, Flower Essences, Natural and Organic Bodycare, Manuka Honey, Sports Nutrition, Natural Hair colouring, Aromatherapy Oils, Gluten free and Dietary foods.

Ethical: A.Vogel Herbal: Gingko Biloba, Hypericum Complex, Hypericum Perforatum, Serotone, St John’s Wort OTC Confined: A.Vogel Herbal: Prostasan.

Non-OTC Confined: A.Vogel Herbal Tinctures: Echinacea for the family, Atrosan, Atrogel, Milk Thistle tincture and tablets, Passiflora, Dormeasan, Cough Spray, Ivy Thyme, Venaforce, Sinuforce, Eye Drops, Bronchosan, Digestisan and Menoforce as well as a full range of other herbal remedies.

A.Vogel Veterinary: Jan De Vries Animal Essences – Animal Separation, Animal Emergency, Animal Highly Strung Essence, Animal Over-Dominant, Animal Timid. Amina Strath – Feed supplement (combination of yeast & herbs).

Avalon: Organic skin and body care. Shampoos, conditioner, moisturiser, shower gels.

Active Edge: Cherry Juice Aromatherapy Oils: Atlantic Aromatics, Absolute Aromas, Ord River Tea Tree, Puressential.

Bach Original Flower Remedies Bioglan: OAD Super Fish Oil, Red Krill, Stat-Guard, Glucosamine SR1500mg, Promensil.

Biomedical: Cardio-K, Cardio-P, and Cardio-T. Bio-Strath: Herbal Tonic Celtic Wind: CBD Oil Eskimo Oil: Brainsharp Omega, Eskimo Kids and Eskimo Omega 3.

Gluten Free and Dietary Foods: Nanny Goats Milk, Barkat, Eat Natural, Nak’d Bars, Linwood’s, Panda, RJ’s Licorice, Vita Coco.

Healthy Snacking: Meridian Nut Butters, Protein Bars (Quest, Fulfil, Deliciously Ella, Satisfi).

Herbal Teas: Pukka, Tea Pigs, Heath & Heather and Yogi.

Higher Nature: The Saltpipe, Balance for Nerves, Red Sterol, Kids Range, Teens range, Full Vitamin range.

Hubner: Gastrointestinal Gel, Iron Vital Tonic, Silicea Caps – For Hair, Skin & Nails, Silicea Cold Sore Lip Gel and Silicea Beauty Gel. Jason: Personal and body care range.

Jan De Vries Essences: Night, Craving, Concentration, Emergency, Relaxation, Confidence, Mood.

Kinvara: Hyaluronic Youth Boost, Active Rosehip Day Cream, 24Hr Rosehip Face Serum, Omega Rich Hand & Nail Cream, Elemental Exfoliating Powder, Eye Wow! Eye Serum.

Life Boost: Children’s Honey & Lemon Syrup.

Lifestyle Products: Ecover, Lilly’s, The Saltpipe and Natracare (personal hygiene).

LithoLexal® Marine Plant ExtractBone Health, Joint Health, Bone Care MAG365: Powder based range of magnesium supplements.

Mother and Babycare: Earth Friendly Baby, Natural Babycare Nappies, Wipes and Bodycare.

Natural and Organic Bodycare: Jason, Avalon, Faith in Nature, Natura Siberica.

Natural Henna: Surya Brasil Naturtint Hair Colours:

Permanent, Reflex (Semi Permanent).

Natura Siberica: Hair and body care range.

Nelsons Homeopathic Remedies: Nelsons Teetha Granules and Gel, Nelsons Arnicare, Nelsons Clikpak, topical and formulated remedies.

Nourkrin Hair Supplements: Nourkrin Maintain, Nourkrin Man, Nourkrin Woman, Nourkrin Post Pregnancy, Nourkrin Active, Nourkrin Radiance, Scalp Lotion, Nourkrin Shampoo & Conditioner Nourella: Active skin support supplement, Active skin rejuvenation cream.

Nupo: Balanced meal replacement.

Optibac Probiotics: A natural range of probiotic supplements suitable for the whole family.

Optima: Aloe Vera Gel, Gentle Action Colon Cleanse, Aloe Dent Toothpastes and Mouthwash, Joint Complex, Aloe Pura Juices, Allergenics Skincare, Lecithin, Optima Lifestyle Vitamins, Australian Tea Tree, Montmorency Cherry Juice, Cranberry Concentrate Juice.

Parasol: Suncare range.

Pernaton Green Lipped Mussel Extract: Pernaton Gel, Pernaton Relaxing Bath Therapy, Pernaton Capsules.

Pre-Conceive: Pre-Conceive preconception supplement Probiotic: Optibac.

Phizz: Rehydration + Vitamins and Minerals.

Rescue Remedy: Rescue Remedy, Rescue Night, Rescue Plus.

Sambucol Black Elderberry Extract: Sambucol Original, Sambucol Kids, Sambucol Effervescent.

Sea-Band, Hay-Band: Sea-Band Child, Sea-Band Adult, Sea-Band Mama.

Silicolgel: Oral gel containing colloidal silicic acid for the treatment of gastrointestinal disorders and IBS. Spatone Iron Supplement: Spatone Original and Spatone Vit C. Sports Nutrition: Optimum Nutrition, Maximuscle, Plantforce.

Te etha: Teething granules and gel.

Zerochol: Zerochol plant sterol supplement.

Zincuflex: Curcumin and Ginger food supplement.

Distribution: Direct to Pharmacies and via wholesalers (specific lines).

Number of Sales Force: 8 Territory: Ireland – For details of your local representative please contact the Wholefoods office on 01 6262315.

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The Game Changer The world’s first fish oil with DPA “The Missing Omega.

Contact Valeo Healthcare today to learn more.

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Proud to be one of Ireland’s leading vitamin suppliers Contact Valeo Healthcare today to learn more

BOOST YOUR

INNER BEAUTY Beauty vitamins to nourish your beauty from the inside.

For more details on opening an account or to place an order, please call +44 (0) 1442 821 419 or email enquiries4@nbty.com Food supplements should not be used instead of a varied balanced diet and a healthy lifestyle.

Nature’s Bounty® is a registered trademark.