THE INDEPENDENT VOICE OF HOSPITAL PHARMACY IN THIS ISSUE: Conference: Seminar hears drug reimbursement is wrongly dictated Report: Can there be harmony in pharmacy? Feature: The future role of pharmacists in Urinary Incontinence News: Mater Hospital phamaists develop new e-learning guide Also available as Distaclor LA 375mg tabs, 125mg/5ml and 250mg/5ml Distaclor suspension.
Abbreviated Prescribing Information. Presentations: Distaclor LA Forte 500mg prolonged release tablets, equivalent to 500mg cefaclor. Distaclor LA Tablets 375mg, prolonged release tablets equivalent to 375mg cefaclor. Distaclor granules for suspension containing 125mg cefaclor/5ml, Distaclor granules for suspension containing 250mg cefaclor/5ml. Uses: Distaclor LA presentations and Distaclor suspensions are indicated for the treatment of upper and lower respiratory tract, skin and skin structure, and urinary tract infections when due to susceptible micro-organisms. Additionally, Distaclor is indicated for otitis media and as part of the management of sinusitis. Dosage and Administration: (For full information see Summaries of Product Characteristics [SPCs]). SPCs should be referred to before prescribing. Cefaclor is administered orally. Adults and the elderly: Distaclor LA Tablets 375mg: The usual dosage is 375mg twice daily. Pneumonia -750mg twice daily. Distaclor LA Forte 500mg Tablets: One tablet twice daily in bronchitis. LA tablets should be taken with meals. Distaclor Suspensions: The usual dosage is 250mg every eight hours. For more severe infections or those caused by less susceptible organisms, doses may be doubled. Distaclor may be administered in the presence of impaired renal function. Under such conditions dosage is usually unchanged (see ‘Precautions’). Children: Distaclor Suspensions are available (Distaclor LA tablets are not recommended). The usual daily dosage for children is 20mg/kg/day in divided doses every 8 hours. In more serious infections, otitis media, sinusitis and infections caused by less susceptible organisms, 40mg/kg/day in divided doses is recommended, up to a daily maximum of 1g. For otitis media and pharyngitis, 12-hourly dosing may be used. In the treatment of beta-haemolytic streptococcal infections, therapy should be continued for at least 10 days. Contra-indication: Hypersensitivity to cephalosporins. Warnings: Cephalosporins should be given cautiously to patients with known penicillin sensitivity. Cross hypersensitivity (including anaphylaxis) has been reported occasionally in patients receiving beta-lactam antibiotics. If an allergic reaction occurs, the drug should be discontinued. The diagnosis of pseudomembranous colitis should be considered if diarrhoea occurs. Usage in pregnancy and lactation: Although animal studies have shown no evidence of teratogenicity, caution should be exercised. Small amounts of cefaclor have been detected in breast milk following administration of single 500mg doses. Caution should be exercised when administering to a nursing woman. Precautions: In patients with markedly impaired renal function, administer Distaclor with caution (see SPCs). Broad-spectrum antibiotics should be prescribed with caution in individuals with a history of gastrointestinal disease, particularly colitis. Prolonged use of cefaclor may result in the overgrowth of non-susceptible organisms. Positive direct Coombs’ and false-positive glycosuria tests have been reported. Drug interactions: There have been rare reports of increased prothrombin time, with or without clinical bleeding, in patients receiving cefaclor and warfarin concomitantly. Renal excretion is inhibited by probenicid. Diminished absorption of Distaclor LA with concomitant magnesium hydroxide or aluminium hydroxide. Side-effects: Gastro-intestinal: Diarrhoea, nausea, vomiting, dyspepsia, colitis. Hypersensitivity: Allergic reactions (urticaria, morbilliform eruptions, pruritis) serum sickness-like reactions, fever, arthralgia/arthritis, rare reports of erythema multiforme major (Stevens-Johnson syndrome), toxic epidermal necrolysis, and anaphylaxis (see SPCs). Haematological: Eosinophilia, positive Coombs’ tests and, rarely, thrombocytopenia. Transient lymphocytosis, leucopenia and, rarely, haemolyticanaemia, aplastic anaemia, agranulocytosis, and reversible neutropenia of possible clinical significance. Hepatic: Transient hepatitis and cholestatic jaundice have been reported rarely, sight elevations in AST, ALT, or alkaline phosphatase values. Renal: Reversible interstitial nephritis has occurred rarely, slight elevations in blood urea or serum creatinine, or abnormal urinalysis. Central nervous system: Reversible hyperactivity, agitation, nervousness, insomnia, confusion, hypertonia, dizziness, hallucinations, somnolence, headache and agitation. Miscellaneous: Genital pruritis, vaginal moniliasis, and vaginitis. Legal Category: S.1.A Product Authorisation Numbers and Holders: Distaclor LA Forte 500mg tablets: PA 1226/1/5 Distaclor LA Tablets 375mg: PA 1226/1/4. Distaclor Suspension 125mg/5ml: PA 1226/1/2.Distaclor Suspension 250mg/5ml: PA 1226/1/3. Flynn Pharma Ltd, Alton House, 4 Herbert Street, Dublin, Ireland. Distributed in Ireland by Clonmel Healthcare Ltd, Waterford Road, Clonmel, Co. Tipperary. Date of preparation or Last Review: August 2009 SPCs are available on request from: Flynn Pharma Ltd, The Maltings, Bridge Street, Hitchin, Herts SG5 2DE. Tel 0044 1462 458974 email: firstname.lastname@example.org or from Clonmel Healthcare Ltd at www.clonmel-health.ie *Community acquired bacterial infections. Distaclor (cefaclor) and Distaclor LA (cefaclor LA) are trademarks of Flynn Pharma Ltd. 2009/ADV/CEF/158
Profile: Hospital Pharmacists Association of Ireland President Joan Peppard talks exclusively to HPN Feature: Advances in the management of Gylceral Titrate - is it being administered correctly? News: New code of practice from IPHA Profile: Exclusive chat with Yvonne Sheehan, President of the National Association of Hospital Pharmay Technicians
ch to op a io o r id p p lge sia
PowerfulonPain reducedriskof opioid-induced constipation
Targin® tablets contain an opioid analgesic TARGIN® 5mg/2.5mg, 10mg/5mg, 20mg/10mg and 40mg/20mg prolonged release tablets Prescribing Information Republic of Ireland Presentation: Film-coated, oblong, prolonged release tablets containing oxycodone hydrochloride and naloxone hydrochloride, marked OXN on one side and the oxycodone strength on the other. Colours: Blue - 5mg (oxycodone hydrochloride)/2.5mg (naloxone hydrochloride), white - 10mg (oxycodone hydrochloride)/5mg (naloxone hydrochloride), pink - 20mg (oxycodone hydrochloride)/10mg (naloxone hydrochloride) and yellow - 40mg (oxycodone hydrochloride)/20mg (naloxone hydrochloride). Indications: Severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut. Dosage and administration: Adults over 18 years: Usual starting dose for opioid naïve patients is Targin® 10mg/5mg, taken orally at 12-hourly intervals. Patients requiring a higher dose are recommended Targin 20mg/10mg tablets. Targin 5mg/2.5mg is intended for dose titration when initiating opioid therapy and individual dose adjustment. The dosage is dependent on the severity of the pain and the patient’s previous history of analgesic requirements. Patients already receiving opioids may be started on higher doses of Targin depending on their previous opioid experience. The maximum daily dose of Targin is 80mg oxycodone hydrochloride and 40mg naloxone hydrochloride. Targin tablets are not intended for the treatment of breakthrough pain. For the treatment of breakthrough pain, a single dose of “rescue medication” should amount to one sixth of the equivalent daily dose of oxycodone hydrochloride. Please refer to the SmPC for further details on dose titration. Targin tablets must be swallowed whole and not broken, chewed or crushed which leads to a rapid release and absorption of a potentially fatal dose of oxycodone. Children under 18 years: Not recommended. Contraindications: Hypersensitivity to the active substances or excipients, any situation where opioids are contraindicated, severe respiratory depression with hypoxia and/or hypercapnoea; severe chronic obstructive pulmonary disease, cor pulmonale, severe bronchial asthma, non-opioid induced paralytic ileus, moderate to severe hepatic impairment. Precautions and warnings: Respiratory depression, elderly or infirm, opioid-induced paralytic ileus, severely impaired pulmonary function, hypothyroidism, adrenocortical insufficiency, toxic psychosis, cholelithiasis, prostate hypertrophy, alcoholism, delirium tremens, history of alcohol and drug abuse, pancreatitis, hypotension, hypertension, galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption, pre-existing cardiovascular diseases, head injury (due to risk of raised intracranial pressure), epileptic disorder or predisposition to convulsions, patients taking MAO inhibitors, renal impairment, mild hepatic
a uni qu e
impairment, pre-operative use or within the first 12 – 24 hours post–operatively. Not suitable for the treatment of withdrawal symptoms. Not recommended in cancer associated with peritoneal carcinomatosis or sub-occlusive syndrome in advanced stages of digestive and pelvic cancers. Interactions: Substances having a CNSdepressant effect (e.g. alcohol, other opioids, sedatives, hypnotics, anti-depressants, sleeping aids, phenothiazines, neuroleptics, anti-histamines and anti-emetics) may enhance the CNS-depressant effect of Targin (e.g. respiratory depression). Interaction with coumarin anticoagulants may increase or decrease INR. Pregnancy and lactation: Not recommended. Side-effects: Common adverse drug reactions are decreased/loss of appetite, restlessness, headache, vertigo, decrease in blood pressure, abdominal pain, diarrhoea, dry mouth, constipation, flatulence, vomiting, nausea, dyspepsia, increased hepatic enzymes, hiccups, altered mood, decreased activity, psychomotor hyperactivity, agitation, dysuria, pruritus, skin reactions, hyperhidrosis, dizziness, drug withdrawal syndrome, feeling hot and cold, chills, asthenic conditions. Some side-effects which are uncommon but could be serious are hypersensitivity, confusion, depression, halluc-inations, disturbance in attention, somnolence, speech disorder, convulsions, syncope, visual disturbances, palpitations, angina pectoris, tachycardia, increase in blood pressure, dyspnoea, respiratory depression, biliary colic, erectile dysfunction, urinary retention, peripheral oedema, abdominal distension and chest pain. Please refer to the SPC for further details of other uncommon side-effects and oxycodone class-effects. Tolerance and dependence may occur. It may be advisable to taper the dose when stopping treatment to prevent withdrawal symptoms. Legal category: CD (Sch2) POM. Package quantities: Blisters of 56 tablets. Marketing Authorisation numbers: PA913/025/001-4. Marketing Authorisation holder: Napp Pharmaceuticals Limited, Cambridge Science Park, Milton Road, Cambridge CB4 0GW, UK. Member of the Napp Pharmaceutical Group. Further information is available from: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Tel: +353 (0)1 2063800. Date of preparation: April 2011. (UK/UNA-11115). References: 1. Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Curr Med Res Opin 2008;24(12):3503-3512. 11144TRG
Adverse events should be reported to Mundipharma Pharmaceuticals Limited on 1800 991830
® The Napp device (logo) is a Registered Trade Mark. ® Targin is a Registered Trade Mark. © 2010-2011 Napp Pharmaceuticals Limited.
➞ ➞ ➞
Targin® provides pain relief that is as effective as oxycodone alone1 Targin® reduces the risk of opioid-induced constipation when compared to oxycodone alone1 Targin® is GMS re-imbursable Targin® is indicated for severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut.
New Memorandum for Pharmaceutical Practice in Ireland P4
Cavan Pharmacist Diana Hogan-Murphy races around the planet P6
Irish Pharmacy Awards - supporting Pharmacists and the Jack and Jill Foundation
NAHPT President Yvonne Sheehan gives her view on the way forward for Pharmacy Technicians P8 Can there be harmony in pharmacy? HPN Special Report P14 Launching the inaugural Irish Pharmacy Awards 2012 P17 HPN talks exclusively with President of the Hospital Pharmacists Association of Ireland, Joan Peppard P38
Regulars Advances in the future of Breast Cancer P28 Urinary Incontinence and the pharmacists role in its management P34
Kelly Jo Eastwood
This issue of Hospital Pharmacy News contains all the details for the upcoming inaugural Irish Pharmacy Awards 2012. Already, nominations have been coming into the HPN offices from right across the country with heart-warming stories of pharmacists and their teams who have been delivering a service well beyond expectations. Indeed it is the recognition of fellow health professionals that has elevated the quantity of nominations above what we would normally expect from pharmacy practitioners’ thoughout the country. The partnership with The Jack & Jill Children’s Foundation will be the subject of a national weekly paper competition in the coming weeks. This is aimed at giving the public a unique opportunity to nominate and praise their local pharmacist. Hardship comes in many forms, whether it is manifest in the immediate needs of pharmacists and their families in real distress through death, illness or business failure or the plight of hundreds of pharmacies throughout the country fighting to maintain their business and operating on wafer thin margins. Promoting excellence through the HPN Awards and publicising the winners will drive awareness of the best we have to offer in professional terms. The competition aimed at the general public will give them the opportunity to share their stories of individual pharmacists and pharmacy practices that have gone the extra mile for them.
Product Profiles P41 HPN goes Out and About P45 Appointments P50
There are many ways to support the pharmacy industry in Ireland. What we at HPN are doing is just one part of the wide spectrum of support that is required.
Hospital Pharmacy News is Circulated to all independent, multiple and hospital pharmacist, pre reg pharmacists, students pharmacy student’s offi cial bodies, government officials and departments, Pharmacy Managers, Manufactures, Wholesalers. Buyers of pharmacy groups and healthcare outlets. Circulation is free to all pharmacists Subscription rate for Hospital Pharmacy News 60euro plus vat per year
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All rights reserved by Hospital Pharmacy News. All material published in Hospital Pharmacy News is copyright and no part of this magazine may be reproduced, stored in a retrieval system of transmitted in any form without written permission. Pharmacy Communication Ireland have taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.
The support of the Jack and Jill Children’s Foundation demonstrates that the wider voluntary and community sector recognises the value of the profession and we should embrace that support.
PUBLISHER IPN Communications Ireland Ltd Carmichael House, Lower Baggot Street, Dublin 2 00353 (01) 6024715
The Pharmacy profession cannot operate alone. We need the support of the wider public but most especially the continued support of those who use their hospital pharmacy services and ensure that thousands of those working in our profession throughout the country have a safe and secure future.
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HPN • Issue 3
Patients losing out in reimbursement battle Ireland is currently producing innovative, cost-effective and much-needed medicines which, in many cases, are not reaching Irish patients as the Government is not reimbursing them. This was one of the key messages from a recent breakfast seminar held in Dublin.
David Gallagher, Matt Moran, Anne Nolan
IPHA President David Gallagher went on to state that significant contributions to Government savings have been made, with €300m delivered under the current agreement since 2006 and an additional €240m delivered in 2010/11 in recognition of the exceptional budgetary constraints. He said: "This was on the express understanding this would ensure that access would be secured for new medicines. This has not happened."
"The Government’s ambitious new Action Plan for Jobs, identifies the need for closer interaction between the health system and industry, while at the same time identifying the lack of engagement between the two, particularly, to quote from it directly, ‘in relation to research, clinical trials, and the development and related manufacturing of innovative healthcare products and services’. The current situation regarding the reimbursement of new medicines is a demonstration of this lack of engagement, which is clearly being dictated by the health system authorities and not the industry”, Mr. Gallagher said.
Over €200,000 for pharmacy software The School of Pharmacy at Trinity has taken delivery of a €280,000 sponsorship package from McLernon’s Computers. The sponsorship has provided for 12 networked high-specification PCs including MPS dispensary management system software, an EPOS till system and 5 year's of both hardware and software support. The MPS Pharmacy Dispensing Systems will be used for Pharmaceutics extemporaneous compounding and dispensing and Practice of Pharmacy practical classes for Pharmacy students in all years of the degree programme. This vital addition to the School’s teaching
Issue 3 • HPN
resources will also facilitate delivery of practical training at postgraduate level. This sponsorship comes at a crucial time for the School as the Pharmaceutical Society of Ireland launches the National Forum for Pharmacy Education and Accreditation to oversee the development and ongoing delivery of the new integrated programme of pharmacy education. Head of the School Professor Marek Radomski commented that: "The School of Pharmacy and Pharmaceutical Sciences Trinity College Dublin is delighted with McLernons donation of
Head of the School of Pharmacy, Professor Marek Radomski is pictured with McLernons Sales Director Robin Hanna and students
the MPS systems. The systems are indispensable for state-ofthe-art teaching of pharmacy students in our school and enrich their educational experience. The School is truly grateful to McLernons for this generous donation and the continuing support of our programme."
Clinical practice in pharmacy steps forward Prof. Conor O' Keane (Clinical Director, MMUH), Prof. Hannah McGee (Dean of the Faculty of Medicine and Health Sciences, RCSI), Mr Ciaran Meegan (Head Of Pharmacy Services, MMUH) and Prof. Paul Gallagher (Head Of The School Of Pharmacy, RCSI).
The signing of a new 'Memorandum of Understanding' between the Royal College of Surgeons School of Pharmacy and the Mater Misericordiae University Hospital Pharmacy Department. heralds the start of a significant enhancement in the teaching and clinical practice of pharmacy in Ireland. "This exciting collaboration will mark a new chapter in the education of pharmacy students and the conduct of pharmacy
practice research in the State," Mr Ciaran Meegan, Head of Pharmacy Services, MMUH said. "As well as this, all opportunities to conduct collaborative research between the RCSI and MMUH, with the view to improving patient journeys and outcomes will also be exploited." Professor Hannah McGee, Dean of the Faculty of Medicine and Health Sciences, and Professor Paul Gallagher, Head of the School of Pharmacy, RCSI joined Mr Brian Conlan, CEO and Mr
Meegan at the signing ceremony and unveiling of a commemorative plaque in the Mater Misericordiae University Hospital. Professor Hannah McGee, Dean of the Faculty of Medicine and Health Sciences, RCSI in her remarks at the signing stated: "RCSI's undergraduate pharmacy students will, as a consequence of this MOU receive structured-placement based pharmacy education at MMUH which will facilitate greater contextualisation of their
clinical knowledge". Professor Paul Gallagher welcomed Mr. Meegan and his colleagues as honorary appointees of RCSI Faculty and commented "that their extensive clinical experience and expertise will greatly enhance the preparedness of our students for professional practice". RCSI graduates approximately 55 students and 200 Pharmacy interns annually.
AMNCH Pharmacists think pink The hospital pharmacy department at Adelaide & Meath Hospital recently held a 'Think Pink Day' fundraiser. All staff dressed in pink and held a pink cake sale during the morning. In total they managed to raised a blushing €400 for the Marie Keating Foundation.
Need to identify savings Róisín Shortall TD, Minister of State for Primary Care at the Department of Health has welcomed the initiatives contained in the Budget to enhance Primary Care and added that the Department will also be taking initiatives in relation to over prescribing to identify at GP and hospital level where there are issues in respect of particular drugs where cost efficiencies can be achieved. In setting out the level of savings
being achieved on drug prices she outlined a number of measures have been taken in recent years to reduce the price of drugs, but expenditure by the HSE on the GMS and community drug schemes still amounted to approximately €2 billion in 2010. These measures are essential if we are to continue to afford reimbursement of new medicines coming on stream, many of which will have a significant budget impact.
In 2011, members of the Irish Pharmaceutical Healthcare Association (IPHA) agreed a series of measures to deliver savings on drug expenditure of €200 million in 2011. As a result, the prices of over 1,000 medicines have been reduced since January last year. Further reductions in the prices of generic medicines were implemented in August 2011 following discussions with the Association of Pharmaceutical Manufacturers in Ireland (APMI).
Further discussions will take place with IPHA aimed at reductions in the price of patent protected drugs in 2012. Further reductions are expected following the introduction of reference pricing and generic substitution in 2012. The Government approved the General Scheme of the Health (Pricing and Supply of Medicines) Bill at the end of September and the legislation will be published in 2012.
HPN • Issue 3
Diana goes for Gobi Endurance runner Diana Hogan-Murphy
Diana celebrates victory with fellow Irish runner Shirley Potter in the 2009 Gobi Dessert Marathon
Hospital pharmacist Diana Hogan-Murphy takes extracurricular activities to a new level. The Antimicrobial Pharmacist is currently taking part in 'The Gobi March' - a 250-kilometre, 6-stage course throughout the Gobi Desert. Diana, current leader in the women’s division is no stranger to these endurance tests, having taken part in numerous ultramarathons over the years, fuelling her passion for competitive sports.
The Cavan General Hospital Pharmacist has recently divulged that she has a secret weapon, and it is a 6-foot tall, burly South African by the name of David Pearse. “We met when we were doing the Marathon de Sables,” said Hogan-Murphy, “and since then we have competed in numerous marathons and ultras.” The camaraderie of these pair is clear, but so is the competitive edge that they share. Pearse has been seen
at various check-points and on the course giving Hogan-Murphy some extremely motivating pep talks, and it seems to be working, because she has taken every stage as the top female competitor, and placing in the top 20 overall. And despite their height differences, they are of a similar athletic ability, thus meaning that they can pace each other well, but also use each other’s strengths and weakness to the other’s advantage.
The Gobi Desert is the largest desert region in Asia and the fifth largest inthe world. It is, also, the windiest non-polar desert in the world. The course starts nearby in the host town Kashgar in a very small place called Gazi Village and will pass by Shipton's Arch / Heaven's Gate, a natural arch which is taller than the Empire State Building.
Revised code of practice The Irish Pharmaceutical Healthcare Association has announced the introduction of a revised Code of Marketing Practice for the Pharmaceutical Industry. In Ireland the research based pharmaceutical industry sets high standards in the implementation of legal requirements and to
Issue 3 • HPN
provide clarity and consistency for members, IPHA has gone further than the existing legislation to precisely define the conditions for ensuring the appropriate use of sampling. Additionally, as part of the European Federation of Pharmaceutical Industries and Associations (EFPIA), IPHA is required to amend its Code
to take into account revised EFPIA guidance: these revised provisions, now adopted by IPHA, relate to samples and increased transparency in interactions with patient associations. Furthermore, IPHA has introduced additional requirements to ensure that members meet all their pharmacovigilance obligations.
The revisions will affect three aspects of the IPHA Code: 1. Samples (Clause 13)2. Relationships with Patient Organisations (Annex III) and 3. Pharmacovigilance (Clause 12). Copies of the revised Code are available from IPHA or can be downloaded at www.ipha.ie
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8 Yvonne Sheehan
HPN talks Technicians with Yvonne Sheehan
It is an important time for hospital pharmacy technicians. Over the last number of years their role has developed and many changes have been encountered. New obstacles have emerged, including a reduction in staff numbers. However the horizon looks bright. As President of the National Association of Hospital Pharmacy Technicians, Yvonne Sheehan highlights that the National Hospital Pharmacy Technicians Association of Ireland continues to work towards equal opportunities and extended roles for pharmacy technicians.
Issue 3 â€˘ HPN
I think opportunities will become available to develop the hospital technician’s role similar to the extended roles held by technicians in the UK.
GETTING THE TECHNICIAN BALL ROLLING Yvonne, Hospital Pharmacy Technician at Adelaide and Meath Hospital incorporating the National Children’s Hospital, Tallaght, obtained her Diploma for pharmacy technicians in 1988 after completing studies in Trinity College Dublin and training in various community pharmacies. In 1989 she applied for a temporary post in the Meath hospital pharmacy department. She continues: "At that time, there was only one other pharmacy technician, with no others working in any hospital in Ireland. I therefore, jumped at the opportunity to work in a hospital pharmacy department and have been working with this organisation ever since. During my twenty three years, the Meath hospital amalgamated
with the Adelaide hospital and the National Children’s hospital to become what is now known as Tallaght Hospital." Yvonne counts her work within the Hospital Pharmacy Technicians Association as one of the 'highlights of my career so far.' Having been involved with the Association since its formation in 1997, Yvonne recounts the early days when the technician grade was emerging as its own entity. "At that time hospitals were beginning to employ more pharmacy technicians but this grade was still very new and there were no opportunities available for technicians to network and share information," she says. "It was an exciting time, working in hospital. However, the hospital pharmacy
technicians that I became acquainted with wanted to learn more; to enable them to develop their competencies and in their new hospital roles. Our Association was formed to address these needs." During her time with the association, Yvonne has witnessed many developments. "Through the Association I was involved in the negotiations for the senior grade post and pay scale. At that time there were a large number of technicians carrying out senior roles and responsibilities without any recognition. It was great to be part of making that change. Another highlight has been the opportunity to represent Irish Hospital Pharmacy Technicians at European level. I first represented Ireland in 2001 in Oslo, Norway when
the European Association of Pharmacy Technicians (EAPT) was in its infancy. I then hosted the EAPT at Tallaght Hospital in 2002. Last year the EAPT became a formal association with Ireland, now holding two seats on the committee." The role of hospital pharmacy technician has developed over the years but the pace at which it has developed varies from hospital to hospital and correlates to the development of the clinical pharmacist’s role within that organisation. As the pharmacist’s role has become more involved at patient level, the pharmacy technician’s roles and responsibilities have increased within the dispensary. "A number of technicians have become involved in purchasing and stock management roles.
HPN • Issue 3
10 Yvonne Sheehan Some departments have embraced the role of accredited checking technicians while other departments have trained technicians to work in medicines management roles at ward level," says Yvonne. "Technicians are now holding supervisory roles and the majority of technicians are involved at times, in the training of students and other staff members. I am fortunate that my department has always been progressive and that all members of staff are supported where possible to develop their roles." A FOUR-FOLD OBJECTIVE PLAN The main objectives of the Hospital Pharmacy Technicians Association are four-fold. • Enhance Pharmacy Technicians' professionalism through communication, continuing education, and networking; • Increase credibility through involvement with other professional organisations in the field; • Build and maintain alliances with other related members of the health services sector. The future of the profession, from humble beginnings, looks bright. Yvonne continues: "As president of the Association I am leading a campaign for the pharmacy technician’s role to move into a statutory regulated position, with the same responsibilities and accountabilities to the public as other regulated healthcare professionals. Our
members believe that regulation is necessary to assure clear standards and competence in the interest of the public and improved patient outcomes." Through statutory regulation they also aim to: • Standardise and protect the use of the title ‘pharmacy technician’ • Develop our role in a structured way • Develop education programmes to support learning needs • Increase pride in the profession • Increase accountability for their work • Commit to self improvement. However the road ahead is not without its obstacles, with budget and staff constraints only part of the bigger picture. "We are now working in an environment that has become more pressured with less staffing numbers and greater demands to provide a more efficient safer service. "We have also experienced cut back in student posts. This has greatly reduced the opportunities for students to gain hospital experience. Staffing has always been one the largest costs to any organisation but I believe that pharmacy managers will now begin to focus on how to utilise their staffing resource by matching staff’s qualifications and abilities to the tasks required to be done. "As a result, I think opportunities will become available to develop the hospital technician’s role
similar to the extended roles held by technicians in the UK. At present, the lack of a national pharmacy strategy and resistance to change are obstacles that we have to overcome. OVERCOMING THE OBSTACLES "We believe that statutory registration and regulation will inspire confidence in our role and allow us to move forward in providing a safer patient service," adds Yvonne. "The members of our committee are always actively involved in working towards the goals of our association with our stakeholders and we keep our members up to date through the publication of our quarterly newsletter. "This year we are looking forward to working with the Pharmaceutical Society of Ireland this year on their evaluation process of the current education and training programmes for pharmacy technicians. Following on from this, some of our course providers are running and/ or developing level 7 clinical pharmacy practice courses for technicians and have requested our input in these programmes. In May, we will be representing Irish hospital pharmacy technicians at the EAPT conference in Budapest. Next year we hope to be in a position to host this event in Dublin again. The F.I.P. congress (International Pharmaceutical Federation) will also be held in Dublin 2013 so this will be a great opportunity for technicians to attend an international conference." Meanwhile, Yvonne will not be allowing the grass to grow; she emphasises the importance of continuity in progressing with their objectives. "I am coming to the end of my first year in term as president of the NAHPT but have one year more ahead of me in this post. It is my hope to continue my work at both a national and European level, thus creating an awareness of the Irish hospital pharmacy technician’s role within pharmacy services on a wider scale."
Issue 3 • HPN
The Hospital Pharmacy Technicians Association Annual Conference and AGM are growing bigger each year and this year is no exception. In 2012 they have moved to a larger venue at the Crowne Plaza Hotel, Santry, Dublin 9. They are inviting pharmacy technicians from all sectors plus students to attend this event which will be held on Saturday 28th April 2012. Further details are available on the website: www. pharmtech.ie Furthermore, in September they plan to run another mid year workshop. The focus this year will be on purchasing and stock management. Hospital Pharmacy News will keep readers abreast of all forthcoming details.
e ements We provide a full procurement service of all Exempt Medicinal Products and operate in line with IMB regulations and HSE reimbursement. We provide a Specialty Ordering Service where we will source, price, supply and deliver unusual and once-off products.
For further details contact: United Drug Telesales Dublin - 01 463 2300 /2307 /2311 Limerick - 061 315 411 Ballina - 096 72 555 Leonora Kinsella Customer Services Development Manager Telephone 01 463 2308 Mobile 087 251 3021 Fax 01-463 2525 www.united-drug.ie
Reimbursement wrongly dictated says Seminar The biopharmaceutical industry is facing unprecedented challenges with potential job losses and a negative impact on multinational investment in Ireland, was the message from a breakfast briefing held at the Davenport Hotel.
IPHA President David Gallagher, PCE Director General, Matt Moran, IPHA Chief Executive, Anne Nolan, IDA Chief Executive Barry O’Leary
However, given the unprecedented challenges the sector is facing, ensuring the sustainability of the sector in Ireland requires innovative and strategic health, economic and education policies and a collaborative joint approach.
Entitled 'The Biopharmaceutical Industry – protecting investment through sustainable policy', the briefing jointly hosted by IPHA and PharmaChemical Ireland (PCI) called on the Government to work alongside the industry to develop sustainable policies to secure and bolster the future success of Ireland’s greatest economic success story. An urgent call to action was made for new policy to secure future biopharmaceutical investment. The event was chaired by PCI Director Matt Moran, Minister of State at the Department of Jobs, Enterprise and Innovation. John Perry, T.D., joined IBEC Director General Danny McCoy, IDA chief executive Barry O’Leary and Issue 3 • HPN
Irish Pharmaceutical Healthcare Association (IPHA) President David Gallagher. OFF PATENT DRUGS TO COST €100BN Opening the briefing, PharmaChemical Ireland Director Matt Moran said: “Government policy needs to urgently recognise the very serious challenges facing the industry. A number of blockbuster drugs are coming off patent, with some commentators estimating the resulting fall in worldwide revenues to be as much as €100bn. Many of these blockbuster drugs are manufactured in Ireland. The key challenge is to continue to develop the sector as a global centre of
excellence for innovation and development. "Our healthcare policy must support access to innovative medicines and medical technologies that are developed in Ireland. It is vital that the Government continues to take a long-term view of the overall cost of healthcare. Medical treatment funding is regarded as an investment in the nation’s health and economic prosperity. Such an approach will send a positive signal to pharmaceutical companies." Employing over 25,000 people, the industry accounts for over 50% of Irish exports (€51 billion) and half of all corporation tax.
IBEC Director General Danny McCoy said: “While it is encouraging to see the key role of the pharma industry highlighted in the Action Plan for Jobs, the Government needs to ensure existing employment is also protected. Ireland needs to continue to work to improve its offering to foreign investors. We need to enhance the R&D tax credit schemes to encourage companies to base R&D functions here and continue to work to ensure our cost base is globally competitive.” IRELAND MUST PROTECT ITS REPUTATION IDA chief executive Barry O’Leary highlighted how important it was that Ireland’s protects its reputation as a choice investment for multinational pharma companies and called for deeper and broader engagement of all stakeholders to work together to ensure this remains the case. “Ireland benefits hugely from pharmaceutical investment and we are now home to 9 out of the top 10 global pharmaceutical companies. Ireland is a key global location
13 Anne Nolan
agreement since 2006 and an additional €240m delivered in 2010/11 in recognition of the exceptional budgetary constraints, on the express understanding this would ensure that access would be secured for new medicines. This has not happened.
for pharmaceutical activities, including manufacturing, services, research and development; as a result of this a number of excellent pharmaceutical investments have been made in Ireland in recent months. Abbott recently invested €85 million in the expansion of its pharmaceutical manufacturing facility in Sligo with the creation of 175 new jobs; Allergan invested $350 million in the expansion of its development and manufacturing facility in Westport with the creation of 200 new jobs; Amgen, the largest biotechnology company in the world, acquired Pfizer’s manufacturing facility in Dun Laoghaire which marked a major win for Ireland due to Amgen’s leading position in the biotechnology industry. Meanwhile, Pfizer, the world’s largest biopharmaceutical company invested $200 million at its Grange
Castle biotechnology site.’’ IPHA President David Gallagher acknowledged the need to make savings in the health budget but argued that this burden must be fairly shared and that any savings must be balanced against ensuring Irish patients can access innovative medicines. “At the heart of the biopharmaceutical industry is the scientific research and discovery of innovative life-saving and life-changing medicines. We are producing innovative, cost effective, much needed new medicines which unfortunately in many cases are not reaching Irish patients as the government is not reimbursing them. We have made a significant contribution to government savings with €300m delivered under the current
The Government’s ambitious new Action Plan for Jobs, identifies the need for closer interaction between the health system and industry, while at the same time identifying the lack of engagement between the two, particularly, to quote from it directly, ‘in relation to research, clinical trials, and the development and related manufacturing of innovative healthcare products and services’. The current situation regarding the reimbursement of new medicines is a demonstration of this lack of engagement, which is clearly being dictated by the health system authorities and not the industry”, Mr. Gallagher said. Mr. Gallagher added that these concessions have resulted in a significant decline in the market in Ireland which was now under severe pressure and was not in a position to endure further price cuts without a very negative impact on employment and future investment. He also urged the government to consider the valuable contribution medicines
make to Irish health. “Existing cuts have already put pressure on jobs across the industry: any further reductions will raise serious question marks over the attractiveness of Ireland as a future investment location and the potential damage to employment - both existing and future would be significant. As Governments seek to maximise public health outcomes on constrained budgets, cost-effective, innovative medicines represent real value for money and efficiency. The debate has to switch from cost to value and recognition of the intrinsic role medicines are contributing to Irish health”, he added. The pharmaceutical and biopharma industry is playing a vital role in this export-led growth recovery. The sector accounts for over 50% of the total Irish exports and employs over 50,000 directly and indirectly, 50% of these hold a third-level qualification. Eight of the top 10 pharmaceuticals companies in the world have major operations in Ireland, benefiting from a favourable tax regime, a highly-skilled workforce, strong compliance record and easy access to European markets. The extraordinary flexibility of the Irish economy and labour market has been recognised by international investors. Investment into Ireland grew strongly in 2010.
Health research in pharmacy practice On April 23rd-24th 2012, The School of Pharmacy, University College Cork has the privilege of hosting the internationally acclaimed prestigious Health Research in Pharmacy Practice Conference. This global event rotates annually to a different country. In the past, the event which attracts over 150 international delegates has enjoyed plenary speakers of worldwide acclaim in the field of Pharmacy Practice. The HSRPP conference is organised on a non-profit basis with a particular emphasis on disseminating the
work of early career pharmacy practice researchers to their peers and experts alike. The theme of this year’s conference is of particular relevance to industry, regulators, educators and both research and practicing pharmacists. The conference title is “Optimisation of Pharmacotherapy - From pharmacovigilance to improved communication”. Professor John Higgins, Head of College of Medicine and Health will be opening the conference followed by International Keynote
speakers including; Professor Michael Wolf (North-western University, Chicago, USA) who will speak on “Lost in Translation: Bridging Communication Gaps to Promote Medication Adherence” as well as Dr June Raine (Director of Vigilance and Risk Management of Medicines), Medicines and Healthcare Products Regulatory Agency (MHRA), Professor Steve Field (Chairman, NHS Future Forum, Chairman, National Health Inclusion Board) & General Practitioner, Bellevue Medical Centre Birmingham and Professor Tony Avery Professor of
Primary Healthcare, University of Nottingham, UK. The format of the conference is a mixture of oral presentations / workshops and poster viewing followed on the Monday evening 23rd with a sumptuous Conference dinner in the highly acclaimed Vertigo restaurant. Further information and registration details can be found at www.hsrpp.org.uk or by contacting Dr Laura Sahm (L.Sahm@ucc.ie) or Dr Stephen Byrne (Stephen. Byrne@ucc.ie )
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Looking towards harmony in pharmacy Written by Richard O’Sullivan B.Pharm M. Pharm MPSI and Laura J Sahm BSc Pharm PhD MPSI MRSPH www.harmonisingpharmacy.org
COMPETENCE: Competence requires the possession of the required skill, knowledge, attitude and behaviour to proficiently carry out a specific role . All health professionals must illustrate competence in order to practice as a qualified professional. Before health professionals acquire these competencies, it is essential that the accurate core competencies are identified to maximise patient safety and quality assurance.
Richard O’Sullivan B.Pharm M. Pharm MPSI
Dr Laura J Sahm BSc Pharm PhD MPSI MRSPH
The emergence of clinical pharmacy has enabled pharmacists to move from a product-oriented role towards a more “patient-facing” one. Clinical pharmacy is made up of a set of functions which advocate and promote the safe, effective and economic use of medicines tailored for the individual patient needs. In the last 25 years there has been an emphasis on the importance of developing the process so that specific patient outcomes can be achieved, and thus it embodies the philosophy of pharmaceutical care described by Hepler and Strand.
active participation on Drugs and Therapeutics Committees, in addition to the more traditional dispensing and supplying of medicines to wards. With such a range of skills it is clear that additional and specialized training is needed for specific areas, but the question then becomes; what level of knowledge and competence should a newly registered pharmacist possess? In other words; what are the core clinical competencies of pharmacists? The establishment, of a globally harmonised competency framework, would promote pharmacy excellence, as harmonisation of competence will allow the development of global pharmacy education quality assurance systems . Currently, we are looking for the answers to the questions above, in a research team comprising Schools of Pharmacy in the USA, UK and Ireland and this article gives some information on the background and aims of this work.
In the hospital setting the role of the clinical pharmacist is varied and can encompass a range of activities including, but not limited to; medicines information, clinical chart review, adverse drug reaction (ADR) reporting and monitoring, compounding of cytotoxic chemotherapy regimens, procurement of stock,
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The minimal competency requirements of a pharmacy licensing body can be given in ‘competency frameworks’. Generally these frameworks detail core competencies that pharmacy students must acquire throughout their educational development to be recognised as fit to practice. Different regions have different competency frameworks. These regional frameworks overlap in desired core competencies; however, there are also major differences. At present, a pharmacy student studying in Ireland, UK or USA must display different set of core competencies even though these regions are culturally similar and their principles of pharmacy practice are similar. Competency frameworks are a modern development in education that allow transparency in training, development and accreditation. These frameworks are essential tools that are increasingly being used to focus education by identifying the core skills that must be taught to health professionals. As stated above, at present the pharmacy competency frameworks are regional, however, a future goal is the conception of a single global competency framework, similar to the one established by The World Federation for Medical Education (WFME) for physicians[4, 5]. IRELANDS COMPETENCY FRAMEWORK: The Pharmaceutical Society of
Ireland (PSI) is the regulatory body of pharmacists within the Republic of Ireland. The PSI commissioned a report of Pharmacy Education and Accreditation Review (PEARs) which was published in 2010. This review recommended that new standards for registration are developed to optimise patient care and identified the competency framework as a key requirement for the development of pharmacy education in Ireland. The PSI has since published a draft competency framework which details the competencies a registered pharmacist in Ireland should ideally possess. This draft competency framework is currently undergoing review, before publication of the finalised PSI competency framework can be achieved. Currently, the Royal College of Surgeons in Ireland (RCSI) is the organisation responsible for the delivery of the National Pharmacy Internship Programme (NPIP) Masters in pharmacy (MPharm) degree. This NPIP is designed to ensure that all interns are provided with training, before registering as pharmacy professional. The RCSI core competency framework is made up of six domains, with each competency domain thought as an individual module of the NPIP curriculum. The following are the six domains which are covered; 1. Patient care and safe dispensing: 2. Inter-professional Prescribing Science: 3a. Community Practice: 3b. Hospital Pharmacy Practice: 4. Professional Practice: 5. Patient Safety and Risk Management: 6. Health and Medicine Information:
15 USA: AACP-CAPE COMPETENCIES: Founded in 1900, the American Association of Colleges of Pharmacy (AACP) is the national organization representing pharmacy education in the United States. The mission of the Association is to both represent and be an advocate for all segments of the academic community in the profession of pharmacy. . The AACP first published the Center for the Advancement of Pharmaceutical Education (CAPE) guidelines in 1994. They were revised and updated in 2004. The CAPE guidelines provide direction for pharmacy education professionals regarding the skills necessary to achieve competency in entry level practice. The Accreditation Council for Pharmacy Education (ACPE), the US accrediting body for pharmacy education, announced new accreditation standards in 2007 that rely heavily on the CAPE guidelines’ competency statements. Since these standards were implemented, an AACP taskforce has worked to define a minimum set of clinical competencies for use by all USA schools and colleges of pharmacy. UNITED KINGDOM CORE COMPETENCIES: The General Pharmaceutical Council (GPhC) regulates pharmacy in Great Britain. Their mission is to “regulate pharmacists, pharmacy technicians and pharmacy premises in Great Britain to protect, promote and maintain the health, safety and wellbeing of patients and the public”. They are responsible for setting standards that ensure the safe effective practice of pharmacy, including the education and training standards for pharmacy professionals. These standards are intended to protect patient safety and are developed as outcome focussed and enabling innovation. GPhC standards comprise: • Standards of conduct, ethics and performance • Standards for owners and superintendent pharmacists of retail pharmacy businesses • Standards for continuing professional development (CPD) • Standards for the initial education and training for pharmacists • Standards for the initial education and training for pharmacy technicians Currently, the GPC have not established a competency framework to guide pharmacy
practice and education in the UK. Instead the major competency framework utilised in the UK was developed by the Competency Development and Evaluation Group (CoDEG) which is a collaborative network of specialist and academic pharmacists, developers, researchers and practitioners. Its aim is to undertake research and evaluation in order to help develop and support pharmacy practitioners and ensure their fitness to practice at all levels. Among its key outputs are the General Level Framework (GLF) and the Advanced Level Framework (ALF). The GLF has been adapted for use in Australia, Singapore, Croatia and Serbia. [9, 10]. The GLF is aimed towards community, hospital and primary care pharmacists and encourages the ‘development of pharmacist as safe, general level practitioners’. The GLF is designed to provide guidance on a competency framework that; facilitates continual professional development, helps identify gaps in knowledge and skills, and provide documentary support for appraisals. The GLF competency framework is structured with four main competency domains: 1. Delivery of Patient Care Competencies 2. Personal Competencies 3. Problem Solving Competencies 4. Management and Organisational Competencies Each domain contains a list of similar competencies, with each competency containing a list of behaviours that demonstrate this competency . Though the CoDEG GLF is not a pharmacy regulating body, the CoDEG GLF document has been acknowledged by the professional bodies in the United Kingdom as a valuable aid to pharmacist development as it will help identify areas for improvement and promote continual professional development. LICENSURE EXAMS: Currently in the USA, UK and Ireland licensing exams are employed prior to registration as a pharmacist. The purpose of the licensing exam in these three regions is to assess whether candidates are competent to practice as health professionals[3, 11]. However as there are no globally accepted core competencies, the prospect of international pharmacy practice standards, which would allow improved mobility of pharmacists, is currently limited .
4 Year Bachelor Degree
4 year Masters Degree
3-4 Years Doctor of
1 Year M Pharm Degree
Pharmacy Degree Registration
NAPLEX computer 1500
competency assessment of
depend the state in which
will be desired.
Figure 4. Path to Registration in the USA, UK and Ireland. GLOBAL HARMONISATION OF PHARMACY COMPETENCIES It has been accepted that the establishment of a single global educational model is not possible, as each region has different pharmacy needs and cultural difference . However, experts believe that a globally recognised set of core competencies can be conceived and would help establish a global vision for pharmacy driving the development quality pharmacy education. The project below is an example of one initiative which may help to achieve this goal. HARMONISING CLINICAL COMPETENCIES FOR PHARMACY STUDENTS AND PROFESSIONALS (HARPCOM) www.harmonisingpharmacy.org This project has received funding from the European Union (EU) Executive Agency Education Audiovisual and Culture (EACEA) and is supported from September 2010-2012. The goals of this policy-oriented project are to compare the current state of practice, specifically clinical activities of pharmacy practitioners in the EU and USA to (a) serve as a baseline for change and (b) harmonize the practice between the countries with the goal of extending/sharing these skills with other EU countries and the international community. The primary objectives are to (1) define and designate a set of basic skills that a student pharmacist must acquire to be competent to enter into practice and (2) compare and contrast pharmacists’ primary practice activities in the USA, Ireland and the UK for the purposes of harmonizing educational requirements maintaining competency of post-graduate pharmacists. The objectives will provide benchmarks for transcontinental and global collaborative programs.
Three primary activities will be undertaken to achieve our goals. The activities are to: (1) develop a survey instrument designed to assess the pharmacists’ activities in practice, (2) define and designate a core set of competencies that a student pharmacist must be able to demonstrate to be considered competent to enter into practice and a post-graduate pharmacist to continue to be competent in their profession using a Delphi panel strategy; and, (3) survey a representative sample of pharmacists in Ireland and the UK informed by the previous work. Data obtained from the first objective will provide educational policymakers insight into the penetration of competency / providing these skills into practice. Next, it will provide information to the educational leadership on how their programs will need to be focused over the next decade and how competency can be assessed by the educational establishment. Finally, the countries will share knowledge and information to enhance the collaborations across the partnerships and develop a strategy to extend it to the whole US and EU. The core competencies should not be viewed as purely increasing pharmacist mobility but rather can serve as necessary qualityassuring credentials of practicing pharmacists wherever they are based. For further information; please visit www.harmonisingpharmacy. org or contact one of the project members; Jennifer Archer (UK) jennifer@jenniferarcherconsulting. com; L.Doug Ried (USA) lried@ health.usf.edu; Diane Beck (USA) firstname.lastname@example.org; Laura J Sahm (Ireland) L.Sahm@ucc.ie; Stephen H Moss (UK) email@example.com . References available on request
HPN • Issue 3
An Interns patience in practice Arriving into the hospital on my first day of my internship my overwhelming thought was of how many people there were to get to know and how much I was going to have to learn! Initially, as is done in many other hospitals, the pharmacy intern starts learning their craft in the dispensary. I spent many happy months working in the dispensary, taking control of managing supplies and stocks to one ward, dispensing controlled drugs, compounding extemporaneous products and generally getting stuck in wherever required. This initial experience helped me understand how the supply of medicines in the hospital worked and the roles played by all parties in the procurement and supply of medicines. As the dispensary was a constant hub of activity it also provided ample opportunities for getting to know people! Lisa Quinn
After Christmas I got the opportunity to go up to the wards with the clinical pharmacists. My tutor started by teaching me the basics; how to navigate a patient’s medical notes to get the information you need, the best sources for obtaining a medication history, how to find lab results… and most importantly, how to bleep him for help! My first few forays into ward-based pharmacy were nerve-racking to
say the least (at one stage I was averaging about one drug kardex per hour!), however slowly but surely I began to build up speed and competence. I worked under the close supervision of another pharmacist who would review my work and answer any questions or queries I had. As the year progressed I rotated through three different wards, taking the opportunity to work in infectious diseases, orthopaedic trauma and cardiothoracics. I also got the chance to observe pharmacists working in other specialities such as oncology and intensive care. Four weeks were spent in the hospital’s aseptics unit and I completed a four week rotation in Merlin Park Hospital (a local hospital with different specialities). I also completed training with the antimicrobial pharmacist and the hospital’s medication safety co-ordinator. A recent feature of the intern year is the M.Pharm and I was in the first cohort of students to go through this course. Many of the modules in this course, e.g. Medicines Information, Patient Safety and Risk Management
and Interprofessional Prescribing Science directly related to the learning I was doing on the job. The M.Pharm also made an Organisational Developmentstyle project compulsory work for all hospital interns. This style of project was completely different to anything I had encountered as an undergraduate and so provided an excellent opportunity to learn about a whole new area. While this project undoubtedly brought many challenges and involved plenty of hard work, it ultimately was one of the best learning experiences of the whole year. For me one of the biggest advantages to completing my internship in a hospital was the opportunity I got to observe and learn from many different pharmacists, each of whom had their own different style and approach to the job. During my time in UCHG I got to work in many different clinical areas and learned so much from everyone I worked with. Article author Lisa Quinn, Pharmacist (previously Pharmacy Intern at University Hospital Galway 2009-2010).
Are you a poster technician? Following last year’s successful launch of the NAHPT Poster Competition in association with Actavis Ireland, Actavis Ireland under the Actavis Academy umbrella has announced the launch of the NAHPT Poster Competition for 2012. The poster competition is an ideal way to share information between Hospital Pharmacy Technicians working in the field.
Business Manager, Actavis Ireland said: “We are committed to supporting and working in partnership with Hospital Pharmacy Technicians across Ireland. We view the poster competition as an excellent way to raise awareness of the vital work that is being done by Technicians in Hospitals across the country. Actavis is committed to sponsoring this award for the foreseeable future.”
Speaking about the competition Caroline Fitzgerald, Hospital
Last year the prize was won by Blathnaid McIntyre from
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AMNCH Tallaght Pharmacy Department. Blaithniad’s poster detailed her work in shadowing and observing the cleaning practices at the Aseptic Unit. Her recommendations and the updating of the SOP were approved and came into practice at the Unit last year. There will be a prize of €500 for the winning entry and closing date for applications is Monday 2nd April 2012. The winning poster will be announced at this year’s NAHPT Conference, which takes place
on the 28th of April at the Crowne Plaza Hotel, Santry. For more information, please see www.pharmtech.ie
Hospital Pharmacy News is proud to annouce the launch of the Irish Pharmacy Awards 2012. The event for 2012, this much publicised awards ceremony takes place on May 19th at The Burlington Hotel, Dublin. There are 13 Award categories in total but a dedicated three exciting awards up for grabs open to all Hospital Pharmacists throughout Ireland. Over the next four pages we profile the three Hospital Awards categories, entry criteria and details of our exclusive partnership with our nominated charity, the Jack and Jill Foundation Ireland. Furthermore, we include all the details for how you can enter these exciting Awards. Awards Entry Criteria The closing date for entries April 18th, 2012 at 12 noon sharp. Each entry should be supported by a statement of no more than 500 words, as to why the entrant feels he/she/ they should win that particular category. For each entry, there should also be a supporting statement of no more than 300 words signed by a manager and/or supervisor verifying
that the entrant has indeed achieved that described in their submission. Each submission will be judged by our prestigious panel of Judges (detailed on the preceeding pages). Each category will have a winner and two runner-up winners. Short-listed candidates will be invited to a gala dinner and awards ceremony at the Burlington Hotel on May 19th, 2012. For further information please see website: www. pharmacynewsireland.com Criteria: You may enter more than one category but each individual entry can only be submitted for a maximum of two categories You will need to submit a 500 word summary with supporting information contained within your application Entries should generally cover the 12 month period from January 2011 - December 2011 Entries can be submitted by post or email so that they reach Irish Pharmacy
Communications Ltd by no later than MIDDAY, WEDNESDAY APRIL 18TH 2012 Please note that entries arriving after this time will not be included in the judging process. Closing date for entries April 18th, 2012 All entries will be handled in the strictest confidence and will not be made available to any party not involved with judging the awards Each finalist can choose how to use this time to best effect to give further information judges to assist with the entry and why they should win the category The judge's decision is final and no correspondance will be entered into Due to quanitity of entries feedback on individual entries cannot be given Finalists and winners must be willing to give interviews to Hospital Pharmacy News and Irish Pharmacy News about their acheivements
The 13 Awards Categories Hospital Pharmacist of the Year Award Hospital Pharmacy Team of the Year Award Hospital and Community Pharmacy Alliance Award Business Development of the Year Award (Independent) Business Development of the Year Award (Chain) Innovation in Service Development Award (Independent) Innovation in Service Development Award (Chain) Health Promotion Award Locum of the Year Award Community Pharmacist of the Year Award Young Community Pharmacist of the Year Award Community Pharmacy Team of the Year Award Counter Assistant of the Year Award
For more information visit www.irishpharmacyawards.ie Telephone Kelly Eastwood on 00353 (01) 602 4715
HPN • Issue 3
18 Making a Difference
Our community is your community You can see the number of families we have supported, and the cost of doing so, via our county breakdown below. Behind the numbers, these are ordinary people with the extraordinary challenge of caring for their sick child at home; a child suffering from severe neurological and developmental delay as a result of brain damage. Their child may take seizures, be peg fed, oxygen dependent and in need of constant monitoring; a precious child who may never go to school or play football. But underneath the disability, this child feels hunger and pain and wants to be held and kept warm and cosy at home, where they belong. This is a child with the ability to take a part of your heart that you never knew existed. This I know from experience.
Jonathan Irwin, Founder, Jack and Jill Foundation, Ireland
I understand the important role played by the pharmacist in the delivery of health care within the home, hospital and within the community. We certainly knew the value of having a good pharmacist when caring for my son Jack at home and it was comforting and reassuring to see how our local GP and pharmacist worked together on Jack’s behalf. Without their practical help we wouldn’t have survived when faced with the dreadful cocktail of medicines and timelines that would make your head spin.
To be named the beneficiary charity for the Irish Pharmacy Awards on 19th May 2012 means so much to the 270 families currently under our wing and to the 1,000 army of nurses and carers behind the Jack & Jill home nursing care model. On our community’s behalf, who are your community of clients, I say a big thank you.
So on 19th May 2012, in the company of my good wife Senator Mary Ann O’Brien, I will attend your awards and hopefully meet you there. Meantime, we see this partnership as an opportunity to foster even stronger links within our collective community. We want to share the Jack & Jill story in which you play a key role, along with the family’s local GP and our Jack &
Jill liaison nurse. We urge you to add your voice to our ongoing campaign for the introduction of a National Paediatric Home Nursing Care Budget on behalf of our children who have no voice. Without a budget our community can’t be cared for in their community in a sustainable way. A model that works for everyone At the core of our Foundation is the belief that there is “No care like home care” which is better for the child, the family and the taxpayer. In Ireland, the average cost of keeping a severely disabled child in hospital is �147,365 per annum, compared to the average cost to care for a child at home at �16,422 per annum nine times less expensive. This was highlighted in an independent Trinity College report in February 2010 entitled “There’s no place like home”. Jack & Jill’s service includes home visits from our nurses and carers around the country who give practical advice, emotional support, information and guidance and bereavement support. A big part of this model is that we provide funding for up to 64 hours of home nursing care per month at �16 per hour. As the Trinity report proves, our model of care is nine times less expensive than hospital care, but we get only 17% of our required �2.7 million annual budget from the State, a figure that will further decrease this year. The harsh fact is that if Jack & Jill didn’t exist and the children under our wing ended up back in hospital, that would cost the HSE and the taxpayer over �40 million per annum.
Jack & Jill costs per county County
Total Annual Costs Families supported since 1997
Total Annual Costs Families supported since 1997
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Hospital and Community Pharmacy Alliance Award Sponsored by Hospital Pharmacy News Good patient care depends on teamwork between the members of the entire healthcare team, including both community and hospital pharmacists. The aim of this award is to highlight inspirational multidisciplinary working. Entries should show how groups of people have worked together to make a difference to the care of patients and those close to them. They may discuss the difficult process of developing an effective team and of overcoming barriers. Alternatively, the focus may be on systems that facilitate the communication of the information needed for different professions to bring their skills to help patients. Examples of crossdisciplinary learning and support will also be considered. The winners of this award must be able to demonstrate, within the context of an overall strategy, how a particular initiative has improved patient care, enhanced services available and benefited cross-discipline working. Entries should indicate results against targets. Criteria: Clear demonstration of multidisciplinary working established to review procedures and modernise patient experience Development and results of new care pathways Evidence of assessment and documentation of objectives, targets and outcomes How have you/the team worked together in identifying team membership and roles How will the team move forward into the future? Please give examplesof anticipated further working relationships Applicants should be able to demonstrate: Excellent and outstanding achievement in all aspects of their organisation Strong growth, innovation and leadership as well as a clear vision
Hospital Pharmacy News is proud to sponsor the Hospital and Community Pharmacy Alliance of the Year Award. Hospital Pharmacy News is dedicated to working with Ireland's pharmacy market as the industry's professionals strive to build on previous successes, creating a stronger future. For us, it's the ability to work with pharmacy's, their owners and management teams to plan for the long term, grow the industry and transfer wealth from one generation to the next. Team working is an essential aspect for success. Within Ireland we are witnessing more frequently multidisciplinary working between hospital and community pharmacists and their staff; with the ultimate goal of improving health initiatives for patients, whether that is in a hospital or community setting. Pharmacy has many unsung heroes, so this Award is a great opportunity for us to be able to support the ongoing dedication and commitment, and help showcase the businesses that are the foundations of the Irish pharmacy market. Hospital Pharmacy News is dedicated to helping pharmacy in Ireland continue to drive success, even in the face of obstacles, challenges and adversity.
How their people development strategy has improved business performance and created a committed, motivated and effective workforce
Hospital and Community Pharmacy Alliance Hospital and Community www.irishpharmacyawards.ie HPN • Issue 3
Hospital Pharmacy of the Year Sponsored by Roche Products (Ireland) Limited At Roche, we have built our success on innovation. We are leaders in providing pharmaceutical and diagnostic solutions that make a profound difference in people’s lives. We play a pioneering role in healthcare by creating innovative products and services for the early detection, prevention, diagnosis and treatment of diseases. These diseases include oncology, rheumatology, virology, transplantation, diabetes and immunology. Our diagnostic tools also assist researchers and clinicians working in the fields of clinical chemistry, molecular diagnostics, histology and research. In Ireland, we contribute on a range of fronts to improving people’s health and quality of life. Roche has provided some of the first products that are tailored to the needs of specific patient groups (better known as Personalised Healthcare). We work in partnership with a broad base of healthcare professionals, healthcare facilities, professional bodies and patient organisations across the country to ensure that the diagnostics and pharmaceutical treatments we deliver meet the medical needs of today and of the future. Our mission, today and tomorrow, is to create, produce and market innovative healthcare solutions of high quality for unmet medical needs.
Members of the hospital pharmacy team have a direct involvement in patient care, influencing treatment choices by being central to decision-making at the point of prescribing. Being part of a number of different teams, from nursing staff to consultants, internal departmental co-operation is essential. The Hospital Pharmacy of the Year Award seeks to reward the pharmacy staff members of any hospital pharmacy department in Ireland; those who can show vision in improving patient care whilst supporting fellow colleagues. The category will recognise a team who has played a part in a health structure with minimal financial resources yet increasing pressures. Applicants will be expected to highlight how they have overcome such obstacles. The definition of a team for this particular award is two or more people working within the same hospital in either day to day work or in a particular task or project. Criteria: How have you demonstrated good practice through team working? What services of excellence have you undertaken or offered over the last 12 months? What relevant obstacles did you encounter and how were these overcome? How have you differed from other hospital pharmacy teams and what opportunities have you exploited? What has been the broader contribution to the profession? Applicants should be able to demonstrate: Outstanding achievement on the job, actions that constitute performance beyond expected standards An ability to contribute to the maximum utilisation of departmental resources Involvement in interesting, challenging or new areas of practice Improved performance or service as a result of team working
Hospital Pharmacy of the Year Hospital Pharmacy www.irishpharmacyawards.ie Issue 3 • HPN
Hospital Pharmacist of the Year Sponsored by Roche Products (Ireland) Limited * This Award may be entered through individual application or nomination The field of Hospital Pharmacy within Ireland has been blessed with some of the most brilliant professionals in Europe. As they say, the cream always rises to the top! Working to ensure patients in the hospital setting receive the best treatment, providing advice and help in all aspects of their medicines, the role of a hospital pharmacist often goes beyond this remit. Perhaps you know someone whose vision and dedication deserves recognition and reward. The Hospital Pharmacist of the Year Award recognises individuals who have clearly demonstrated their excellence in the profession during the last twelve months. On shortlisting applications and choosing a subsequent winner, judges will be looking for an individual who can demonstrate creativity and ‘thinking outside the box’ in contributing to the field of hospital pharmacy throughout Ireland. Applicants will be able to show how they, or their nominated colleague, have consistently met or exceeded challenging objectives to ensure the highest quality of provision of hospital pharmacy services. Criteria: What is your,their background in hospital pharmacy and how long have you/they been involved in this area in Ireland? What campaigns or initiatives have you/they been involved in within the last twelve months in the field of hospital pharmacy? What has been the success/outcome of these? What benefits have others derived from your/their activities? What has been exceptional about your/their contribution? What have you/they gained from your work in this field? Applicants should be able to demonstrate: Open to any Pharmacist working within a Hospital Pharmacy Department in Ireland Supporting information with applications must relate to the past twelve months An individual who has had a significant impact in the area of Hospital Pharmacy Someone who has had involvement in shaping any aspects of Ireland's Hospital Pharmacy arena An ability to demonstrate outstanding commitment and contribution Evidence of an ability to identify opportunities and develop them through initiative and strong interpersonal skills
At Roche, we have built our success on innovation. We are leaders in providing pharmaceutical and diagnostic solutions that make a profound difference in people’s lives. We play a pioneering role in healthcare by creating innovative products and services for the early detection, prevention, diagnosis and treatment of diseases. These diseases include oncology, rheumatology, virology, transplantation, diabetes and immunology. Our diagnostic tools also assist researchers and clinicians working in the fields of clinical chemistry, molecular diagnostics, histology and research. In Ireland, we contribute on a range of fronts to improving people’s health and quality of life. Roche has provided some of the first products that are tailored to the needs of specific patient groups (better known as Personalised Healthcare). We work in partnership with a broad base of healthcare professionals, healthcare facilities, professional bodies and patient organisations across the country to ensure that the diagnostics and pharmaceutical treatments we deliver meet the medical needs of today and of the future. Our mission, today and tomorrow, is to create, produce and market innovative healthcare solutions of high quality for unmet medical needs.
Those nominating a candidate for this Award must include their own name and contact details. All information will be handled in the strictest confidence
Hospital Pharmacist of the Year Hospital Pharmacist www.irishpharmacyawards.ie HPN • Issue 3
Eli Lilly & Company is to invest €330m in a new commercialisation and manufacturing facility in Cork, Ireland The plant will be built at the US pharma company’s Kinsale campus creating up to 200 biopharma jobs and the investment was supported by IDA Ireland, an organisation responsible for the attraction and development of foreign investment in Ireland. “The government is determined to ensure that more announcements like this become real in the coming years. By implementing the Action Plan for Jobs, we can support more businesses, rebuild the economy and create the jobs we so badly need.”
The announcement follows the recent publication of the Action Plan for Jobs - the Irish government’s wide-ranging strategy to identify and invest in key sectors to rebuild the country’s economy and create new jobs. The plans, which include developing the country’s life sciences sector, were welcomed by the Irish Pharmaceutical
Healthcare Association (IPHA) and PharmaChemical Ireland. Commenting on Lilly’s new proposal, Ireland’s Minister for Jobs, Enterprise and Innovation Richard Bruton said: “That this world-leading company is making a substantial investment in expanding its facility in Kinsale with the creation of up to 200 permanent jobs shows what is possible in these areas.
Aliskiren-containing meds The European Medicines Agency finalised a review of aliskiren-containing medicines, recommending that these medicines should be contraindicated in patients with diabetes or moderate to severe renal impairment who take angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). In addition, the Agency recommended the inclusion of
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a warning that the combination of aliskiren and ACE inhibitor or ARB is not recommended in all other patients because adverse outcomes cannot be excluded. Aliskiren-containing medicines are approved for the treatment of essential hypertension. Essential means that there is no obvious cause for high blood pressure.
The planned 240,000-squarefoot facility will focus on manufacturing treatments in cancer and diabetes, and follows the completion of another biopharmaceutical manufacturing and new-product commercialisation facility at Kinsale in 2010. Lilly’s senior VP global of API and dry product manufacturing Paul Ahern described the investment as “is part of Lilly’s planned growth strategy” and said it was proof that Lilly has confidence in its product pipeline. This includes 12 molecules in phase III development,
according the company’s 2011 financial results, including Alzheimer's drug candidate solanezumab. It is expected that drug could achieve double-digit billion dollar peak year sales thanks to the lack of treatments that address the underlying neuronal damage that characterises the disease. Lilly is relying on the success of these developmental products, with generic competition set to hit the company hard over the next few years. It has already lost patent protection on treatments such as its top-selling antipsychotic Zyprexa (olanzapine) and the cancer drug Gemzar (gemcitabine). Meanwhile Lilly's antidepressant Cymbalta (duloxetine) and Humalog (insulin lispro) for diabetes are also scheduled to lose exclusivity in 2013.
CONTACT NATALIE TEL: 01 602 4715
19th May 2012 The Burlington Hotel Table of 10 €1,500 Dress code black tie 7pm to 8pm drinks reception Followed by dinner and awards ceremony Live band Make sure you don’t miss out on a great evening and a chance to network with your colleagues from the pharmacy industry. Nexazole 20 mg & 40 mg gastro-resistant capsules, hard
This is an excellent opportunity to bring your team or enter one of the three Awards honouring Hospital Pharmacy. The objective of this evening is to celebrate excellence in pharmacy and present 13 awards. If you have a vested interest in this sector you will want to be there. Nexazole: for the treatment of erosive reflux oesophagitis Prescribing Information for Nexazole 20 mg & 40 mg gastro – resistant capsules, hard. Qualitative and Quantitative Composition: Each capsule contains 20 mg or 40 mg of esomeprazole (as esomeprazole magnesium dihydrate). Pharmaceutical Form: Hard, gastro-resistant capsule: Slightly pink body and cap, containing white to almost white pellets. Therapeutic Indications: Treatment of erosive reflux oesophagitis. Prevention of relapse of healed oesophagitis in longterm management of patients. Symptomatic treatment of gastroesophageal reflux disease (GERD). Eradication of H. pylori concurrently given with appropriate antibiotic therapy for treatment of H.pylori-associated ulcers. Treatment of NSAIDassociated gastric and duodenal ulcers in patients requiring continued NSAID-treatment. Prophylaxis of NSAID-associated gastric ulcers and duodenal ulcers in patients at risk requiring continued therapy. Prolonged treatment after i.v. induced prevention of rebleeding of peptic ulcers. Treatment of Zollinger Ellison Syndrome. Dosage and Method of Administration: Capsules should be swallowed whole with liquid. The capsules can be opened and the pellets mixed in half a glass of noncarbonated water or if desired this solution administered through a gastric – tube in patients with swallowing difficulties. The capsules and / or contents should not be chewed or crushed. Treatment of erosive reflux oesophagitis: 40 mg once daily for 4 weeks. Long-term management of patients with healed oesophagitis to prevent relapse: 20 mg once daily. Symptomatic treatment of gastroesophageal reflux disease: 20 mg once daily. Eradication of H. pylori for treatment of H.pylori-associated ulcers: 20 mg with 1 g amoxicillin + 500 mg clarithromycin, all twice daily for 7 days. NSAID associated gastric & duodenal ulcers: 20 mg once daily for 4 – 8 weeks. Prophylaxis treatment: 20 mg once daily. Prolonged treatment after i.v induced prevention of rebleeding of peptic ulcers: 40 mg once daily for 4 weeks. Zollinger Ellison Syndrome: Initial dose is 40 mg once daily. Dosage should be individually adjusted. Daily doses up to 160 mg have been used. If the required daily dose exceeds 80 mg, it should be divided and given twice daily. Severe liver impairment: Patients should not exceed a max. dose of 20 mg. Contraindications: Hypersensitivity to esomeprazole or to any of the excipients. Esomeprazole should not be administered with atazanavir. Pregnancy and breast-feeding due to insufficient data. Children under 12 years. Special warnings and precautions for use: The possibility of a malignant gastric tumour should be excluded as Nexazole may alleviate symptoms and delay diagnosis. Regularly monitor patients on long-term treatment. Patients on on-demand treatment should contact their physician if symptoms change in character. If esomeprazole is used in combination with antibiotics, then the instructions for the use of these antibiotics should also be followed. Treatment with esomeprazole may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter. Contains sucrose – Patients with rare hereditary problems of fructose intolerance, glucose – galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Drug Interactions: Esomeprazole can affect the absorption of ketoconazole and itracanazole. Dose reduction may be required when administered with drugs metabolised by CYP2C19 as esomeprazole may increase their plasma concentration. Monitor patients when given in combination with warfarin or other coumarine derivatives. Undesirable effects: Common: Headache, abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting. Shelf Life: 2 years. Marketing Authorisation Holder: Pinewood Laboratories Ltd., Ballymacarbry, Clonmel, Co. Tipperary. Marketing Authorisation Holder Number(s): PA 281/146/1-2. This medicine is a prescription only product. Further prescribing information is available on request. Date of revision of text: July 2010.
Beneficiary charity of the evening Ireland’s No. 1 Generic Healthcare Specialists
THE INDEPENDENT VOICE OF PHARMACY
24 Mental Health
How a pharmacist can deliver medicines education for mental health inpatients Since 2009 a pharmacist in Galway has been contributing to medicines education for mental health inpatients.
All inpatients in the department of psychiatry have the opportunity to attend the “activities” programme. This is co-ordinated by two psychiatric nurses and includes relaxation, gym, discharge planning, healthy lifestyle advice and music. A recent addition to the activities programme is a session on
medicines education, run by the mental health pharmacist.
questions and misconceptions about medication.
The medicines education sessions run once every fortnight. This means that the majority of patients will be able to attend at least one session during their admission. Each session is a stand alone class. It was decided not to run a course on medicines information as many patients would miss one or more sessions.
• Common side effects and how to overcome them.
The pharmacist is accompanied by one member of nursing staff for security reasons and to encourage the patients to ask questions and join in the discussion. Each one hour class begins with an introduction by the pharmacist and information about the pharmacy service. A fifteen minute formal teaching session then takes place. The topics are rotated to avoid repetition for patients that attend more than one session.
I feel very sleepy on my medication, how can I overcome this?
Teaching sessions in the class include; • How do psychiatric medicines work? • What is the difference between addiction, tolerance and dependence? • True or False? – Common
The second part of the class is “Ask your pharmacist.” The patients can ask about anything relating to medication. Common questions include; What is the name of my medicine and what are the side effects?
I have gained weight on medication – is this related to appetite increasing or a change in metabolism? My medication is expensive, how can I reduce the cost? One of the aims of the medication education group is to encourage compliance with medication once the patient leaves the hospital. A large percentage of readmissions in psychiatry are relating to noncompliance with medication. The pharmacist will emphasise the importance of long term medication and talk about ways to improve compliance. In this patient group, non-compliance
is sometimes deliberate – ie the patient chooses not to continue medication. It is clear that compliance aids such as “dosette” trays will not be the answer in this case. The aim is to encourage knowledge about medication, how to handle side effects and who to talk to if the patient has concerns about their medication. The mental health pharmacist will always promote the community pharmacist as a “first port of call” once the patient is living at home. Patients are encouraged to build a good relationship with one community pharmacist to enable the patient to have the confidence to ask questions about their medication and for the pharmacist to pick up changes to medication. The impact of the medicines education group is currently being evaluated. It is possible that the group will be introduced for outpatients in the future, to compliment the excellent advice already given by community pharmacists. Author Allison Dunne, Mental Health Pharmacist, West Galway Mental Health Services.
Pharmacy Prizegiving 2011 Pictured is Ms Fiona Mulligan, winner of the McNeil Ltd. Prize for best final year performance in the Practice of Pharmacy in the B.Sc.(Pharm) Examination. Fiona is pictured with Professor Marek Radomski, Head of School of Pharmacy, TCD, Mr David Hall, McNeill Ltd, Professor Mary McCarron, Dean of Health Sciences, TCD and Dr Martin Henman, Associate Professor of Pharmacy Practice, TCD.
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So many symptoms...
Treat the of depression with Lexapro®
The No.1 prescribed anti-depressant in Ireland Abbreviated Prescribing Information: Please refer to the Summary of Product Characteristics before prescribing. Presentation: Lexapro® tablets 5 mg, 10 mg, 15 mg and 20 mg containing escitalopram (as oxalate). Indications: Treatment of major depressive episodes. Panic disorder with or without agoraphobia. Social Anxiety Disorder. Generalised Anxiety Disorder. Obsessive Compulsive Disorder. Dosage: Major depressive episodes Adults: Usual dosage is 10 mg once daily. The dose may be increased to a maximum of 20 mg/day. Panic Disorder with or without agoraphobia: An initial dose of 5 mg is recommended for the first week before increasing the dose to 10 mg/day. The dose may be further increased, up to a maximum of 20 mg/day. Social Anxiety Disorder: Usual dosage is 10 mg once daily. The dose may subsequently be decreased to 5 mg or increased to a maximum of 20 mg/day. Generalised Anxiety Disorder: Initial dosage is 10 mg once daily. The dose may subsequently be increased to a maximum of 20 mg/day. Obsessive Compulsive Disorder: Initial dosage is 10 mg once daily. The dose may be increased to a maximum of 20 mg daily. Elderly (>65 yrs): Initial dosage is 5 mg once daily. Depending on individual patient response the dose may be increased to 10 mg daily. The efficacy of Lexapro in social anxiety disorder has not been studied in elderly patients. Children and adolescents (<18 years): Not recommended. Poor metabolisers of CYP2C19: In known poor metabolisers of CYP2C19, 5 mg/day Lexapro is recommended for the first 2 weeks, the dose can be increased to 10 mg after assessment. Reduced hepatic function: In mild/moderately impaired hepatic function an initial dose of 5 mg/day for the first two weeks of treatment is recommended, the dose may be increased to 10 mg/day. Caution and extra careful dose titration advised in patients with severely reduced hepatic function. Reduced renal function: Dosage adjustment is not necessary in patients with mild or moderate renal impairment. Caution is advised in patients with severely reduced renal function (CLcr<30 ml/min). Contraindications: Hypersensitivity to escitalopram or to any of the excipients. Concomitant treatment with a nonselective, irreversible monoamine oxidase inhibitor (MAOI). Concomitant treatment with reversible MAO-A inhibitors e.g. moclobemide or reversible non-selective MAO-inhibitors e.g. linezolid. (Lexapro may be started 14 days after discontinuing treatment with an irreversible MAOI. At least 7 days should elapse after discontinuing Lexapro treatment, before starting a non-selective irreversible MAOI). Lexapro is contraindicated together with medicinal products that are known to prolong the QT interval and in patients with known QT interval prolongation or congenital long QT syndrome. Fertility, Pregnancy & Lactation: Lexapro should not be used during pregnancy unless clearly necessary. Neonates should be observed if maternal use of Lexapro continues into the later stages of pregnancy, particularly the third trimester. Abrupt discontinuation should be avoided during pregnancy. Use of SSRIs during pregnancy may increase the risk of persistent pulmonary hypertension (PPHN) in the newborn. Refer to the full prescribing information for a list of serotonergic or discontinuation symptoms, which may occur in the neonate after maternal SSRI/SNRI use in later stages of pregnancy. Breast-feeding is not recommended during treatment. Precautions: Patients should be cautioned about the potential risk to their ability to drive a car and operate machinery. No pharmacokinetic or pharmacodynamic interactions are expected with concomitant alcohol intake, however the combination is not advised. Insulin and/or oral hypoglycaemic dosage may need to be adjusted in diabetics. Hyponatraemia has been observed rarely with SSRI use, caution is required in patients at risk of hyponatraemia. Caution is advised with coadministration of ECT and in patients with a history of mania/hypomania. Caution is advised with concomitant use of oral anticoagulants, products affecting platelet function and in patients with known bleeding tendencies. Avoid in patients with unstable epilepsy & monitor patients with controlled epilepsy. Discontinue if patient develops seizures or if there is an increase in seizure frequency. Caution is advised with concomitant use of serotonergic compounds. Stop treatment immediately if patient develops serotonin syndrome. Use at a low starting dose for panic disorders. Avoid abrupt discontinuation. Gradual discontinuation by dose tapering is advised. As with all SSRIs it is advisable to closely monitor patients for suicide and self-harm risk in the first few weeks of treatment and until significant remission occurs. The use of SSRIs/SNRIs has been associated with the development of akathisia, increasing the dose in these patients may be detrimental. Caution is advised in patients with coronary heart disease. As Lexapro has been found to cause a dose-dependent prolongation of the QT interval, caution is advised for patients with risk factors such as female gender, pre-existing QT interval prolongation, significant bradycardia, recent acute myocardial infarction, uncompensated heart failure, hypokalaemia, hypomagnesaemia or other cardiac diseases. Consider an ECG review before starting Lexapro in patients with stable cardiac disease. If signs of cardiac arrhythmia occur during treatment with Lexapro, the treatment should be withdrawn and an ECG performed. Drug Interactions: MAO inhibitors (see Contraindications), advise caution in use with irreversible selective MAO-B inhibitors (selegiline). Medicinal products that prolong the QT interval (see Contraindications). Caution in use with lithium, tryptophan, serotonergic medicinal products or with products capable of lowering the seizure threshold. Avoid concomitant use with St. John’s Wort. Caution is advised with co-administration of drugs metabolised by enzymes CYP2C19, CYP3A4 and CYP2D6. Co-administration with CYP2C19 inhibitors, and general enzyme inhibitors e.g. cimetidine may require reduction of the Lexapro dose. Lexapro is an inhibitor of CYP2D6, caution is advised with concomitant use of drugs (particularly those with a narrow therapeutic index) mainly metabolized by CYP2D6. Caution is advised with concomitant use of oral anti-coagulants, medicinal products known to affect platelet function and non-steroidal anti-inflammatory drugs (NSAIDs). Adverse Events: Adverse reactions are most frequent during the first or second week of treatment and usually decrease in intensity and frequency with continued treatment. Frequencies are not placebo-corrected. Very Common (≥1/10): Nausea. Common (≥1/100 to <1/10): Weight increased, insomnia, somnolence, dizziness, paraesthesia, tremor, sinusitis, yawning, diarrhoea, constipation, vomiting, dry mouth, sweating increased, arthralgia, myalgia, decreased and increased appetite, fatigue, pyrexia, ejaculation disorder, impotence, anxiety, restlessness, abnormal dreams, male & female libido decreased, female anorgasmia. Uncommon (≥1/1,000 to <1/100): weight decreased, tachycardia, taste disturbance, sleep disorder, syncope, mydriasis, visual disturbance, tinnitus, epistaxis, gastrointestinal haemorrhages (incl. rectal), urticaria, alopecia, rash, pruritus, oedema, metrorrhagia, menorrhagia, bruxism, agitation, nervousness, panic attack, confusional state. Rare (≥1/10,000 to <1/1,000): Bradycardia, serotonin syndrome, anaphylactic reaction, aggression, depersonalisation, hallucination. Not known (cannot be estimated from the available data): Liver function test abnormal, thrombocytopenia, dyskinesia, movement disorder, convulsion, urinary retention, ecchymosis, angioedemas, inappropriate ADH secretion, hyponatraemia, orthostatic hypotension, hepatitis, galactorrhoea, male priapism, mania, suicidal ideation, suicidal behaviour, psychomotor restlessness, akathisia, anorexia, ECG QT prolonged and ventricular arrhythmia including Torsade de Pointes. Others: discontinuation symptoms (SSRIs/SNRIs), increased risk of bone fractures (patients ≥50 years) (SSRIs/TCAs). Overdose: Clinical data on escitalopram overdose is limited and many cases involve concomitant overdoses with other drugs. Doses between 400-800 mg of Lexapro alone have been taken without any severe symptoms. Symptoms seen in reported overdose of Lexapro mainly relate to the central nervous system, the gastrointestinal system, the cardiovascular system and electrolyte/fluid balance conditions. There is no specific antidote. Treatment is symptomatic and supportive with monitoring of cardiac and vital signs. In case of overdose ECG monitoring is advised in patients using concomitant medications that prolong the QT interval, in patients with altered metabolism (e.g. liver impairment) and in those with congestive heart failure and bradyarrhythmias. Gastric lavage and the use of activated charcoal should be considered. Legal Category: POM. Product Licence Holder: H. Lundbeck A/S, Ottiliavej 9, DK-2500 Valby, Copenhagen, Denmark. PA Numbers: 5 mg PA805/2/1; 10 mg PA805/2/2; 15 mg PA805/2/3; 20 mg PA805/2/4. Further information is available upon request from Lundbeck (Ireland) Ltd., 7 Riverwalk, Citywest Business Campus, Citywest, Dublin 24. ‘Lexapro’ is a registered trademark ® 2002 Lundbeck Ltd. Date of preparation: January 2012. Reference: 1. Combined IMS Hospital and IRLP Unit Sales Data (YTD/Dec/2011). LX2/1/12
26 E-volutionary approach to errors
E-volutionary approach to address medication errors The Hospital Pharmacy Department at the Mater Misericordiae University Hospital are at the leading edge of groundbreaking research and have, for many years, been an example for others to follow in developing new initiatives and services for the profession. More recently, they have developed a ground breaking e-learning programme to heighten the awareness of the top 10 high risk drugs and drug groups, and the potential risks in how medicines are often prescribed and administered. With nearly 7,000 medication errors reported in Irish hospitals and community healthcare facilities in 2010, the online education and training resource aims to improve medicines management, and enhance patient safety and care standards. The innovative e-learning solution highlights the top 10 high-risk drugs, or drug groups, that can cause harm; how medication errors can occur, and how to avoid them; and the importance of reporting medication errors. The programme is being actively used in the retraining of existing clinicians, to support the induction of new clinical staff, and to provide enhanced training to all healthcare professionals involved in the drug use process. AVOIDABLE MEDICATION ERRORS The HSE and the State Claims Agencyâ€™s patient safety data * showed that medication errors
Ciaran Meegan, Chief Pharmacist, Mater Hospital Pharmacy Department along with Maria Creed, Medications Safety Facilitator, MMUH
accounted for 8% of incidents reported in 2010, with threequarters of these occurring in the acute care sector. Of the 6,882 medication errors recorded, 730 involved giving the wrong medication, with dosage mistakes at 1,250. Between 2004 and 2010, in Ireland, there were 35,310 incidents involving medication, the most common again being incorrect dosage (7,022), followed by missed medication (5,095), incorrect medication (4,199), incorrect labelling (1,852), or medicine given at the incorrect time (1,029).
individual prescribing the drug, to those dispensing and administering it, thereby creating a collaborative approach to the overall drug safety culture. The initiative,
which clearly highlights key risk areas in drug use, reflects the Mater Hospitalâ€™s commitment to reducing medication errors and enhancing patient safety.
The innovative new e-learning programme addresses the need to improve the safety of high risk medications by educating healthcare professionals right across the chain of care, from the High risk medications programme up and running
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27 the Pharmacy Department, Peamount Hospital of very successful results of independent trials of the training from two different test sites; the Mater Hospital, and Peamount Hospital in Dublin. The delivery of the new training is fully tracked, recorded and measured, providing audit data for quality and safety governance purposes. Speaking of how Pfizer is supporting national access to the e-Learning programme, Paul Reid, Specialty Care Business Unit Lead and Company Director of Pfizer Healthcare Ireland said "Pfizer is delighted to be given the opportunity to support the Mater Hospital in the development of an innovative and essential healthcare initiative." Pictured are members of the presenting committee at the launch of the medication safety e-system
Ciaran Meegan, Head of Pharmacy Services at MMUH, said that both the training content and its flexible format will make a major contribution to patient safety. â€œThis new e-Learning initiative enables training on a critical, potentially high-risk aspect of healthcare, to be delivered efficiently and cost-effectively, in a flexible and accessible format, to a large number of healthcare staff, which can only ultimately benefit our patients. It also helps address the on-going challenges hospitals face with medication errors, by providing a training module that covers the top 10 high-risk drugs, and outlines compelling case-histories of drug errors to inspire and sustain cultural change."
web-based training had practical demonstrations of the e-learning experience, and detail on how the delivery of training is managed, in advance of the National Access Programme to hospitals countrywide. SUPPORTING EDUCATIONAL INITIATIVES Delegates also heard from Ms Debbie Davies from Michelle McGuirk, Pharmacy Project Co-ordinator, MMUH and Debbie Davies, Chief Pharmacist Peamount Hospital
Hospital Chief Pharmacists and other stakeholders from around the country attended the launch, which featured presentations from the Mater Misericordiae University Hospital (MMUH), UK e-learning specialists, Learning Industries, and Pfizer Healthcare Ireland, which supported the development of the online programme on high-risk medications. Medical professionals attending the launch of the Ciaran Meegan at the launch of the new e-volutionary initiative
HPN â€˘ Issue 3
28 Breast Cancer
Poor prognosis in breast cancer tumours MAGE-D4B is a novel marker of poor prognosis and potential therapeutic target involved in breast cancer tumors Written by: Serena Germano, Susan. Kennedy, Sweta Rani, Grainne Gleeson, Martin Clynes, Padraig Doolan, Susan McDonnell, Linda Hughes, John Crown and Lorraine O’Driscoll School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland St. Vincent’s University Hospital and Molecular Therapeutics for Cancer Ireland (MTCI), Dublin, Ireland MTCI, C/o National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland School of Chemical and Bioprocess Engineering, University College Dublin, Dublin, Ireland
adhesion, migration and invasion and by modulating expression of invasion-suppressor gene E-cadherin. THE INCIDENCE OF BREAST CANCER
Melanoma-associated antigen (MAGE) family members are generally described as tumorspecific antigens. An association between MAGE-D4B and breast cancer has yet to be reported and the functional role of the encoded protein has never been established. We performed microarray analysis of 104 invasive breast tumors and matched noncancerous breast biopsies. Issue 3 • HPN
qPCR was used for validation in an independent biobank. To investigate the biological relevance of MAGE-D4B in breast tumorigenesis, its phenotypic effects were assessed in vitro. Overall, MAGE-D4B was detected in 43% of tumors while undetected in normal breast tissue. MAGED4B was found to correlate with tumor progression and to be an independent prognostic
marker for poor outcome in term of relapse-free and overall survival, with potential predictive relevance in relation to response to chemotherapy. RNA interferencemediated knockdown of MAGED4B significantly hampered the invasive properties of Hs578T cells by affecting anchorageindependent growth, adhesion, migration and invasion affecting anchorageindependent growth,
Breast cancer is the most common cancer in women and one of the leading causes of death and it is characterized by high heterogeneity at the histopathologic and molecular levels, which is ultimately reflected in the clinical course of the disease and responses to treatment. The prognosis and clinical management of patients with breast cancer are commonly determined by clinicopathological factors and immunochemical markers. Histological type, grade, tumor size, lymph node involvement, estrogen (ER) and progesterone (PR) receptors status and HER2-receptor overexpression/gene amplification all influence prognosis and probability of response to systemic therapies; however, they fail to fully capture the varied clinical course of breast cancer. Expression of human melanomaassociated antigen (MAGE) family genes has been recently associated with several types of cancer. The first human MAGE family member was discovered as a gene encoding a tumor-specific antigen. Since then, more than 50 MAGE genes have been identified and
Decisive action for your arthritis patients with increased GI risk1
Prescribing Information - Celebrex® Celebrex 100 mg Capsules containing celecoxib 100 mg. Celebrex 200 mg Capsules containing celecoxib 200 mg. Refer to Summary of Product Characteristics before prescribing. Indications: Symptomatic relief in the treatment of osteoarthritis, rheumatoid arthritis or ankylosing spondylitis. The decision to prescribe a selective COX-2 inhibitor should be based on an assessment of the individual patient’s overall risks. Dosage: Celebrex should be introduced at the lowest effective dose and for the shortest duration possible. In the absence of therapeutic benefits with the maximum daily dose, other therapeutic options should be considered. Patient’s need for continued therapy should be re-evaluated periodically. Osteoarthritis: Usual recommended daily dose is 200 mg taken once daily or in two divided doses. The maximum daily dose is 400 mg taken as two divided doses of 200 mg if needed. Rheumatoid arthritis: Initial recommended daily dose is 200 mg taken in two divided doses; maximum daily dose 400 mg taken in two divided doses. Ankylosing spondylitis: Usual recommended daily dose is 200 mg taken once daily or in two divided doses. The maximum daily dose is 400 mg taken once daily or in two divided doses. Elderly: Initial recommended dose is 200 mg per day; maximum daily dose 400 mg in two divided doses. Take particular caution with elderly patients who have a body weight less than 50kg. Hepatic impairment: Initiate treatment at half the recommended dose in established moderate impairment (serum albumin 25-35 g/l). Renal impairment: Experience is limited in mildmoderate impairment. Patients should be treated with caution. Children: Not indicated. Contraindications: Hypersensitivity to celecoxib or excipients, known sulphonamide hypersensitivity. Active peptic ulceration or gastrointestinal (GI) bleeding. Patients who have experienced allergic-type reactions after taking aspirin or NSAIDs including COX-2 inhibitors. Pregnancy, women of childbearing potential unless using effective contraception, breast feeding. Severe hepatic dysfunction (serum albumin <25 g/l or Child-Pugh score >10). Inflammatory bowel disease. Patients with creatinine clearance <30 ml/min. Congestive heart failure (NYHA II-IV). Established ischaemic heart disease, peripheral arterial disease and / or cerebrovascular disease. Warnings/Precautions: Upper gastrointestinal complications, some of them resulting in fatal outcome, have occurred in patients treated with celecoxib. Therefore caution is advised in patients most at risk of developing a gastrointestinal (GI) complication with NSAIDs (e.g. elderly, patients using any other NSAID or aspirin concomitantly, patients with history of GI disease such as ulceration and GI bleeding). There is further increase in the risk of GI adverse effects for celecoxib (GI ulceration or other GI complications) when celecoxib is taken concomitantly with aspirin, even at low doses (see Interactions). Avoid concomitant use with non-aspirin NSAIDs. Increased risk of serious cardiovascular events, mainly myocardial infarction, observed in a long term study at dose of 200mg BID and 400mg BID. Cardiovascular risks of celecoxib may increase with dose and duration of exposure so the lowest effective dose should be used for the shortest possible duration. The need for symptomatic relief and response to therapy should be re-evaluated periodically, especially in patients with osteoarthritis. Patients with significant risk factors for CV events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated after careful consideration. Celecoxib is not a substitute for aspirin for cardiovascular prophylaxis. Celecoxib should be used with caution in patients with history of cardiac failure, left ventricular dysfunction, hypertension or pre-existing oedema for any other reason. Caution is also
required in patients taking diuretic treatment or at risk of hypovolaemia. Like all NSAIDs, celecoxib can lead to onset or worsening of hypertension, which may contribute to increased incidence of cardiovascular events. Monitor blood pressure closely during initiation and throughout treatment. The elderly are more likely to develop compromised renal, hepatic function and especially cardiac dysfunction and therefore treatment should be monitored with appropriate medical supervision. NSAIDs, including Celecoxib may cause renal toxicity. Clinical trials with celecoxib have shown renal effects similar to those seen with comparator NSAIDs. Carefully monitor patients at greatest risk for renal toxicity, including those with impaired renal function, heart failure, liver dysfunction, and the elderly. Some cases of severe hepatic reactions (some with fatal outcome or requiring liver transplant) including fulminant hepatitis, liver necrosis and hepatic failure have been reported with celecoxib. Most of the severe adverse hepatic events developed within one month after initiation of celecoxib treatment. Appropriate measures should be taken and discontinuation of celecoxib therapy should be considered if there is a deterioration of organ system functions. Serious skin reactions, some of them fatal, have been reported very rarely in patients receiving celecoxib. The highest risk for onset of these reactions in the majority of cases is within the first month of treatment. Serious hypersensitivity reactions (anaphylaxis and angioedema) have been reported in patients receiving celecoxib. Patients with any other drug allergy may be at greater risk of serious skin reactions or hypersensitivity reactions. Discontinue at the first sign of skin rash, mucosal lesion or other sign of hypersensitivity. Celecoxib may mask fever and other signs of inflammation. In patients on concurrent warfarin therapy, serious bleeding events have occurred (see Interactions). Exercise caution when combining celecoxib with warfarin and other oral anticoagulants. Patients with hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption should not take celecoxib. Celecoxib inhibits CYP2D6. Caution should be exercised in patients known to be poor metabolisers of CYP2C9 and with medicines known to affect CYP2D6. Interactions: Monitor anticoagulant activity in patients taking warfarin or other anticoagulants, particularly when starting or changing the dose of celecoxib. NSAIDs may reduce the effect of diuretics and antihypertensive drugs. The risk of acute renal insufficiency, usually reversible, may be increased in some patients with compromised renal function when ACE inhibitors or angiotensin II receptor antagonists are combined with NSAIDs, including celecoxib. Monitor renal function when celecoxib is given in combination with these medicines especially in the elderly or when given with ciclosporin or tacrolimus. Celecoxib can be used with low dose aspirin but is not a substitute for aspirin for cardiovascular prophylaxis. Concomitant administration of celecoxib with low dose aspirin increases the risk of GI ulceration or GI complications compared with celecoxib alone. Dose reduction may be necessary for individually dose-titrated drugs metabolised by CYP2D6 (e.g. antidepressants (tricyclics and SSRIs), neuroleptics, anti-arrhythmic drugs). Celecoxib had no clinically relevant effects on the pharmacokinetics of oral contraceptives (norethisterone/ ethinylestradiol). Celecoxib had no significant effect on the pharmacokinetics of methotrexate but consider adequate monitoring when combining these two drugs. Closely monitor patients on lithium when celecoxib is introduced or withdrawn. In known CYP2C9 poor metabolisers avoid combination of celecoxib and CYP2C9 inhibitors. Use half the recommended dose of celecoxib in patients on fluconazole, a CYP2C9 inhibitor. Concomitant use of inducers of CYP2C9 such as
rifampicin, carbamazepine and barbiturates may reduce plasma concentrations of celecoxib. Adverse effects: Very common (>1/10): hypertension. Common (>1/100, <1/10): sinusitis, upper respiratory tract infection, urinary tract infection, allergy aggravated, insomnia, dizziness, hypertonia, myocardial infarction, pharyngitis, rhinitis, cough, dyspnoea, abdominal pain, diarrhoea, dyspepsia, flatulence, vomiting, dysphagia, rash, pruritis, flu-like symptoms and peripheral oedema/fluid retention. Uncommon (>1/1000, <1/100): anaemia, hyperkaelemia, anxiety, depression, tiredness, blurred vision, paraesthesia, somnolence, cerebral infarction, tinnitus, hypoacusis, heart failure, palpitations, tachycardia, hypertension aggravated, constipation, eructation, gastritis, stomatitis, aggravation of gastrointestinal inflammation, abnormal hepatic function, increased SGOT and SGPT, urticaria, leg cramps, increased creatinine and BUN increased. Rare (>1/10,000, <1/1000): leucopenia, thrombocytopenia, confusion, ataxia, taste alteration, duodenal, gastric, oesophageal, intestinal and colonic ulceration, intestinal perforation, oesophagitis, melaena, pancreatitis, eleveation of hepatic enzymes, alopecia and photosensitivity, Postmarketing experience (frequency not known): pancytopenia, serious allergic reactions, anaphylactic shock, anaphylaxis, hallucinations, headache aggravated epilepsy, meningitis aseptic, ageusia, anosmia, fatal intracranial haemorrhage, conjunctivitis, ocular haemorrhage, retinal artery or vein occlusion, arrhythmia, flushing, vasculitis, pulmonary embolism, bronchospasm, nausea, gastrointestinal haemorrhage, colitis/colitis aggravated, hepatic failure (sometimes fatal or requiring liver transplant), fulminant hepatitis (some with fatal outcome), liver necrosis, hepatitis, jaundice, ecchymosis, bullous eruption, exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, angioedema, acute generalized exanthematous pustulosis, arthralgia, myositis, acute renal failure, interstitial nephritis,hyponatraemia, menstrual disorder NOS, chest pain. Please refer to the SmPC for details of previously unknown adverse reactions occurring in polyp prevention trials. Packaging quantity and price: Pack of 30 capsules: €26.85 (Celebrex 200 mg). Pack of 60 capsules: €26.85 (Celebrex 100 mg). Marketing authorisation numbers and holder: PA 936/20/1 (100 mg) and PA 936/20/2 (200 mg); Pharmacia Ireland, 9 Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24, Ireland. Legal category: POM. Further information is available on request from: Medical Information at Pfizer Limited, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, UK. Tel: +44 (0) 1304 616161. Date of Preparation of P.I. October 2011. PI ref CB4_1 References: 1. Chan FK, Lanas A, Scheiman J et al. Celecoxib versus Omeprazole and Diclofenac in Patients with Osteoarthritis and Rheumatoid Arthritis: A Randomized Trial Comparing a Composite Outcome across the Entire GI Tract (The CONDOR Trial). Lancet 2010; 376: 9736,173-179. Date of Preparation: January 2012 CEL/2011/065
30 Breast Cancer
classified as type I and type II genes, based on differences in gene structure and tissue-specific gene expression. Type II MAGE-D genes are characterized by a more complex genomic structure compared to type I genes, with an open reading frame encoded by multiple exons. One of these genes, MAGE-D4B, has been reported in human malignancies, including gliomas, non-small-cell lung cancers and oral squamous cell carcinomas. However, an association of MAGE-D4B expression with breast cancer has not previously been established and the functional role of the encoded protein remains uncharacterized. In this study, by genome-wide microarray analysis of a large cohort of patients, we identified MAGE-D4B to be differentially expressed in invasive breast tumors compared with normal breast tissue and to be significantly associated with poor outcome. Gene silencing experiments indicated thatMAGED4B critically contributes to the tumorigenesis of breast cancer cells by regulating anchorageindependent growth, motility, invasiveness and expression of the invasionsuppressor gene E-cadherin. MAGE-D4B may thus represent a valuable prognostic biomarker for breast cancer and an attractive target for cancer therapy. MATERIALS AND METHODS Patient characteristics and tissue sampling The study involved analysis of 104 cases of primary breast cancer from patients aged between 31 and 89 years at the time of diagnosis. Nineteen non-cancerous breast biopsies were included in the study. Tissue specimen were obtained from patients undergoing surgery at St Vincent’s University Hospital (SVUH, Dublin, Ireland) and were analyzed following approval from SVUH Ethics Committee and with patients’ informed consent. Patients were followed-up for a maximum of 3,026 days. Following surgical resection and pathologic evaluation, tissues were snap
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frozen in liquid nitrogen and stored at 80 C before RNA isolation. Tumors were typed, graded and staging was performed as described previously. RNA extraction, cDNA preparation and quantitative realtime PCR Total RNA was isolated from tissue samples using Tri reagent (Sigma-Aldrich, Arklow, Ireland) as described previously. RNeasy mini kit (Qiagen, Crawley, UK) was used for total RNA isolation from cell lines according to the manufacturer’s instructions. cDNA was prepared from 100 ng RNA using MMLV reverse transcriptase (Sigma-Aldrich) according to the manufacturer’s instructions. Real-time PCR was performed, using a Mastercycler ep realplex2S system (Eppendorf, Cambridge, UK) and TaqMan Gene Expression Assays (Applied Biosystems, Warrington, UK). Samples were analyzed in triplicate, cDNA-absent and minus reverse transcriptase samples were included as negative controls. TaqMan Array Human Tumor Metastasis Fast 96-well plates (Applied Biosystems) were run on a 7900HT Fast Real-Time PCR System (Applied Biosystems) according to the manufacturer’s instructions. Expression was normalized to the endogenous control gene GAPDH, identified as suitable based on our previous studies. The comparative CT method was used for data analysis. Microarray A total of 100 ng of RNA isolated from each breast tissue sample were amplified and labeled as described previously. Gene expression was examined using whole-genome microarray(Affymetrix, U133 Plus 2.0) as reported previously. Cell culture and transfection The Hs578Bst breast cell line was obtained from the American type culture collection (ATCC) and maintained according to ATCC guidelines. The Hs578T breast cancer cell line was obtained from ATCC and the highly invasive
cloneHs578Ts(i)8 was kindly provided by Susan McDonnell. These cells were grown in Dulbecco’s Modified Eagle’s Medium (Sigma-Aldrich supplemented with 10% fetal bovine serum (FBS, Lonza, Wokingham, UK), 5% L-glutamine and 10 lg/mL bovine insulin (Sigma-Aldrich). Transfections of small interfering RNAs (siRNAs) and plasmid vectors were carried out with Lipofectamine 2000 (Invitrogen, Dun Laoghaire, Ireland) according to the manufacture’s instructions. Transfected cells were harvested 48 hr post-transfection for RNA extraction or biological assays and 72 hr after transfection for protein extraction. siRNA were purchased from Ambion (Warrington, UK) and transfected at 50 nM. Two independent siRNAs were used to target MAGE-D4B (siRNA 1, pre-designed ID 130972; siRNA 2, 50 CCCGGAGCUCAGAGAGGAGtt 30) and a scrambled-siRNA (Silencer Negative Control #1) was used as a negative control. MAGE-D4B fulllength cDNA was subcloned from pOTB7 vector (clone ID3502168, Open Biosystems, Dublin, Ireland) by PCR into pcDNA 3.1(�) zeo vector (Invitrogen). The obtained construct was verified by DNA sequencing. Immunoblotting Total cellular proteins were extracted by using the SDS lysis buffer (250 mM Tris-HCl, pH 7.4, 2.5% SDS), quantified with the micro BCA protein assay kit (Pierce, Dublin, Ireland) and dissolved in Laemmli sample buffer. Proteins were resolved by 10% SDS-PAGE and transferred to PVDF membranes (Millipore, Carrigtwohill, Ireland). Membranes were blocked in 5% low-fat dry milk (Bio-Rad Laboratories, Blessington, Ireland) and incubated with the indicated primary antibodies (anti-MAGE-D4 clone H-188, Santa Cruz Biotechnology, Heidelberg, Germany; anti-btubulin, Sigma-Aldrich; anti-Stat3, anti-phospho Stat3, anti-NFkB and anti-phospho NFkB,
Cell Signalling, Bray, Ireland). Membranes were incubated with appropriate horseradish peroxidase-conjugated secondary antibodies (Cell Signaling) and proteins were visualized by chemiluminescence (Millipore). Detection was performed with the Chemidoc exposure system (BioRad Laboratories). Immunohistochemistry All steps were performed at room temperature unless otherwise indicated. Tissue sections were dewaxed in xylene (2 - 5 min), rehydrated in grading alcohols 100%, 90% and 70% (2 - 3 min each) to H2O. Endogenous peroxidase activity was quenched by placing tissue sections in 3% (v/v) H2O2/ distilled water for 15 min. All slides were blocked for nonspecific staining with normal serum, (Vestastain ABC Kit, Vector Laboratories CA, PK-6101) for 20 min. Excess blocking serum was shaken off and 100 lL of the primary antibody (MAGE D4) was added to each section. Specifically, anti-MAGE-D4 clone H-188 (Santa Cruz Biotechnology, Heidelberg, Germany) was diluted 1:500 in phosphate buffered saline (PBS; pH 7) and incubated overnight at 4 C. Samples were then washed (3 5 min) with PBS, followed by a 30min. incubation with biotinylated secondary antibody (Vectastain ABC Kit, PK6101). Finally, following another 3 - 5 min wash step, Vector DAB substrate for peroxidise (Vector Laboratories, SK-4700) was applied for 5 min. All slides were washed (3 - 5 min) in running water. Tissue sections were then lightly counter-stained with Harris Haematoxylin for 1 min. After this, slides were dehydrated in grading alcohols 70%, 90% and 100% (2 - 3 min). Samples were then cleared in xylene and mounted in DPX (BDH, UK). Positive control using sections of glioma tissue (using same experimental conditions) and negative control samples (in which primary antibody were replaced with 100 lL PBS) were included in all experiments.
IV DRUGS / ONCOLOGY Product
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3B Fingal Bay Business Park Balbriggan Co. Dublin Tel: 00353 1 8413030 Fax: 00353 1 8496949 Preparation Mar 12
32 Breast Cancer
Cell proliferation assays Cells were plated in 96-well plates at a density of 5 103 cells/well and proliferation was measured at the indicated time points using the acid phosphatase assay. Anchorage-independent growth assays Assays were performed using the CytoSelectTM 96-Well Cell Transformation kit (Cell Biolabs) according to the manufacturerâ€™s instructions. 103 cells/well were incubated for 8days in a semisolid agar media before being lysed and detected with the CyQuant GR Dye in a fluorescence plate reader. Anoikis assays An amount of 1 105 cells/well were plated onto standard 24-well tissue plates or Poly(hydroxyethyl methacrylic) acidcoated (SigmaAldrich) plates and cultured for 24 hr. 100 lL of Alamar blue dye (Serotec, Oxford, UK) were then added to each well and absorbance was measured at 570 nm, with a reference wavelength of 600 nm. Wound-healing assays An amount of 2 105 cells/well were seeded on 6-well plates, transfected and cultured for 48 hr to confluency. Monolayers were scratched with a pipette tip and the resulting wounded areas were monitored by phase contrast microscopy and determined using NIH Image J software. Migration and invasion assays Assays were performed using 8 lm pore size 24-well Transwell chambers (BD Biosciences, Oxford, UK). For invasion assays the inserts were pre-coated with ECM (Sigma-Aldrich). An amount of 5 104 cells/well were seeded in the upper compartment and allowed to migrate for 48 hr. Cells in the upper chamber were mechanically removed and migrated cells were stained with crystal violet. Staining was solubilized in 10% acetic acid and absorbance was measured at 595 nm. Next issue of HPN features the results.
Issue 3 â€˘ HPN
Figure 2. MAGE-D4B is differentially expressed in syngenic breast normal and tumor cell lines and can be efficiently downregulated by RNA interference. (a) qRT-PCR analysis of syngenic cell lines showing increased MAGE-D4B mRNA expression in the tumor (Hs578T) compared to the non-tumorigenic (Hs578Bst) cells. The invasive subclone (Hs578Ts(i)8) displayed even higher expression levels. (b) MAGE-D4B protein levels were analyzed in the same cell lines by immunoblotting showing a concordant expression pattern. b-tubulin immunoblotting confirmed equal loading. (c) qRTPCR analysis showing reduced MAGE-D4B mRNA expression upon transfection of the Hs578T cell line with MAGE-D4Btargeted siRNAs. No variation was observed in scrambledtransfected cells when compared to non-transfected (nt) cells. D, immunoblotting analysis indicating a marked reduction of MAGED4B protein levels in Hs578T cells transfected with MAGED4B specific siRNAs compared to scrambled-transfected and non-transfected cells. b-tubulin confirmed equal loading.**p < 0.01; ***p < 0.001. Figure 3. MAGE-D4B gene silencing affects anchorageindependent cell growth and survival. (a) Soft agar assays showing a marked reduction in colony formation upon MAGE-D4B-targeted siRNAs transfection of Hs578T cells. Relative fluorescence unit (RFU) is expressed as mean 6 SE of three independent experiments. (b) Proliferation assays on siRNAtransfected Hs578T cells indicating that monolayer cell growth was not affected by MAGE-D4B gene silencing. Cell proliferation is expressed as mean 6 SE of three independent experiments, relative to absorbance of seeded cells. (c) Anoikis assays were performed by culturing Hs578T cells on poly-HEMA coated dishes or uncoated control dishes. The level of anoikis was assessed as the percentage cell death relative to adherent controls, and expressed as mean 6 SE of three independent experiments. MAGE-
D4B gene silencing resulted in a significant increase of cell death under anoikis conditions. **p < 0.01; ***p < 0.001.Figure 3. MAGE-D4B gene silencing affects anchorage-independent cell growth and survival. (a) Soft agar assays showing a marked reduction in colony formation upon MAGE-D4B-targeted siRNAs transfection of Hs578T cells. Relative fluorescence unit (RFU) is expressed as mean 6 SE of three independent experiments. (b) Proliferation assays on siRNAtransfected Hs578T cells indicating that monolayer cell growth was not affected by MAGE-D4B gene
silencing. Cell proliferation is expressed as mean 6 SE of three independent experiments, relative to absorbance of seeded cells. (c) Anoikis assays were performed by culturing Hs578T cells on polyHEMA coated dishes or uncoated control dishes. The level of anoikis was assessed as the percentage cell death relative to adherent controls, and expressed as mean 6 SE of three independent experiments. MAGE-D4B gene silencing resulted in a significant increase of cell death under anoikis conditions. **p < 0.01; ***p < 0.001.
Urinary Incontinence In Women Dr Clare O’Loughlin (Registrar in Obstetrics and Gynaecology) Dr Suzanne O’Sullivan (Consultant in Obstetrics and Gynaecology) Cork University Maternity Hospital
Dr Suzanne O’Sullivan (Consultant in Obstetrics and Gynaecology)
Urinary incontinence in women may be either stress, urge or mixed. Stress incontinence (SI) occurs when bladder pressure exceeds that of the urethral sphincter e.g. on sneezing or laughing, leading to leakage of urine. Urge incontinence (UI) involves detrusor overactivity (DO) leading to urinary frequency, urgency and incontinence. Symptoms of both may co-exist in mixed incontinence. Rarer causes are neurogenic or chronic retention. Overactive bladder (OAB) is characterised by frequency,
nocturia and urgency with or without incontinence, affecting approximately 17% of the population.1
on society with an estimated combined cost of OAB in Germany, Italy, Spain, Sweden and the UK of $5 billion.
Incontinence has a profound effect on psychosocial, occupational, physical and sexual functioning leading to distress and embarrassment.2 Up to 40% of people affected have never discussed their symptoms with a physician.
The total OAB cost was estimated at $12.0 billion in the United States in 2000, as demonstrated in the graph only 10% of this cost was for pharmacological treatments.4
Health related consequences of OAB include more GP visits, increased risk of urinary tract infection and falls.3 OAB confers a considerable economic burden
ASSESSMENT A detailed history should be taken to determine symptoms of stress, urge or mixed urinary incontinence and effect on quality of life. Initial investigation includes a thorough urological, gynaecological and
Symptom Assessment Symptoms
Urgency (strong, sudden desire to void)
Frequency with urgency (>8 times/24 h)
Leaking during physical activity; eg, coughing, sneezing, lifting
Amount of urinary leakage with each episode of incontinence
Large (if present)
Ability to reach the toilet in time following an urge to void
Waking to pass urine at night
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neurological examination and urinalysis. Presence of leukocytes and nitrates may indicate infection. Glycosuria may occur in diabetes. Haematuria, in the absence of infection, should be investigated to out rule underlying malignancy. A bladder diary will demonstrate frequency and episodes of incontinence. OAB may be treated in a primary care setting where there is evidence of urgency with a normal urinalysis. Referral to urologist or urogynaecologist is appropriate where there is incomplete voiding, neurological, metabolic, urological or gynaecological abnormalities. Urodynamic testing measures bladder capacity, post void residual volume and may demonstrate stress incontinence. It performed where initial therapy has failed, evidence of neurological dysfunction and prior to surgery for SI or prolapse. Cystourethoscopy is used to out rule malignancy, interstitial cystitis and calculi. TREATMENT Conservative therapy includes lifestyle changes such as reducing caffeine intake, smoking cessation and weight loss if obese. Behaviour modifications like bladder retraining aim to reestablish voluntary control over micturition by gradually increasing length between voids. Treatment should last at least six weeks. Physiotherapy, concentrating on pelvic floor exercises strengthen muscles controlling micturition thus improving symptoms of stress incontinence. Vaginal devices such as pessaries reduce pelvic organ prolapse and may improve symptoms of stress incontinence in those who are not suitable for surgery. Of the pharmacological therapies available antimuscarinics have been shown to improve symptoms of urgency, frequency and
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reduce episodes of incontinence. Anticholinergics are competitive muscarinic receptor antagonists. All five subtypes of antimuscarinics receptor have been found in the bladder. M2 and M3 are found in the smooth muscle cells of the detrusor and although M2 receptors outnumber the M3 threefold it is M3 receptors that have been shown to be responsible for micturition contraction. Antimuscarinic drugs depress voluntary and involuntary bladder contractions but are not selective for receptors in the bladder. They are available in oral immediate release (IR) and extended release (ER) tablets and transdermal patches. Tertiary amines are easily absorbed but have a high hepatic first pass metabolism. Some drugs have claimed to have functional bladder selectivity, suggesting their effects on the bladder are more pronounced than in other areas however their extrabladder side effects may still be dose-limiting. Common side-effects include dry mouth, constipation, dyspepsia, blurred vision and drowsiness. Rarer, serious side effects are anaphylaxis, confusion and prolonged QT interval. Contraindications are myasthenia gravis, narrow angle glaucoma, urinary retentions, active ulcerative colitis and bowel obstruction. Oxybutinon (Ditropan®, Lyrinel XL®, Kentera®) is a tertiary amine with higher affinity for M1 and M3 than M2. Tolterodine (Detrusitol®), another tertiary amine, with relatively low lipophilicity, is claimed to have functional selectivity for the bladder. Fesoterodine (Toviaz®) is a prodrug, metabolised to tolterodine. The OBJECT5 Trial compared oxybutinion ER 10mg OD with tolterodine IR 2mg BD and found oxybutinon to be more effective in reducing urge, total and weekly incontinence with similar side effect levels. The OPERA6 Trial compared the
same dose of oxybutinon with tolterodine ER 4mg OD and found no difference in urge incontinence, less frequency in the oxybutinon group and less dry mouth with tolterodine. Comparisons of efficacy between Detrusitol® ER and oxybutinon ER showed no significant difference in mean weekly urge incontinence episodes but Detruistol® significantly reduced frequency and less dry mouth.7 When transdermal oxybutinon patches were compared with tolterodine ER they equivalently significant. Both reduced daily incontinence episodes and while there were significantly greater antimuscarinics side effects with tolterodine, 14% of recruits reported application site pruritis with the patches and there were nearly 9% withdrew from the study. Solifenacin (Vesitirim®) is another tertiary amine with once daily dosing of 5 and 10mg. The STAR Trial8 was a 12 week randomised control trial comparing tolterodine ER 4mg with Solifenacin 5mg. After 4 weeks recruits could elect to increase their dose to Tolterodine 4mg + Placebo (the maximum dose of tolterodine is 4mg) or Solifenacin 10mg. Almost the same number in each group increased their dose (48% vs 51%). The study found a significantly higher proportion of patients became dry after treatment with solifenacin compared with tolterodine ER. Adverse effects were similar in both groups. Trospium chloride (Regurin®) is an atropine derivative with a quaternary ammonium group making it less soluble across the blood brain barrier with a lower incidence of CNS side effects however it has a relatively nonselective antimuscarinic action. Intravesical therapies used in the past include oxybutinon, capsaicin and resinferatoxin. Botox is being used increasingly for refractory detrusor overactivity.
It has recently been licensed for neurogenic DO. Botox is a toxin inhibiting acetylcholine release at the neuromuscular junction. Under local or spinal anaesthetic 200-400iu botox are injected into 20-30 sites in the bladder wall under cystoscopic guidance. Reitz et al used doses of 300iu of botox in their study and showed clinical and urodynamic improvement at 12 and 36 weeks post treatment with 73% previously incontinent recruits being dry at 12 weeks. It is an easy, effective treatment with high levels of patient satisfaction however the duration of action is on average 3 months, it is expensive and some patients may develop urinary retention requiring intermittent self catheterisation. Surgical option for OAB not responding to pharmacotherapy include sacral nerve stimulation, cystodistension, cystoplasty, detrusor myomectomy and ultimately urinary diversion with formation of an ileal conduit. In some patients long term indwelling catheters may be required. Stress incontinence is treated by either physiotherapy or surgery. Physiotherapy is effective in up to 70% of cases. The most common operation for stress incontinence is a mid-urethral sling which can be either retropubic or transobturator. In summary, urinary incontinence is a common condition which has a significant impact on quality of life. Most patients can be managed effectively in the primary care setting using a combination of lifestyle modification, behavioral therapies and anticholinergics. Referral to secondary care may be required when these measure fail to improve symptoms or initial investigation prompt the need for specialised management. REFERENCES ON REQUEST
A New Option for your post-menopausal osteoporosis patients Bone PLUS Protection from the start1
ABBREVIATED PRESCRIBING INFORMATION. Conbriza速 Film-Coated Tablets, bazedoxifene acetate. Before prescribing Conbriza please refer to full Summary of Product Characteristics (SmPC).Presentation: Conbriza 20 mg Film-Coated Tablets. Each tablet contains 20 mg bazedoxifene (as acetate). Indications: For the treatment of postmenopausal osteoporosis in women at increased risk of fracture. Dosage: Adults - for Oral use only. One 20 mg tablet daily, at any time of day, with or without food. Doses higher than 20 mg are not recommended. Calcium and/or vitamin D should be added to the diet if daily intake is not adequate. Dosage adjustments are not required in elderly patients or for mild/moderately renally impaired patients. However caution should be used in patients with severe renal impairment and use is not recommended in patients with hepatic impairment. Children - not indicated for use in paediatric patients. Contra-indications: Hypersensitivity to any of the ingredients; active or past history of venous thromboembolic events, deep vein thrombosis, pulmonary embolism and retinal vein thrombosis; patients with unexplained uterine bleeding; patients with signs or symptoms of endometrial cancer. Conbriza is only for use in postmenopausal women and must not be taken by women of child bearing potential. Warnings and Precautions: Conbriza is not recommended for use by women at an increased risk for venous thromboembolic events and should be discontinued prior to and during prolonged immobilisation (e.g., post surgical recovery, prolonged bed rest). Women taking Conbriza should also be advised to move about periodically during prolonged travel. Conbriza is not recommended for use in premenopausal women and any uterine bleeding during Conbriza therapy is unexpected and should be investigated. Conbriza is also not recommended for use in patients with hepatic impairment or in the treatment or prevention of breast cancer. Caution is advised in patients with known hypertriglyceridaemia, as Conbriza may increase serum triglyceride levels, and also in patients with severe renal impairment. Conbriza tablet contains lactose and should not be administered to patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose galactose malabsorption. Pregnancy & Lactation: Conbriza is not recommended in pregnant or breast-feeding women. Undesirable Effects: Very common reported sideeffects are hot flushes and muscle spasms. The following common side effects have also been reported; hypersensitivity reactions, somnolence, dry mouth, urtcaria, peripheral oedema and increases in blood triglycerides, alanine and aspartate aminotransferases. Uncommon and rare reported side-effects include retinal and deep vein thrombosis and superficial thrombophlebitis. Legal Category: S2B. Package Quantities and Marketing Authorisation Numbers: Conbriza 20 mg (28 tablets) EU/1/09/511/002, Conbriza 20 mg (84 tablets) EU/1/09/511/004. Product Authorisation Holder: Pfizer Limited, Ramsgate Road, Sandwich, Kent, CT13 9NJ, United Kingdom. Telephone: 01 4493500. Further information is available on request from: Medical Information, Pfizer Limited, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, United Kingdom. Date of revision: April 2011. Company Reference: CO 1_1. References. 1. Conbriza Summary of Product Characteristics. Date of preparation: September 2011. CON/2011/007.
38 Joan Peppard
A view from the top - with Joan Peppard The role of a hospital pharmacist changes and evolves constantly. Their remit now encompasses medication safety, review of oncology preparations, amongst many other duties. Hospital pharmacists are recognised as an integral part of the hospital multidisciplinary team. However the profession is not without its challenges. Essential changes to the career structure have been highlighted as of critical importance. HPN took the opportunity to speak exclusively with newly elected President of the National Association of Hospital Pharmacists Ireland, Joan Peppard.
Issue 3 â€˘ HPN
One of the best features has been the development and progress in hospital pharmacy services and the increasing benefit that appropriately used medicines bring to the management of diseases that used to be life threatening.
REPRESENTING THE VIEWS OF HOSPITAL PHARMACISTS Joan has been working within hospital pharmacy since 1984, having always worked in the Midlands. Currently Chief Pharmacist in the Midland Regional Hospital Tullamore she was appointed President of the National Association of Hospital Pharmacists Ireland last year. "Over the years I have enjoyed the many and varied roles that the hospital pharmacist undertakes. One of the best features has been the development and progress in hospital pharmacy services and the increasing benefit that appropriately used medicines bring to the management of diseases that used to be life threatening," she says. "There is constant change in hospital pharmacy. This presents a challenge every day so one can always look forward to constant stimulation. Achieving improved health or assisting in the best possible management of patient needs with careful and effective use of medicine and pharmaceutical knowledge is always rewarding." No two days are ever the same for this busy pharmacist, but one of her key objectives for the coming year has been identified as completing the implementation of the career structure agreement. "Hospital Pharmacy has
changed dramatically since I started in this industry. Clinical pharmacy was in its infancy in Ireland then. Now pharmacists are an integrated part of the multidisciplinary team and are recognised as the experts in medicine. NO LONGER FIT FOR PURPOSE "Oncology services could not be provided without the clinical pharmacists that review the oncology prescriptions and the hospital pharmacy production units that exist to manufacture the medicines in a very clean environment. "Pharmacists specialise in antimicrobial therapy and promote the safe use of antibiotics so that we will continue to have antibiotics that work. As there are now so many medicines, pharmacists also work in the area of medication safety. This area is growing in importance as there are so many medicines to be managed. "Patients are admitted and discharged from hospitals very quickly so there is a growing need for accurate information. Hospital Pharmacists have identified this need so we have a growing number of pharmacists involved in electronic prescribing and other electronic initiatives to promote patient safety. "The main challenge in the next twelve months is managing the changes in the health services while operating under a thirty five year old
structure that is no longer fit for purpose. "The health services would be enhanced by engaging the energies of hospital pharmacists in developing and managing the changes than by further delaying the required changes to the career structure. This is why the implementation of the agreement reached in 2011 is of critical importance. The Hospital Pharmacists Association exists: a) To further the development of hospital pharmacy practices. b) To assist in the provision of continuing pharmaceutical education. c) To represent the views of the Hospital Pharmacist on issues of relevance to hospital pharmacy. d) To advance the professional welfare of its members. "The association is an interest group in the IMPACT union. The executive will continue to seek implementation of the agreement as submitted to the Department of Health and Children in December 2011," highlights Joan as part of the association's endeavours to further the profession.
undertaking a Masters in Ethics with an emphasis on clinical ethics.," she says. "After that who knows. We live in changing times."
Clinical pharmacy was in it's infancy in Ireland in the 1980s. Now pharmacists are an integrated part of the multidisciplinary team and are recognised as the experts in medicine.
"Our annual conference and AGM is on April 21st and 22nd in the Crowne Plaza Santry. As for the future career progession for Joan, there are many avenues still to be explored. "I am currently
HPN • Issue 3
Hospital pharmacists consider the risks The latest information on product usage and safety was shared at a symposium held in Milan. The event, 'packaging and safety symposium' was organised by the Actavis Hospital Business Unit and brought together industry experts and end users from across the world. During the symposium, experts in 2D bar-coding, compounding and dose banding presented to almost 200 hospital pharmacists from 22 different countries. packaging protection systems and innovative preparation methods, Actavis continually strives to maximize the safety of the company’s products for those who interact with them. Actavis is focused on developing innovative product solutions to reduce the workload in pharmacies, freeing up resources for more valuable tasks. With the introduction
The event also incorporated two days of plant tours at the Actavis Nerviano manufacturing plant. The Actavis Nerviano facility produces vials for oncology treatments providing freezedried solution products, as well as high volumes of cytotoxic and non- cytotoxic injectables for sale globally. The Irish Hospital Business team along with three Irish customers attended the symposium. All found the trip
and progressive roll out of 2D bar coding we are investing to reduce the risk of dosing and administrative errors.” If you would further information about the Packaging and Safety Symposium or would be interested in attending this year’s event please Caroline Fitzgerald, Actavis Hospital Business Manager on 087 054 5344.
very informative and worthwhile. Speaking at the event in Milan, Caroline Fitzgerald, Actavis Ireland, Hospital Business Manager said: “Hospital pharmacists have to consider the risks associated with the handling and administration of chemotherapeutic and other high potency drugs every day. Focusing on areas such as contamination,
Date for your Diary The National Association of Hospital Pharmacy Technicians of Ireland are holding their Annual Conference at the Crowne Plaza Hotel, Santry on April 28th, 2012. Pharmacy technicians from all sectors are welcome to attend. For further information contact Yvonne Sheehan at: firstname.lastname@example.org ph: 01 4142566 or email@example.com
Issue 3 • HPN
Irish Charity Right to Sight Wins Novartis XOVA Award
Right to Sight, the Irish nonprofit organisation founded by consultant eye and oculoplastic surgeon Kate Coleman, has been recognised with a global award as part of the Novartis XOVA Programme. The XOVA (Excellence in Ophthalmology Vision Award) Programme provides funding, in the form of a grant, to medical specialists who have devised initiatives that are expected to have a significant impact on unmet needs in the field of ophthalmology.
Launches of Latanoprost and Timolol
New hospital web portal
New Fresubin® Jucy replaces ProvideXtra®
Right to Sight was selected from over 80 applications from throughout Europe for its proposal to fund a state of the art sustainable cataract surgeon training centre in Rift Valley, Kenya. Judged by a committee comprising 38 international experts in ophthalmology, the project was commended for its long-term viability and potential to improve the quality of ophthalmic care in this rural region. Pictured (L-R) are Carl Farrelly, Novartis; Loretto Callaghan, managing director, Novartis; Dr.
Actavis Ireland is delighted to announce the successful launches of Latanoprost Actavis 50 mcg/ml Eye Drops Solution & Latanoprost/ Timolol Actavis 50 microgram/5.0 mg per ml Eye Drops Solution on Day one following patent expiry. Latanoprost Actavis & Latanoprost/Timolol Actavis represent a record-breaking seventh first to market day one launch from Actavis in the last year. Together with numerous other product launches and line extensions planned for this year they will further add to Actavis’ continued position as the fastest growing generic company on the Irish market *.
Latanoprost Actavis is indicated in the reduction of elevated intraocular pressure in patients with open angle glaucoma and ocular hypertension. Latanoprost/Timolol Actavis is indicated in the reduction of intraocular pressure (IOP) in patients with open angle glaucoma and ocular hypertension who are insufficiently responsive to topical beta-blockers or prostaglandin analogues. Both Latanoprost Actavis & Latanoprost/Timolol Actavis are GMS reimbursable and available now from all wholesalers now. Latanoprost Actavis &
New web portal, www.cmrg.ie/ hospitals, allows you to easily place your order for exempt medicinal products electronically removing the need to fax your order through.
This new site allows you to manage all aspects of the exempt medicines part of your business including: Checking the availability of stock, pricing and re-printing of invoices. Contact Alchemy for login details: (01-6305432)
Fresubin® is delighted to announce a new member to the family, Fresubin® Jucy 200ml Drink. Fresubin® Jucy Drink is a juice style, high energy 300kcal oral nutritional supplement containing 8g (100%) whey protein. It is an excellent tasting alternative to milk supplements. Fresubin® Jucy is suitable for patients with:
Fresubin® Jucy Drink is enriched with vitamins, essential trace elements and calcium. In addition, it is fat and fibre free, gluten free and clinically free from lactose and cholesterol.
• Increased energy and protein needs • Dislike or fatigue of milky oral nutritional supplements • Fat malabsorption
Kate Coleman, consultant eye surgeon, Blackrock Clinic and founder of Right to Sight; Sarah Connellan, communications & development manager, Right to Sight
Latanoprost/Timolol Actavis are subject to medical prescription. For further information on the Actavis portfolio please contact 1890 33 32 31 or visit www.actavis.ie
taste best when chilled. Versatile, Fresubin® Jucy can be frozen and enjoyed as ice cream.
Fresubin® Jucy Drink 200ml will replace ProvideXtra®Drink 200ml, and will be substituted by Fresubin Jucy Drink as stock of flavours sells through in wholesalers. The GMS code and price for both is the same. Fresubin® Jucy Drink is available in a variety of flavours including Apple, Orange, Pineapple and Blackcurrant, which
HPN • Issue 3
42 Glyceryl Trinitrate
Do Patients Know How to Use Sublingual Glyceryl Trinitrate? Written by Deasy E1, Kirke C1, Naddy H2, Henman M2; Pharmacy Department, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children’s Hospital; School of Pharmacy, Dublin University Dr Martin Henman
glyceryl trinitrate spray may not always be understood1. SURVEY Patients were interviewed to assess use, storage and knowledge of glyceryl trinitrate. Dosing and use of spray knowledge scores were calculated by awarding each correct answer one point. The questionnaire and scoring were developed based on a related publication2. 14 patients newly admitted to the Coronary Care Unit (CCU) with a cardiac event and 12 patients attending an outpatient Cardiac Rehabilitation programme following a recent chest pain admission were interviewed.
INTRODUCTION Sublingual glyceryl trinitrate provides rapid (within 5 minutes), short-term (duration 20-30 minutes) relief of angina symptoms. Appropriate as required use of tablets and sprays e.g. Nitrolingual®, Glytrin® can prevent unnecessary pain and distress to patients. Glyceryl trinitrate is a nitrate, a potent coronary vasodilator Issue 3 • HPN
which exerts its principal benefit by reducing venous return, which reduces left ventricular work. Vasodilation is also associated with the undesired effects of flushing, headaches and postural hypotension. Recent research carried out in the Adelaide and Meath Hospital, Dublin, Incorporating the National Children’s Hospital (AMNCH), has shown that crucial messages that patients need to understand regarding their
varied e.g. ‘as directed’, ‘spray one spray as directed’, ‘max 3 puffs at a time’, ‘one puff as required’. Most patients had referred to written guidance on using the glyceryl trinitrate spray, with 14 referring to the patient information leaflet. Patient Understanding of Correct Use of Glyceryl Trinitrate Spray The average dosing knowledge score was 38% in newly admitted and 73% in cardiac rehabilitation patients. Low scoring questions included the maximum number of sprays to take and in what timeframe and when to seek medical attention.
Glyceryl trinitrate was first prescribed > 3 years ago for 11 patients and during last month for 2 patients. 42% had used glyceryl trinitrate in the last month.
Average use of spray knowledge was 50% in newly admitted and 76% in cardiac rehabilitation patients. Dosing knowledge decreased and use of spray knowledge increased the longer the patient had been prescribed glyceryl trinitrate.
[Picture]Storage and Sources of Information on Correct Use of Spray
KEY POINTS FOR PHARMACISTS
The majority of patients received education on the use of glyceryl trinitrate spray from a nurse or doctor. The spray should be stored in the box with the Patient Information Leaflet (PIL), to protect from light and ensure the PIL is available for reference when needed. However, only 42% kept the spray in the box with PIL as intended. 11 sprays were examined during the interview, of which 6 had pharmacy labels. The labelling
1.Patient knowledge - Patient knowledge about their glyceryl trinitrate therapy is suboptimal. Patients may be unsure as to how to self-dose in an acute chest pain episode and may not refer promptly for medical attention for uncontrollable chest pain. There is a worrying lack of knowledge regarding: • how many sprays may be taken at once,
BabyD is a paediatric food supplement of cholecalciferol (vitamin D3) BabyD is suitable for newborns during the first 12 months BabyD can be accurately measured using the oral dosing syringe provided Each 0.2mL dose provides 5Âľg of vitamin D3 BabyD is odourless and tasteless BabyD is available in all pharmacies BabyD is manufactured in Ireland
BabyD is a food supplement
ROI Freephone: 1 800 42 62 82 Email: firstname.lastname@example.org Web: www.kora-health.com
44 Glyceryl Trinitrate
The spray should be stored in the box with the Patient Information Leaflet (PIL), to protect from light and ensure the PIL is available for reference when needed. However, only 42% kept the spray in the box with PIL as intended. ACKNOWLEDGEMENTS Many thanks to Pharmacy, CCU and Cardiac Rehabilitation staff who supported and facilitated the study. Also thanks to Professor Kimble for sharing her survey questionnaire and scoring method. Correspondence to email@example.com References Naddy H. Audit of glyceryl trinitrate spray knowledge. Project in part fulfilment of BSc(Pharm), Trinity College Dublin, 2010 Kimble L, Kunik C. Knowledge and use of sublingual nitroglycerin and cardiac related quality of life in patients with chronic stable angina. Journal of Pain and Symptom Management. February 2000;19(2):109-117.
Figure 2: Storage of glyceryl trinitrate spray Storage of glyceryl trinitrate spray
11 sprays were examined during the interview, of which 6 had pharmacy labels. The have more than one spray to 3.Need for repeated patient • what time interval to leave labelling varied e.g. ‘as counselling directed’, ‘sprayon one ‘max 3Bailie puffs a knowledge ensureas you directed’, always have it with - Research the spray between sprays, G, Kayat E. Patients’ of sublingual glyceryl trinitratie, British you. Check the expiry date subject identifies that verbal time’, ‘one puff as required’. Medical Journal 1998; 297:32 • what the maximum dosage is
regularly and get a new spray if information is preferred by your old one is out of date. patients and that information Kelly J. Sublingual nitroglycerin: needs to be repeated at improving patient compliance with a Most patients had referred to written guidance •on using the glyceryl trinitrate spray, • when to seek medical Sit down (as you may become intervals for optimum patient demonstration dose. Journal of the attention. light-headed with 14 referring to the patient information leaflet (figurewhen 3). using the American Board of Family Practice 1988 understanding. This study Oct-Dec; 1(4):251-4. spray). confirms this, as dosing Dosing knowledge is lower in knowledge was found to be Ingram S, Love J. Cardiac patients’ patients prescribed glyceryl • If new pump being used or lower in patients on glyceryl perceived education and use of trinitrate for a longer time and Never, 8 pump not in use for a week or trinitrate for a longer time. There sub-lingual glyceryl trinitrate on in newly admitted chest pain more, spray one puff into the is a clear need and opportunity commencement of outpatient cardiac patients who have not yet air to get the pump working rehabilitation. Coronary Health Care for community pharmacists to received hospital education. properly. 1999;3:128-134 review patient understanding These findings are in line with of their glyceryl trinitrate spray Kimble L, Kunik C. Knowledge and Use • Spray 1-2 sprays under the other research on the subject. in line with the counselling of Sublingual Nitroglycerin and Cardiac tongue. PIL, 14 recommendations below. –Related Quality of Life in Patients with 2. Availability of written Chronic Stable Angina. Journal of Pain • Close mouth, do not inhale. information - Over half of COUNSELLING and Symptom Management February patients carry the glyceryl Label from 2000;19(2):109-117 • Wait 5 minutes. Pharnacy, 1 trinitrate bottle without the box The glyceryl trinitrate spray or PIL. Hence these patients McGovern E. Mackay C. Hair A. Lindsay may be used for chest pain • If pain persists, spray 1 further H. Bryson S. Pharmaceutical care needs on Box, will only have access toInstructions the (angina), chest tightness or spray under the tongue, close of patients with angina Pharmacy World information on the glyceryl 3breathlessness (where these and Science. 2001 Oct;23(5):175-6 mouth, wait 5 minutes. trinitrate bottle rather than the are the patient’s symptoms of more complete information in used Figure 3. Have you written guidance? Fan M. Mitchell M. Cooke M. Cardiac angina). The sprayglyceryl may also be trinitrate • The maximum dose is 3 sprays the PIL. The current labeling patients’ knowledge and use of used to prevent symptoms of over 15 minutes. sublingual glyceryl trinitrate (SLGTN). of glyceryl trinitrate products angina, e.g. before exercise or Australian Journal of Advanced Nursing is suboptimal. The following is Patient Understanding of Correct Use of Glyceryl exertion. • If pain is Trinitrate uncontrollable orSprayMarch-May 2009;26(3):32-38 considered by the authors to persists after 15 minutes, seek be the key information which You should store your spray urgent medical attention. patients need to use dosing their spray knowledge in the box withscore the patient The average was 38% in newly admitted and 73% in cardiac safely and effectively. The results information leaflet, to protect it • After using the spray, rest. rehabilitation patients. Low scoring questions included the maximum number of of this study have been shared from light and ensure that you When you first stand up after with manufacturers of glyceryl have written information if youwhen using spray,medical do so slowlyattention. sprays to take and in what timeframe and to the seek trinitrate sprays. need it. It is usually helpful to and be aware you may feel faint. and over what interval and
Issue1st 3 • HPN spray
into air if new
Out and About
HPN goes out and about Pharmacy hails new bodies The Pharmaceutical Society of Ireland has launched two new important structures in the education and training of pharmacists in Ireland, the Institute of Pharmacy and the National Forum.
A major pharmaceutical congress is also to be held in Dublin in August, 2013.
1) Paul Fahey, PSI President, An Taoiseach, Enda Kenny 2) An Taoiseach with members of the National Forum at Dublin Castle.
A taste for pharmacy More than 500 students from second-level schools throughout Ireland received a taste for life as a medical, pharmacy and physiotherapy student at the annual Royal College of
Surgeons in Ireland (RCSI) Open Day. During the day-long event, Leaving Certificate and A' Level students had the opportunity to meet with RCSI staff, students and graduates,
to give them an idea of what it is like to study medicine, pharmacy and physiotherapy and take up careers in these areas.
1) Anastasia Azareva from St Paul's Secondary School Dublin. 2) Mikaela Forde (17) a 6th Year student from Yeats College, Galway viewing some x-ray's at the RCSI Open Day
HPN â€˘ Issue 3
46 Out and About
Record graduations at RCSI The Royal College of Surgeons in Ireland conferred 717 students with undergraduate degrees and postgraduate awards at three conferring ceremonies in the
College at the end of last year.
commenced at 10.00am with the conferring of Degrees of Masters of Surgery, Masters in Pharmacy and Higher Degrees by Research to 182 students.
This was the largest number of students to graduate from the College in one day. The day
At 12.30pm, 228 students were conferred with undergraduate degrees in Medicine, Pharmacy and Physiotherapy and Degrees of Masters of Science (MSc).
1) Maryam Al Obaidly (BSc Pharmacy Graduate) 2) Aileen Cullen (BSc Pharmacy), Rachel Brady(BSc Pharmacy) 3) Yanette Bueno Diaz, Colm McDermott, Sinead Sullivan, Tadhg Reddan (Masters in Pharmacy Graduates) 4) Dr Judith Strawbridge, Lecturer in Pharmacy Practice, RCSI and PhD graduate Dr Helen McVeigh
Issue 3 â€˘ HPN
47 1) Dr Brian Cleary, Ms Michelle Flood and Dr James Barlow, RCSI School of Pharmacy staff 2) Suhanniya Logeswaran, Rachael Stewart, Gillian Doyle (BSc Pharmacy Graduates) 3) Gillian Doyle (BSc Pharmacy Graduate) 4) Sarah Ann Walsh and Angela Lally
HPN â€˘ Issue 3
48 Pharmacy representative visit to Uniphar Hospital pharmacists, technicians and representatives from some of Irelands leading pharmacy manufacturers visited Uniphar in Citywest on Thursday 8th March last. The evening began with a short presentation from Brendan O’Connell, Managing Director of Allphar Services. Brendan spoke about the service offered by the Allphar Hospital team on behalf of the manufactures who avail of Allphar Services. Many of these manufacturers also attended the meeting – Lundbeck, Roche, Phoenix Labs, Actavis, Goldshield, Healthcare, Merck Serono, Boehinger Ingelheim, Gerard Laboratories, Ecolab, Pharmscosmos to name a few.
Tony Toomey from Uniphar Wholesale then spoke about Pharmasource which is the EMPs service offering from Uniphar Wholesale. Tony highlighted the success of Pharmasource since its launch - Pharmasource was a finalist in the National Procurement Awards in 2011 for the ‘Best Use of Technology’ – after less than one year in operation. Tony gave a live demonstration on how easy it is to order Pharmasource products on line and explained that orders for EMPs can also be ordered by free phone and by free fax.
product is handled –from order through to delivery to their pharmacy. The facility, costing in the region of €64 million, is one of Europe’s most advanced pharmacy distribution centres. The tour highlights included the unique ‘pick by light’ technology, the effective ‘A ‘frame product pick and the amazing ‘crane’ like products used to pick from high bay. Most importantly as Thursday 8th March was International Woman’s Day – every lady received a small gift of a Newbridge pendant.
After these short presentations, everyone was invited to see the fantastic warehouse facilities. Pharmacists and technicians saw how a
1) Fiona Murray, Noilin O'Hara, Uniphar Pharmasource and Rebecca Corrigan, Connolly Hospital. 2) Clare Blaney, Roche Products, Tony Toomey, Uniphar Pharmasource, Rob Saunders, Uniphar wholesale, Francis Galvin, Roche PR. 3) Catriona Wyer, Ann O'Brien, Laura Lyons, Mater Hospital, Gillian Whooley, St Brendans Hospital and Eimear Hesling, Conolly Hospital.
4) Ciara Devlin, Gerard Labs, Oria Johnston, Beaumont Hospital and Sandra Duffy, St Brendans Hospital. 5) Kate Gargam, Our Lady of Lourdes, Orla O'Connor, Marketing Manager, Uniphar, Muireann Nihan, Uniphar, Christine Doyle, Our Ladys of Lourdes. 6) Jack Daly, Grunenthal Pharma and Clare Blaney, Roche Products. 5
7) Helen Heenam -, Goldcrest, Frank Corr, Managing Director, Corr Healthcare and Michael Griffin, Sales Manager, Uniphar.
8) Fiona Clerkin, and Lynne McGrath, Echolabs. 9) Niamh Ruame and Linda Murname, Clontariff Hospital.
Issue 3 • HPN
49 10 10) Evelyn Nolan, Liam Quinn, Director of Operations, Uniphar, Mary Kirwan, Sandra Ragget and Sharon Fox, Portaloaise Hospital. 11) Paul Ryan, Group Sales and Marketing, Uniphar, Yvonne Sheehan, President, NAHPT and Jennifer O'Meara, Tallaght Hospital. 12) Aiofe Conroy, Allphar Hospital Services Supervisor, Paul Doyle, Temple St Hospital and Caroline Fitzgerald, Hospital Business. 13) Rory O'Roirdan, Phoenix, Ann Ryan, Niche Generics, Brendan O'Connell, Managing Director, Uniphar and Elaine Condon, Commercial Director, Allphar.
HPN â€˘ Issue 3
Richard Price Chief Operating Officer of the European Association of Hospital Pharmacists (EAHP) Jennie De Greef today announced the appointment of Richard Price to the new position of Policy and Advocacy Officer.
Richard will join the EAHP in January to lead the association’s advocacy efforts in Brussels and Strasbourg on important issues such as the Professional Qualifications Directive, the Medical Devices Directive and the Patient Information Directive.
Richard has 9 years experience of representing organisations’ interests to European, national, and regional government audiences. He joins from the Pharmaceutical Society of Northern Ireland.
Professor John Fitzpatrick Professor John Fitzpatrick has been appointed Head of Research at the Irish Cancer Society. He will be responsible for developing a strategic plan for cancer research and will co-ordinate research efforts throughout Ireland, while encouraging collaboration through
mechanisms such as the Cancer Research UK model of cancer centres. Commenting on the recent appointment, John McCormack, CEO, the Irish Cancer Society said, “Appointing Professor Fitzpatrick as our new Head of Research is
a major step forward for us in the fight against cancer. Research is an area of great strategic importance for the Society, and with his expertise, we want the Irish Cancer Society to develop a major leadership role in cancer research in Ireland.”
Peter Gray United Drug has announced that Mr Ronnie Kells, who has been a Non-Executive Director of the Company since 1999 and Chairman for the last six years, will retire from the Board following
the conclusion of the Company's Annual General Meeting on 7 February 2012. Mr Peter Gray, who has been a Non-Executive Director of the
Company since 2004 will succeed Mr. Kells as Chairman. Mr. Gray is Vice Chairman and former Chief Executive of ICON plc and is also a Non-Executive Director of Danica Life Limited.
James Nagle James Nagle (Reckitt Benckiser) has been elected as IPHA VicePresident. General Manager of Reckitt Beckiser Ireland Ltd since 2009, James has worked at the company for over a decade in a
number of senior roles, including Marketing Director for Russia and Global Brand Marketing Manager UK. Prior to that he worked in
marketing for Proctor and Gamble and was based in Belgium. He holds a law degree from the Queen’s University, Belfast and an MBA from Georgetown University – McDonough School of Business.
Dr David Hall Dr David Hall (Johnson and Johnson) has been elected to the IPHA Board of Directors. Dr Hall is Head of Sales and Country Lead at Johnson and Johnson (Ireland) Ltd since 2010 where he is a member
of the Board of Directors, as well as at McNeil Healthcare (Ireland) Ltd. Educated at Imperial College London where he studied
Aeronautical Engineering and Combat Aircraft Design, he received his MBA from the University of California at Berkeley in 2004.
Mary Dickens Mary Dickens (Sanofi Aventis) has been elected to the IPHA Prescription Medicines Division Strategy Board. Mary Dickens
Issue 3 • HPN
joined the Sanofi Group in 1984 as a Medical Representative in UK. She held various positions including Regional Business
Manager in the UK before returning to Ireland in 1999 to join Abbott Laboratories as Divisional Manager.
FINALIST Bestt use Technology of Tech hnology
Pharmasource – Your Sourcing Solution for all exempt medicinal products, manufactured specials and bespoke procurement requirements. Pharmasource has expertise in logistics, national and international regulatory affairs and quality control. A premium all in one service from orders to delivery is provided: Highly experienced professionals are ready to take your callpharmacist and pharmacy technicians on site High service level – in many cases product available for next scheduled delivery Multi ordering system – by fax, email, online and enquiries by phone Unique online ordering system – no need for manual order completion or faxing No minimum order charge Unparalleled competitive pricing, leveraging a global network of suppliers Traceability and counterfeit monitoring and observing of adverse effects Certificate of Analysis TSE Compliance – supplier verification Compliance with IMB regulations and HSE reimbursement scheme Order tracking providing further reliability Cold chain service Most orders despatched with your next scheduled delivery* Free phone number: 1800 440 440 Free fax number: 1800 441 441 Email: firstname.lastname@example.org Website: www.unipharlink.ie * in some cases unusual/hard to source items may take longer, please call 1800 440 440 for more information
Uniphar Group, 4045 Kingswood Road, Citywest Business Park, Dublin 24
Published on Apr 29, 2012
Published on Apr 29, 2012
IN THIS ISSUE: Conference: Seminar hears drugreimbursement is wrongly dictated - Report: Can there be harmony in pharmacy? - Feature: The fu...