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April 2013 Volume 5  Issue 4


Now on TV

In this issue: NEWS:

Medicines robot brings pharmacy into 21st century Page 7


IACPT President Clare Ward on the growing importance of technicians in pharmacy Page 12


Variatrions in drug pricing evident following recent NCA survey Page 18


The issue of complex patients and the role of the pharmacist Page 24


The incidence of Type 2 diabetes written by Ronan Sheridan Page 31


The link between asthma and eczema in childhood Page 48

Avaibable from Ocean Healthcare and United Drug

NEWS: Naturally good.

Irish Pharmacy.indd 1

Ricola International

27/3/13 14:29:03

Pharmacy retirees are bade farewell at Trinity Page 57

“ I used to be stuck on smoking. With NICORETTE® INVISIPATCH™, nicotine I’m sticking with quitting” 90% more effective at helping smokers quit compared with placebo at 12 weeks1 (34% quit on NICORETTE® INVISIPATCH™ vs 17.5% on placebo; p<0.001).

Well tolerated with a good safety profile2 Nicorette Invisi Patch Product Information: Product Name: Nicorette Invisi 10mg/16 hours Transdermal Patch. Nicorette Invisi 15mg/16 hours Transdermal Patch. Nicorette Invisi Extra Strength 25mg/16 hours Transdermal Patch Composition: 10mg Patch - Nicotine, 10mg released over 16 hours use. 15mg Patch - Nicotine, 15mg released over 16 hours use. 25mg Patch - Nicotine, 25mg released over 16 hours use. Pharmaceutical Form: Beige semi-transparent patch consisting of pre coated backing layer, nicotine source layer, a skin contact adhesive layer on a pre-coated, aluminized and siliconised release layer with “nicorette” printed on the top face of the patch. Indications: For the treatment of tobacco dependence by relieving nicotine craving and withdrawal symptoms, thereby facilitating smoking cessation in smokers motivated to quit. Dosage: Adults and the Elderly: Nicorette Invisi Patch should not be used concurrently with any other nicotine products and patients must stop smoking completely when starting treatment. The patch should be applied to an intact area of the skin upon waking up in the morning and removed at bedtime. Patch treatment mimics the fluctuations of nicotine over the day in smokers, with no nicotine administration during sleep. Daytime nicotine patch treatment does not give the nicotine induced sleep disturbances seen with nicotine administration during sleep.Heavy smokers are recommended to start at Step 1 with the 25 mg/ 16 hours patch and use one patch daily for 8 weeks. Gradual weaning to the 15 mg/16 hours patch for 2 weeks followed by the 10 mg/16 hours patch daily for 2 weeks. Light smokers are recommended to start at Step 2 (15 mg) for 8 weeks and decrease the dose to Step 3 (10 mg) for the final 4 weeks. Use of the patch beyond 6 months is generally not recommended. Special Warnings and Precautions: Nicotine in any dose form is capable of inducing a dependence syndrome after chronic use and is highly toxic after acute use. However, dependence with Nicorette Invisi Patch is a rare side-effect and is both less harmful

and easier to break than smoking dependence. Particular cardiovascular patient groups should only use Nicorette Invisi Patch after consulting a physician. These patients include those who have experienced a serious cardiovascular event, or hospitalisation for a cardiovascular complaint, in the previous 4 weeks (e.g. stroke, myocardial infarction, unstable angina, cardiac arrhythmia, coronary artery bypass graft and angioplasty) or those who suffer from uncontrolled hypertension.Nicorette Invisi Patch should be used with caution in patients with severe/moderate hepatic impairment, severe renal impairment, active duodenal and gastric ulcers. The risk of using nicotine replacement therapy should be weighed against the risk of continued smoking. Nicotine, both from nicotine replacement products and smoking, causes the release of catecholamines from the adrenal medulla. Therefore Nicorette Invisi Patch should also be used with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma. Patients with diabetes mellitus may require lower doses of insulin as a result of smoking cessation. Patients with chronic dermatological disorders such as psoriasis, chronic dermatitis or urticaria should not apply Nicorette Invisi Patch to the affected areas. Erythema may occur. If it is severe or persistent, treatment should be discontinued. Interactions: Smoking (but not nicotine) is associated with an increase in CYP1A2 activity. After cessation of smoking, reduced clearance of substrates for this enzyme may occur. This may lead to an increase in plasma levels for some medicinal products of potential clinical importance and for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. The plasma concentration of other drugs metabolised in part by CYP1A2 e.g. imipramine, olanzapine, clonipramine and fluvoxamine may also increase on cessation of smoking, although data to support this are lacking and the possible clinical significance of this effect is unknown. Limited data indicate the metabolism of flecainide and pentazocine may also be induced by smoking.

Designed to help your smokers quit for good Undesirable Effects: Nicorette Invisi Patch may cause adverse reactions similar to those associated with nicotine administered by other means and are mainly dose dependent. About 20% of users experienced mild local skin reactions, during the first weeks of treatment. Some symptoms, such as dizziness, headache and sleeplessness may be related to withdrawal symptoms associated with abstinence from smoking. Increased frequency of aphthous ulcer may occur after abstinence from smoking. The causality is unclear. Nervous system disorders: Common:Dizziness, headache.Cardiac disorders: Uncommon:Palpitations. Very rare: Reversible atrial fibrillation. Gastrointestinal disorders: Common: Gastro-intestinal discomfort, nausea, vomiting. Skin and subcutaneous. Uncommon: Urticaria tissue disorders: General disorders and Very common: Itching administration site, Common: Erythema disorders. Marketing Authorisation Holder: McNeil Healthcare (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland. Marketing Authorisation Number: 10mg Patch - PA 823/49/21, 15mg Patch PA 823/49/22, 25mg Patch – PA 823/49/23. Date of (Partial) Revision of the Text: March 2011. Legal Category: Supply through pharmacies only. Product not subject to medical prescription.Further information available upon request from Johnson & Johnson (Ireland) Ltd. References: 1. Data on file – CEASE 4. 2. Tønnesen P et al. Eur Resp J 1999; 13: 238–246. IRE/NI/12-0218 For every cigarette, there’s a nicorette®

Contents 7

Page 6 Mullingar pharmacists take to their bikes for charity

Foreword GETTING THE BALANCE RIGHT Antibiotics are losing their effectiveness at a rate that is both alarming and irreversible – similar to that of global warming. Whereas it is virtually too late to do much about global warming, it is not too late to do anything about the over-use of antibiotics if it is done right now. In some countries, the supply of antibiotics has become quite irresponsible. They are dished out like sweeties, over the counter, to anyone who asks for them and are ‘dirt cheap’. And so, slowly but surely, antibiotics are becoming resistant to bacteria and, unfortunately there are very few alternatives being developed in the pipeline.

Page 11 Pharmacy claims - getting paid what you're owed

Page 14 IPU pharmacy technicians graduate with honours


Page 18 NCA survey displays signs of inequality in drugs pricing

Page 24 Complex patients and pharmacists management of them

Page 31


The incidence of Type 2 diabetes written by Ronan Sheridan

At a national level, pharmacists can – and do need to – ensure that any of their patients, who have been prescribed the drug should take it in the correct way, ensuring that patients know that it really is vital to take the right dose and to ensure that the course is completed - and explain why this is so important. If a patient understands the whys and the wherefores, they are far more likely to be compliant. As it would be particularly difficult for a pharmacist to intervene when a patient presents with a prescription for antibiotics, it would also be particularly advantageous to have a word with the local doctors about their views on the subject. Intervening is always delicate at the best of times and rather more so with children. However, obesity in children is very much on the increase and something has to be done to combat this trend, if only to prevent further problems in the future.

PUBLISHER IPN Communications Ireland Ltd. Carmichael House, Lower Baggot Street, Dublin 2 00353 (01) 6024715 MANAGING DIRECTOR Natalie Maginnis GROUP SALES MANAGER Debbie Graham 0044 7450274112

Irish Pharmacy News is circulated IRISH to all independent, PHARMACY NEWS multiple and hospital pharmacist, pre reg pharmacists, students pharmacy student’s official 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 Irish Pharmacy News ¤60 plus vat per year.


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

ACCOUNTS - Lorraine Moore ADVERTISING MANAGER Nicola McGarvey CONTRIBUTORS - Ronan Sheridan ART DIRECTOR - Smart Page Design


Good skincare management

By the time children go to school, one in ten is obese and, by the time they reach senior school, no less than two, if not three in ten (dependent on the area) are obese or clinically obese. Pharmacists could turn this to their advantage and, before anyone says, rather cynically that people who stay obese will bring them future business, they could actually obtain some of that business right now. The aim of everyone in healthcare is to keep the population healthy. Let’s do it. EDITOR Bridget Casey


Out and About


Product Profiles


The seasonal issue of hayfever 43

Clinical Profiles




         


 


E45 are announced as Foundation Partners of the newly formed Irish Skin Foundation E45, the number 1 selling brand for Eczema in Ireland, is proud to announce the brand becoming a Foundation Partner with the Irish Skin Foundation. E45 is a skincare brand that stretches from licensed medical creams to beauty lotions for normal, dry and sensitive skin with the backing of medical credentials including Irish Dermatologists. E45 works closely with key leaders in skincare including Eczema and Psoriasis Associations, expert dermatologists and GP’s in order to educate the consumer about all that is on offer from juniors to adults within the expert range. The new partnership means that E45 will continue its important work with top medical experts on skin conditions affecting Irish people including psoriasis, eczema, dermatitis, allergy sufferers and other dry skin

conditions. Together with the Irish Skin Foundation, E45 will also have access the leading skin research and statistics being established in Ireland. All of this will help to better understand Irish skin conditions and treatment options best suited to specific skin conditions. Speaking about the Partnership, Georgina Cunningham, Brand Manager for E45 said, “We are delighted to have become a Foundation Partner with the Irish Skin Foundation. It is broadly known that E45 provides a unique formula that is clinically proven to treat and soothe dry, itching, flaking chapped and rough skin. Now with this partnership we look forward to working even closer with the broad Irish Medical community & research teams in order to help create a better understanding of Irish skin conditions.” For further information about E45’s wide range of products, visit











The e45 range offers Complete emollient therapy, in line with dermatologistâ&#x20AC;&#x2122;s reCommendations1



Prescribing Information Abbreviated prescribing Information: E45 Cream White Soft Paraffin 14.5% w/w Light Liquid Paraffin 12.6% w/w Anhydrous Lanolin 1.0% w/w E45 Cream is a white smooth emollient cream containing white soft paraffin 14.5% w/w, light liquid paraffin 12.6% w/w and anhydrous lanolin 1.0% w/w. Also contains Cetyl alcohol 0.5% w/w, Methyl Hydroxybenzoate (E218) 0.15% w/w and Propyl Hydroxybenzoate (E216) 0.04% w/w. Uses: For the symptomatic relief of dry skin conditions where the use of an emollient is indicated, such as flaking, chapped skin, ichthyosis, dermatitis, sunburn, the dry stage of eczema and for use as emollient adjunctive therapy in the treatment of dry cases of psoriasis. Dosage & Administration: Adults, children and elderly: For topical use, apply to the affected part two or three times daily. Contraindications: E45 Cream should not be used by patients who are sensitive to any of the ingredients. Special Warnings and Precautions: For external use only. If symptoms persist consult your doctor. May cause allergic reactions such as local skin reactions. Keep medicines out of the reach & sight or children. Pregnancy & Lactation: No clinically significant interactions know. Undesirable Effects: Occasionally hypersensitivity reactions, otherwise adverse effects are unlikely, but should they occur may take the form of an allergic rash. Should this occur the use of the product should be discontinued. Package Quantities: 50g tube, 125g tub and 500g tub (pump dispenser). Legal Category: Available as an item through general sale. Product Authorisation Number: 979/43/1. Marketing Authorisation Holder: Reckitt Benckiser Ireland Ltd., Citywest Business Campus, Dublin 24. For complete prescribing information please refer to SmPC. Full prescribing information and additional information available on request. Product queries please call 01-6305429. Date of Preparation: February 2011 *IMS, AC Nielsen Jan 2012 1. Cork MJ et al. Getting results from emollient therapy on atopic eczema. Derma Prac 2004. Vol.12 No. 3; 16-20 Item Number: E45-IE-10-12 Date of preparation: April 2012

News Investment is needed news brief from the young SURVEY SHOWS PHARMACY PRICE COMPETITION According to a National Consumer Agency survey, some patients are being charged twice the price for the same drug, depending on what pharmacy they go to. The survey shows that price gaps for some drugs can vary from 37pc to 199pc in different outlets, depending on the mark-up and dispensing fee added on by the pharmacist. The findings from the National Consumer Agency (NCA), based on a survey of 45 pharmacies, showed: - The largest percentage variation in price for an individual product within a local area was for Losec Mups 20mg ,a medicine commonly used to treat stomach ulcers. The difference in price in Waterford was found to be 122pc, with prices ranging from ¤22.43 to ¤49.69. - The second highest percentage price variation within an area was for the product Zoton Fastab Tabs 30mg ,used to treat patients with stomach complaints. In Dublin, prices ranged from ¤19.96 to ¤42.33, a difference of 112pc. The survey shows that price gaps for some drugs can vary from 37pc to 199pc in different outlets, depending on the mark-up and dispensing fee added on by the pharmacist. 132 pharmacy stores were selected for inclusion in the survey and from those, information was received from 45 (34%). This response rate was in the expected range and the NCA is confident that the methodology and sample size are robust and that the results represent an accurate description of the levels of price variation in the sector.


The majority of healthcare professionals, including pharmacists, feel young people need to invest in private health insurance in order to maintain and protect the principle of community rating. Laya healthcare conducted a study with healthcare professionals to gauge their satisfaction with the healthcare system. The majority felt the future of the private healthcare system requires the encouragement of young people to invest in health insurance. Peter McElwee, pharmacist at McElwee Pharmacy said; “It is important for my patients to have health insurance. I often meet patients who have ended up in

some level of difficulty and have been outside the availability of the public system and they often show regret at that point. I think young people don’t think about insurance until their 30’s. ” Commenting on the findings, Dónal Clancy, Managing Director of Laya healthcare said, “The research confirms our worst fears that the price spiral affecting private health insurance will force more people to drop their cover this year.

Finding ways to incentivise people - especially the young and healthy - to take up private health cover, will be critical if we are to transition successfully and seamlessly to the new Universal Healthcare system promised for 2016. McElwee added, “Health insurance needs to be hassle free, with minimum paperwork in order to encourage young people to avail of it.”

Pharmacist gears up to raise over €10,000 for Ovarian Cancer John Keane, a pharmacist in the Market Point Pharmacy, Mullingar is looking to recruit anyone from the world of Pharmacy to take part in a sponsored 213-kms bicycle ride from Dublin to Galway, to be known as Ovarian Cancer Cyle. Keane told The Irish Pharmacy News, “In 2011, a group of pharmacists helped to promote awareness of prostate cancer with the Prost8 campaign. We raised over ¤10,000 for the Irish Cancer Society with our sponsored bicycle ride and, this year, we decided to shift our focus to the fourth largest cancer amongst women in Ireland, ovarian cancer.

who would like to take part in the event but he is hoping to recruit many more. “We are looking for as many pharmacists, technicians, sales assistants, reps, tutors, pre-reges or anyone at all linked to our profession to take part in the ride and make it a success,” he said.

As for the training that Keane will require for such a gruelling cycle ride, he says, “We'll tackle that one closer to the time!” If you would like to take part or donate to the Ovarian Charity Cycle please log on to to register.

"The 213-km cycle ride will attract a lot of publicity and will certainly help to raise more awareness of ovarian cancer. We are really looking forward to the challenge.” The itinerary is spread over two days. The first leg will be from Dublin to Athlone, leaving Phoenix Park on July 12. The second leg of the journey, on the Saturday will end in Galway. So far, Keane has received applications from ten other people,

8th pharmacy franchise for Life Life Pharmacy has opened its 8th franchise in Leixlip county Kildare. The conversion of Griffins Pharmacy to Griffins life Pharmacy was undertaken mostly through night work and as a result, the pharmacy traded its normal hours

throughout the entire program. The pharmacy maintained its sales volume even though the floors, ceilings, shop-front and wall fixtures were replaced! This is the second franchise opening for life pharmacy in

2013, with more to come.If you are interested in finding out more about life pharmacy, please contact Paul Spiller, the life Pharmacy Franchise manager.

News Bradley’s Pharmacy fit with state of the art robot Bradley’s Pharmacy, 5 Lower Kilmacud Road, Stillorgan recently received a total 21st Century makeover. This long established pharmacy has been completely refitted throughout. However what makes this pharmacy refit so high tech & different is the installation of the state of the art German robotic dispensing system. Willach the German supplier of the robot are world leaders in robotic dispensing systems. The installation of the robot allows more popular, higher volume medicines to be dispensed robotically. This means that the preparation has been greatly reduced especially during busy periods. This allows for quicker dispensing turnaround times. Not only has dispensing service become faster & efficient, the robot allows all Pharmacists & dispensary team much more time to interact with patients/ customers. Now, on presenting a prescription the pharmacist is involved directly with the patients at stage one.

news brief KERRY PHARMACIST’S GREAT WALK Kerry pharmacist Joe Crowley recently braved the Camino Walk and raised a whooping ¤19k for the Cystic Fibrosis Association of Ireland and the Pharmacy Benevolent Fund. Crowley walked the Santiago de Compostela (The Way of St James) , followed the ancient pilgrimage route in Northern Spain, beginning at the foot of the Pyrenees on August 24th and finished in Santiago in the north-west corner of Spain in late September 2012, a distance of 800km.

The new, state-of-the-art robot that has taken up residence in Bradley's Pharmacy, Stillorgan

This is known as forward dispensing process. The Pharmacist is available to discuss the patients’ prescription there and then whilst the robot prepares & quickly dispenses the correct medication. The Pharmacist then completes the prescription & discusses the patients’ medication.

The robot is 100% safe & accurate, all medication dispensed by the Robot is double checked by the Pharmacist prior to handing to the patient. The Pharmacist completes the prescription & is available to the patient at every stage.

PSI visit American Pharmacists congress PSI President Paul Fahey along with Kate O’Flaherty recently attended the American Pharmacists Association (APhA) Annual Congress in LA at the beginning of March. Promoting the International Pharmaceutical Federation (FIP) Congress on a booth in the exhibition area, they met with enthusiastic US pharmacists intending to be in Dublin later this year. From a US perspective there is great interest in the global event taking place this year in Ireland.

US Pharmacists speaking with Kate O'Flaherty and Paul Fahey, PSI at APhA Congress

PHARMACY STUDENT RECEIVES AWARD UCC scientists received three of the nine awards granted to Irish third level institutions for cancer research at the recent annual Irish Cancer Society Research Awards Ceremony. James Evans was awarded a Research Scholarship for research in the area of prostate cancer under the supervision of Professor Caitriona O’Driscoll, School of Pharmacy. James hopes to improve on existing prostate cancer treatments by designing a gene-based therapy. The Fellows and Scholars awards are designed to foster home-grown cancer research talent in Irish educational institutions and to ensure that new research projects are undertaken on breast, oesophageal, colorectal, gastrointestinal and prostate cancers. The research projects span a wide range of research areas and will investigate a number of potentially important topics, such as the response of cancer cells to chemotherapeutics and the manner in which they interact with our immune system.


At Pinewood Healthcare,

we stand for


As the Leading Generic supplier in Ireland, we are proud to offer the medical community throughout the countr y the choice to prescribe and dispense quality generic treatments. In doing so, we are working with you to help your patients benefit from quality and cost-effective medications. With over 30 years manufacturing healthcare products in Ireland, Pinewood Healthcare is one of the largest generic suppliers with a workforce of over 340 people. We are always committed to providing the Irish market with quality brands at inexpensive prices.

Irelandâ&#x20AC;&#x2122;s No1 Generic Healthcare Specialists


Pharmacies take spotlight at business awards Three Irish Pharmacies were accredited for their innovation and diversity at this year’s Deloitte’s Best Managed awards.

Sam McCauley and Patrick McCormack (Sam McCauley) and Michael Guerin, Medicare

Sam McCauley Chemists, Medicare Pharmacy Group and Cara Pharmacy were recognised at the event on 1st March in The Burlington Hotel, Dublin. Cara Pharmacy took home the winning title of one of Ireland’s ‘Best Managed Company’ for the second year in a row. Speaking about the awards Ramona Nicholas, Joint Director, Cara Pharmacy said: “This has been a very exciting year for Cara Pharmacy and we are thrilled to have again been recognised as one of Ireland’s Best Managed Companies, which is a testament to our wonderful Team Members

and Customers, who have been exceptionally supportive and loyal to our company over the last number of years.’’ Kevin Sheehan, a partner in Deloitte, spoke about what an award means to the image of pharmacies as a business as well as a health care service, he said; “Some of the key characteristics of many of the winning companies over the last number of years have been their ability to innovate, diversify, and capitalise on new market opportunities in particularly challenging times. This is something we have observed with the pharmacies which have

received this accolade.” John Bruton, Former Taoiseach and Chairman of IFSC Ireland, who was a guest at the ceremony, said of the awards; “The achievements of the winning companies here tonight are even more exceptional in light of the challenges that companies continue to face all around the country. This sector is of fundamental importance to the Irish economy, and I congratulate all involved.” The three pharmacies recognised in this year’s awards have requalified for next year’s awards.

United Drug 6th Pharmacy Show United Drug have announced details for their 6th Pharmacy Show and it promises to be an extra special one as it celebrates a milestone in United Drug’s history by welcoming their 65th year of business!

For further information please contact Ann Walsh at:

DIABETES SELFMANAGEMENT A self management patient education programme for people with diabetes is taking place in Kenmare on Thursdays 4th April until May 9th 2013 in the Kenmare Primary Care Centre, Kenmare. The programme, which is being organised by the HSE South’s “Community Nutrition and Dietetics Departments” in conjunction with local general practitioners, is aimed at improving people’s awareness about the up-to-date treatment and management of diabetes. Patients participate in 2� hour weekly education sessions for six weeks where improving patient’s health and increasing patient’s control over their illness is a key element of the programme. Patients may also attend further education sessions at three months, six months and at one year if required. Maria Browne, HSE Community Dietician said “the motivation for such an education programme is due to the prevalence of type 2 diabetes which has increased globally in recent years.”

PSI COUNCIL CANDIDATES 2013 The Pharmaceutical Society of Ireland has published the following is the list, in alphabetical order, of the names and addresses of the candidates for the 2013 election for appointment to the Council of the PSI. These persons, for whom nomination papers were received by 12.00 noon on Wednesday 20th March 2013, have been formally declared as candidates by the Returning Officer Ciara McGoldrick, PSI Acting Registrar, following validation of their nominations in accordance with Rule 8 of the PSI (Council) Rules 2008 Nicola Cantwell, Department of Science & Health, IT College Carlow Richard Collis, Pharmacist, Dublin


6 5

Georgina Ann Frankish, Pharmacy Department, Rotunda Hospital


Eoghan Hanly, Pharmacist, Galway

The event is being held at the Aviva Stadium Conference Centre from Sunday 9th to Tuesday 11th June. For 2013, they have decided to showcase 65 things that United Drug have done, and indeed will do, to ensure continued growth and strengthen their core ethos, which is to ensure survival of retail Pharmacy in Ireland. As always, the Pharmacy Show will be a unique event in the pharmacy calendar.

news brief

Edward MacManus, Pharmacist, Castleknock Rose Caroline McGrath, Dublin David O’Sullivan, Pharmacist, Kildare

65 years and the best is yet to come...

Conor Phelan, Pharmacist, Carrigaline



A new approach in early Alzheimer’s Disease.

Souvenaid® contains a unique, patented combination of nutrients* which have been shown to improve memory in early Alzheimer’s Disease1,2. It is a well-tolerated,1,2 convenient (125ml) once-daily drink. Souvenaid is based on more than 10 years of research. Souvenaid will be available to purchase over the counter in pharmacy. To find out more information go to

or call our Freephone Careline (ROI) 1800 923 404 Souvenaid® is a Food for Special Medical Purposes for the dietary management of early Alzheimer’s Disease and must be used under medical supervision. Unique, patented combination of nutrients: Omega 3 fatty acids (DHA & EPA), uridine monophosphate, choline, phospholipids, B vitamins and other cofactors which are all required to make neuronal membranes3.


1. Scheltens P, et al, J Alzheimers Dis, 31(2012) 225-236 2. Scheltens P, et al, Alzheimers & Dementia, 6(2010) 1-10 3. Kennedy EP Weiss SB (1956) J Biol Chem 222(1):193-214


Pharmacy Claims Article “Get Paid what you’re owed, and save time and money into the bargain”. “My claims are ok”…. This is often a response we get when talking about our claims reimbursement service. In all of these cases bar one we’ve shown that even well run claims processes in stores are leaking profits. As Pharmacies face into further cuts in government reimbursement and an ever deepening recession it’s growing more and more evident that every cent counts. The same can of course be said for any business, but Retail Pharmacy has two distinct advantages. Firstly they can rely on a largely loyal customer base with a guaranteed footfall, but perhaps more importantly they have one customer who by and large spends more with them than the rest of their customers put together- the PCRS. Despite this fact this is so often a transaction that is taken for granted, and not given the attention it deserves. Tills are recounted to find small amounts of money which have gone missing, or suppliers are endlessly chased for stock they may not have sent, but too often hundreds, and in some cases thousands of euro go unclaimed on a monthly basis due to a lack of a proper claims submission and management process. Over the last two years we’ve reviewed the historical situation in hundreds of Pharmacies, and found on average ¤5,000 worth

of outstanding claims. In many cases the figures are in to the tens of thousands, and in one case ¤70,000. Obviously this has a significant effect on margin and profitability as it is effectively cash missing directly from the bottom line. The system itself is often blamed for the level of rejections and I’ve no doubt the complexity of the claims process could be made easier. However the fact remains that in the vast majority of instances, any claim submitted correctly will be paid. There are three areas I would urge all Pharmacies to look at going forward:• Check your historical claimshave you been paid for all the prescriptions you’ve submitted? There is a wide variance across the industry at the moment in how this is carried out. This includes those who submit every reclaim and check every payment, those who submit but don’t follow up, those who only submit reclaims sporadically, and those who do not submit rejects at all. • Reduce the level of rejectionsthis is far and away the most

important step in the process. Training should be implemented for the dispensing system you have, and also on the process that surrounds submission and management. Our experience has shown that those Pharmacies who have well trained staff and a well managed process can reduce the number of scripts they get rejected to virtually zero. This has other beneficial knock on effects such as increased productivity as it is one less job that needs to be done, and improved cashflow as you are receiving your payments quicker from the PCRS. • Monitor future payments- put in place a system to check your submissions versus payments, and chase outstanding claims until resolved. If step two has been delivered, this is a check that will take about half an hour a month. In terms of the time/money investment needed to look historically, it’s more than worth it. Looking forward, once there is a proper system in place it undoubtedly saves time in the future. We’ve personally worked with many within the industry, successfully reclaiming significant amounts of money for Pharmacies,

Conor Walker, Director TONiC Consultancy

and working with them to implement management processes to reduce rejections, and increase cash flowing into their business. TONiC Consultancy was formed two years ago, specifically targeting the Retail Pharmacy sector. They specialise in solutions with tangible business benefits, their aim being to work with their clients to achieve the extraordinary.

Recognition for pharmacy technicians The IACPT annual conference was in Dublin this year, with regulation and recognition for Pharmacy Technicians still the hot topic. “This conference gives technicians the opportunity to network and feel valued; professionals, students and drug companies come together.” Julie Dunne, DIT course Co-ordinator said. Up until this year the conference has been held in Athlone IT but this year DIT Cathal Brugha St campus in Dublin hosted the annual event. The conference hosted several speakers, one of which was Maura Kinahan of Pfizer who spoke about Reference Prices and Generics. When asked about the importance of pharmacy technicians she said; “I would hope technicians in Ireland would be recognised in the same way as their UK counterparts.” Turn the page to read our exclusive profile with IACPT President Clare Ward. Pictured: Seana Hogan, PSI; Julie Dunne, DIT Course Co-ordinator, Clare Ward, President and Emmett Moran, ICAPT



Ward still campaigning for technician’s rights Clare Ward has campaigned for the regulation and registration of Pharmacy technicians since she was elected president of the Irish Associations of Community Pharmacy Technicians in 2011. She anticipates regulation and registration to come into place in an estimated five years but believes that with more awareness on the importance of pharmacy technician regulation and registration, the smoother and easier the process will be. “Pharmacy technicians are the support staff and have a very important role to play in the pharmacy team, especially now pharmacies have become much more clinical with vaccinations and the morning after pill. They are now talking to patients more and are consequentially turning to technicians more than ever before for assistance in the pharmacy. I think it’s very important that we have confident, highly trained and experienced technician staff at the dispensary.” Ward is a qualified technician and worked in a number of pharmacies before she took on her role as president. “I started off, as many pharmacy technicians do, at the perfume counter when I was 16 in Smyth’s pharmacy in Dundalk, Co Louth. I didn’t really know what profession I wanted to pursue at the time and had a huge variety of careers on my CAO application form.” She studied hard for her Leaving Cert and achieved a good result but was still unsure what career path to take “The IPU (Irish Pharmacy Union) had just started the technician’s course and my boss Anne McEntegart, asked me if it was something I would be interested in. I was still unsure what career path to take so I decided to do the course.” Ward studied with the Irish Pharmacy Union’s technician course for two years and


continued to work in Smyth’s Pharmacy Dundalk for seven. During this time she gained valuable experience, under the direction of the pharmacist, Anne McEntegart. “Smyths have generations of families coming to them. This is due, in no small part, to their excellent customer service skills. They put a big emphasis on this area and I feel that I gained invaluable experience in patient empathy,”she said. “They are a small but very busy pharmacy. Because of this I got great experience in all areas from the dispensary to the front of shop. In a smaller pharmacy you are taught to better adapt to every area and not just confined to one part of the business.” After her seven years in Smyths pharmacy, Ward decided to spread her wings and get some culture and life experience; she went to Australia for a year. She worked in a large pharmacy in Melbourne city centre; it was here that she saw the difference between the two countries and pharmacy models. She experienced first-hand what Irish pharmacies were lacking. “The pharmacy was so big, it was like working in a supermarket. It was such a beneficial experience working in Melbourne. I improved and changed as a technician,” she said. “You realise the amount of wastage and the amount of costing with the generics and branding products in Ireland.

In Australia, the government will subsidise the generic drugs but if you want the branded product you pay extra. I think this is a good cost cutting idea, especially in a recession.” When Ward finished her time in Australia, she came back to Ireland equipped with her developed skills and worked briefly with McCabes pharmacy in Gorey and then with Adrian Dunne Pharmacy. “As Adrian Dunne is a group pharmacy, there were more established roles. Therefore, I was based almost solely in the dispensary. This meant that I got more experience and had the role of Senior Technician, which brought more responsibility. Team work was of great importance and great emphasis was put on this. As it was a group, there was more emphasis on meeting targets and it was great to rise to those challenges.” She said. Ward worked with Adrian Dunne pharmacy for three years. At this point in her career she decided to take a career break as she had just gotten married and was then struck with illness. “After my career break I jumped two feet into the IACPT (Irish Association of Community Pharmacy Technicians). I was elected president in 2011 and had a complete career change. I went from a pharmacy technician to a representative, manager, public relations officer and campaigner all rolled into one,” she said “It’s a bit scary because I am the voice for community technicians and sometimes I don’t feel it’s as strong as it should be but that’s something I have to overcome.” She stresses that the IACPT is not a union but an association that provides support. “We want to advise our members, everyone that works at IACPT are all voluntary, people are scared of unions and we want to differentiate ourselves from that.” She explained to the Irish Pharmacy News how she realised how important the campaign of regulation and registration was; “Before joining the IACPT, I had heard of regulation and registration but, to be honest, I didn’t totally understand the significance of it. When you

are working in a certain way in an industry where there isn’t registration and regulation for your profession, it can take a while to fully understand the necessity and significance of it. From attending the European Association of Pharmacy Technicians in 2011, and talking to Yvonne Sheean (President of the NAHPT) I began to fully understand the significance of ensuring that regulation and registration were made a priority in the Irish pharmacy sector.” Over the past two years, since Ward has become president of IACPT, the Pharmacy technician course in Athlone IT has been recognised as a level 7 degree and Ward and Sheehan were elected on to the advisory council on the pharmacy practice development committee in November 2012. This is seen as a huge step forward in the pursuit of the occupation being recognised as a profession and part of the integral pharmacy and healthcare team. Speaking of her current role Ward told Irish Pharmacy News, “I hope I’ve been a good face for pharmacy technicians, I have strived for their cause. We have had talks with the IPU and PSI in regards to registration and recognition. I feel this has progressed in recent years and not just from me personally but from Sheehan, president of NAHPT. She has been on this pursuit for 10 years, longer than us and has invited the IACPT into talks where she has already broken down barriers. She has helped us along the way enormously.”

"As Adrian Dunne is a group pharmacy, there were more established roles. Therefore, I was based almost solely in the dispensary. This meant that I got more experience and had the role of Senior Technician, which brought more responsibility. Team work was of great importance and great emphasis was put on this. As it was a group, there was more emphasis on meeting targets and it was great to rise to those challenges."

the PSI, it’s on their service plan and they are hoping it will take five years approximately.”

COMPETITION FOR TECHNICIANS The International Pharmaceutical Federation (FIP) will host its Annual Congress in collaboration with the Pharmaceutical Society of Ireland (PSI) and its Irish partners. In a constantly evolving environment, where advances in science, technology and communications require us all to adapt, it is vital that the pharmacy profession is at the forefront of change; responding to medical innovations alongside changing patient needs. Today pharmacy in Ireland is undergoing its biggest transformation thanks to legislative change to regulate the profession and expand the roles of pharmacists in Ireland. Much has changed since Dublin last hosted the Congress in 1975! It is hoped that these experiences can be shared with visiting delegates. 2013 is the second year of the Technicians Symposium and IACPT are delighted to announce they will sponsor TWO of their members to attend the Technicians Symposium. The topics covered are: • The role of pharmacy technicians in managing complex patients • Complex Patient Case Studies • Collaborative Approaches to Managing Complex Patients.

The IACPT hope that with regulation, a regulatory body will be set up and allow technicians to have standards that will be set and adhered to. They believe the benefits of regulation and registration will support career improvement. They also believe registration will require all technicians to take part in CPD (Continuing Professional Development), in the same way it did for pharmacists, and therefore provide a higher standard in the profession.

Most of the talk that accompanies pharmacy technicians is their recognition and regulation. Ward told Irish Pharmacy News what she believes is the future for technicians beyond that; “I think as the pharmacists role develops, the role of the technician must develop with it. We need to have a higher clinical background as well as the pharmacist. I hope to see accredited technicians, I hope to see a higher standard and a higher self-worth with CPD and education.”

Ward believes it will take five years for the IACPT’s campaign to take effect. She said, “That may seem like a long time but considering it took the UK 60 years it isn’t that long. We have come to the five year conclusion from reading between the lines in

Ward is unsure if she will try for re-election when her presidency is over. She said, “To be honest, I haven’t even thought about re-election yet. We are still in the process of finalising our Constitution. We’ll see what happens this time next year!”

To find out the latest news or to become a member of the IACPT see their website

If you would like to be in with a chance to win this fantastic prize, simply finish off the sentence in no more than 300 words. I would benefit from attending the Technicians Symposium because…….. Closing date for entries is the 1st of May 2013. Please return your entry to, communitytechnician@ .


News Bradley’s Pharmacy NEW FREE news brief Pharmacy App Now Available IPU PHARMACY TECHNICIANS Local pharmacy services will be supported with the graduation of 123 pharmacy technicians who were awarded with a levelthree National Vocational Qualification (NVQ) from City and Guilds at a special ceremony held in Dublin last month. Pharmacy technicians provide a vital supporting role to pharmacists in the delivery of high-quality frontline healthcare services in the community.

Developed by Ista Technologies – A First for the Sector In a first for the pharmacy sector and a first for Bradley’s Pharmacy Group, Ista Technologies have launched an innovative new App for Bradley’s Pharmacy Group. The new and Free Pharmacy App allows customers to communicate directly with Bradley’s Pharmacy to order repeat prescriptions, get details of local clinics and opening times, set pill reminders and query non-prescription products amongst other services. Developed by Cork Company Ista Technologies, the specially developed platform allows Bradley’s Pharmacy Group to have their own tailored App, completely branded with their own pharmacy name, logo and information. It is now available to download for iPhone and android users for free.

Presenting the graduates with their certificates, Rory O' Donnell, President of the Irish Pharmacy Union, said, "Pharmacy technicians have always played a key role in our pharmacy teams. The future of pharmacy lies in developing the professional role of the pharmacist in areas such as medicine use reviews, health promotion, health screening and chronic disease management. In order for pharmacists to develop these new roles, it is essential that we have a professional and experienced pharmacy team to work alongside us to ensure that the highest possible standards in the dispensing process are maintained.

The app will also help to furtherstrengthen the importance of the pharmacy to its community. It shows the commitment of the Bradley’s Pharmacy Group in providing advice and services to their patients, while using innovative technology to respond to the needs and demands of the consumer.

"It is only in developing our professional role that we can advance our position as an integral part of primary healthcare and secure the future of the essential services we provide to our patients," Mr O'Donnell said.

Bradley’s Pharmacy Group was established in 2001 & currently consists of 18 stores: Ardee,

The comprehensive twoyear training course for pharmacy technicians is delivered and administered by the Irish Pharmacy Union in conjunction with City and Guilds.

Brian Pagni MPSI & Managing Director of Bradley’s Pharmacy said: “We are delighted to extend our services to our customers even further with our new Pharmacy app, reaffirming the valued customer relationship. Our customers can interact with us on their repeat prescriptions, as well as access our local networks of GPs, physiotherapists, out of hours’ medical services, dentists and opticians.

We see this as a further commitment to our customers and our community in responding to their needs of advanced technology. We invite all of our customers to let us know what services they would like to see in the future on the App.” Ista Chief Executive and Pharmacist, Ciaran O’Connor said: “We are delighted at Ista Technologies that Bradley’s Pharmacy Group is one of the first Pharmacies in the country to adopt the Pharmacy App for their store. It shows

how forward thinking they are as a business and their deep commitment as a Pharmacy, to their customers, that they now offer this service for free.”

Pharmacy and sport join forces The research based pharmaceutical industry and the anti-doping community are working closely together to enhance the fight against doping in sport and restrict the misuse of licensed and unlicensed medicines. Following on from a Joint


Blackrock (Louth), Blanchardstown, Carlingford, Carrickmacross, Churchtown, Clondalkin, Drogheda, Dunleer, Dorset Street, Killester, KCR, Mounttown, Mulhuddart, Ringsend, Stillorgan, Trim, Wicklow.

Declaration on Cooperation in the Fight against Doping in Sport (2011), WADA, IFPMA and BIO have come together to develop a campaign 2 FIELDS 1 GOAL: Protecting the Integrity of Science in Sport. As the representative body for the international research the

based pharmaceutical industry in Ireland, IPHA strongly endorses the importance of ensuring that the misuse of medicinal products by athletes is robustly addressed and that the industry is engaged in the global fight against doping in sport.

Advanced Defence Sensitive blocks 92% of dentine tubules in just 6 rinses in vitro* 1

Introducing the first in a new expert range from Listerine® – a twice-daily mouthwash built on potassium oxalate crystal technology that blocks dentine tubules deeply for lasting protection from sensitivity.2,3 In just six rinses Advanced Defence Sensitive blocks 92% of dentine tubules; twice as many as the leading recommended pastes.1,4 It can be used alone for lasting protection,3 or in combination with the most recommended paste from the leading sensitivity brand, to significantly increase the number of vitro 4,5 tubules the paste blocks in vitro. * Based on % hydraulic conductance reduction

References: 1. Dentine Tubule Occlusion, DOF 1 – 2012. 2. Tubule Occlusion Stability, DOF 3 – 2012. 3. Relief of Hypersensitivity, DOF 4 – 2012. 4. TNS – Sensitivity Market Research 1 – 2012. 5. Combination Tubule Occlusion, DOF 2 – 2012. UK/LI/12-0494m

Recommend Advanced Defence Sensitive for expert care when you’re not there

Do not recommend this product if patients have a history of kidney disease, hyperoxaluria, kidney stones or malabsorption syndrome, or take high doses of vitamin C (1000mg or more per day).

News news brief

Bringing new styles of leadership


Cormac Tobin has been appointed MD of Celisio UK and is “hoping to bring a new style of leadership to the company.” Tobin has been managing director of Unicare/DocMorris Ireland since 2006.

Draft Misuse of Drugs (Amendment) Regulations are currently being prepared and are due to be published shortly, it has been revealed. Minister Alex White made the statement following a recent Dáil Éireann Debate following a question from Depputy David Stanton. Stanton asked the Minister for Health ‘he is concerned about the abuse of prescription drugs by drug users; if his attention has been drawn to the types of prescription drugs commonly abused in this way; and if he will make a statement on the matter.’ Minister White stated, “The problem of the misuse of prescription drugs has been recognised at national, European and international levels. Through the framework of the National Drugs Strategy 2009-2016, the Department of Health is working in collaboration with the relevant statutory agencies to monitor the availability of controlled drugs, including prescription medicines, through illicit channels. “As a result of consultations with key stakeholders, draft Misuse of Drugs (Amendment) Regulations are currently being prepared. These will be published on the Department’s website shortly and comments will be invited to be made in the subsequent two-week period. “Following this, it will be necessary to seek Government approval to notify the proposed regulations to the EU Commission and other Member States under the Technical Standards Directives because of the implications of the proposed regulatory changes on trade in pharmaceutical products. Subject to successful completion of the EU notification period, which may take up to 3 months, it is anticipated that the new regulations will be introduced in mid-2013.


Cormac Tobin, new Managing Director of Celesio UK

In that time he has “in the last five years filled a trophy cabinet, we used to have a tag rugby trophy on its own and now it’s full and it’s all retailing and people experience,” Tobin told Irish Pharmacy News.

bring a new style of leadership, particularly a leadership that looks at future marking the company not bench marking it; looking at where it needs to be because it’s going to change.”

DocMorris is part of the Irish Celisio group, Celisio UK, the parent company, is best known for Lloyds Pharmacy. When asked what Tobin plans to do differently as the new MD of the international company he said; “I’m hoping to

He is hoping to bring with him the experience he gained from working under Fergal Quinn in SuperQuinn for 29 years and what he has learned in Unicare/DocMorris. “I will also bring a very strong people culture and value ethic to

an organisation. It is fundamentally about people.” Tobin added; “I want to bring the ‘you must add but not subtract’ philosophy, we share in rewards here (Unicare/DocMorris) and I want to bring that over there. It is a successful organisation but it needs to move in to the future.” Tobin will remain as a non-executive on the Irish Celisio Board and will have an input on future decisions.

FIP preperations underway Preperations are well underway for the FIP Annual Congress taking place at the end of August. The theme of the 2013 conference- Towards a future vision for complex patients: Integrated care in a dynamic continuum - will address these developments, and the central role of the pharmacist in delivering patient care in an ever more challenging setting. Today pharmacy in Ireland is undergoing its biggest transformation thanks to legislative change to regulate the profession and expand the roles of pharmacists in Ireland. Much has

changed since Dublin last hosted the Congress in 1975! It is hoped that these experiences can be shared with visiting delegates. In addition, a Forum for Pharmacy Policy-makers and Chief Pharmacists will be held

in Dublin in conjunction with the FIP Congress. Continuing on the outcomes of the 2012 Ministerial Summit, emphasis will be placed on interaction between participants to facilitate an open venue for debate on issues affecting our patients and our profession.





Your advice on using REGAINE Foam twice daily can stay with them, even if you can’t. ®

Scientifically proven to regrow hair and stabilse hereditary hair loss in men Many men with hereditary hair loss can now look forward to hair growth with the new twice-daily Regaine® Foam.1 And it’s not only effective but also quick and easy to apply, slotting readily into their daily grooming routine. Further information available from

FOAM Regaine for Men Extra Strength Scalp Foam 5 % w/w Cutaneous Foam. Compostion: Minoxidil 5% w/w. Indications: Treatment of androgenetic alopecia in men. Dosage: Regaine is for external use only. Do not apply to areas of the body other than the scalp. Hair and scalp should be thoroughly dry prior to topical application of the foam. A dose of 1 g (equivalent to the volume of half a capful) of Regaine should be applied to the total affected areas of the scalp twice daily. The total dosage should not exceed 2 g. It may take twice-daily applications for 8 to 16 weeks before evidence of hair growth can be expected. Users should discontinue use if there is no improvement seen after 16 weeks. If hair regrowth occurs, twice daily applications of Regaine are necessary for continued hair growth. Special populations: There are no specific recommendations for use in elderly patients or in patients with renal or hepatic impairment. Pediatric population: Regaine is not recommended for use in children below the age of 18 years due to lack of data on safety and efficacy. Method of administration: Hold can upside down and press the nozzle to dispense foam onto the hand. Spread with fingertips over entire bald area. Hands should be washed thoroughly after application. Contraindications: Hypersensitivity to minoxidil or to any of the excipients. Special warnings and precautions for use: Regaine should be used when the scalp is normal and healthy. i.e it is not red or inflamed or not infected or irritated or painful. Minoxidil is not indicated when there is no family history of hair loss, hair loss is sudden and/or patchy, hair loss is due to childbirth, or the reason for

hair loss is unknown. Patients with known cardiovascular disease or cardiac arrhythmia should contact a physician before using Regaine. The patient should stop using Regaine and see a doctor if hypotension is detected or if the patient is experiencing chest pain, rapid heartbeat, faintness or dizziness, sudden unexplained weight gain, swollen hands or feet or persistent redness or irritation of the scalp. Regaine contains ethanol (alcohol), which will cause burning and irritation of the eye. In the event of accidental contact with sensitive surfaces (eye, abraded skin and mucous membranes) the area should be bathed with large amounts of cool tap water. Regaine also contains butylated hydroxytoluene, which may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes or mucous membranes, and cetyl and stearyl alcohol, which may cause local skin reactions (e.g. contact dermatitis). Some patients have experienced changes in hair colour and/or texture with Regaine use. Increased hair shedding can occur due to minoxidil’s action of shifting hairs in the resting telogen phase to the growing anagen phase (old hairs fall out as new hairs grow in their place). This temporary increase in shedding generally occurs two to six weeks after beginning treatment and subsides within a couple of weeks (first sign of action of minoxidil). If shedding persists users should stop using Regaine and consult their doctor. Users should be aware that, whilst extensive use of Regaine has not revealed evidence that sufficient minoxidil is absorbed to have systemic effects, greater absorption because of misuse, individual variability, unusual sensitivity or decreased integrity of the epidermal

barrier caused by inflammation or disease processes in the skin (e.g. excoriations of the scalp, or scalp psoriasis) could lead, at least theoretically, to systemic effects. Accidental ingestion may cause serious cardiac adverse events. Therefore this product has to be kept out of the reach of children. Undesirable effects: Nervous system disorders; Common: Headache. Vascular disorders; Uncommon: Hypotension Rare: Palpitations, Heart rate increase, Chest pain. Respiratory, thoracic and mediastinal disorders; Uncommon: Dyspnoea. Skin and subcutaneous tissue disorders; Uncommon: Hypertrichosis (unwanted non-scalp hair including facial hair growth in women), pruritus (including rash pruritic and application site, generalized and eye pruritus, temporary hair loss (see section 4.4), changes in hair texture and hair colour, skin exfoliation (including application site), rash (including application site, pustular, papular, generalized and macular rash), acne, dermatitis (including contact, application site, allergic, atopic and seborrhoeic dermatitis) and dry skin (including application site dryness). General disorders and administration site conditions; Uncommon: Oedema peripheral, Application site irritation (including skin irritation), application site erythema (including erythema and rash erythematous). PA No.: PA 823/48/3. Date of revision of text: August 2012. PA Holder: McNeil Healthcare (Ireland) Ltd. Airton Road Tallaght, Dublin 24, Ireland. Product not subject to medical prescription. Further information available upon request from Johnson & Johnson (Ireland) Ltd. Reference: 1. Olsen EA et al. J Am Acad Dermatol 2007; 57: 767-74. IRE/RE/13-0259

Debate Pharmacists encourage customers to shop around The National Consumer Agency (NCA) and many Irish pharmacists are urging patients to shop around for their medications because a national survey has revealed that patients are paying as much as triple the price for the exactly the same drug in different pharmacy premises.

pharmacy and not the patient.” The survey found, along with price variation, there was a range of different policies applying to dispensing fees as well. Some pharmacies apply a standard dispensing fee. With others, the dispensing fee varies with the price of prescription medicines and, in a small number of instances pharmacists do not charge a dispensing fee on certain items. Richard Collis, supervising pharmacist at Richard Collis Pharmacy in Dublin and past Irish Pharmacy Union president, told Irish Pharmacy News why, in his opinion, there is such a discrepancy in price. “The present hiatus over pricing is basically due to competition between the different generic companies looking to get a market foothold,” he said. “Some pharmacies pass on discounts to their customers, some may not. This is probably a function of the level of discounts available.”

Richard Collis

The survey took place in February 2013 when 45 pharmacies took part. A list of 39 different medications were selected by the Health Service Executive (HSE) from a list of commonly prescribed medicines. Each pharmacy was asked to price the items. The largest percentage variation in price for an individual product within a local area was for Losec Mups 20mg (28), commonly used to treat stomach ulcers. The price in Waterford was found to be 122% more expensive than the lowest price for this item, with prices ranging from ¤22.43 to ¤49.69. Karen O’Leary, chief executive of the NCA commented, “Our survey shows that there are huge differences in the cost of individual prescription medicines in local areas. Many private consumers may not be aware of these price differentials. We would urge these patients,


especially those on long-term medication and who do not meet the criteria for the various State-funded drug schemes to compare the costs of prescription medicines in their local area before choosing a pharmacy.” The second highest percentage price variation was for Zoton Fastab Tabs 30mg (28), commonly prescribed for patients, again with stomach complaints. In Dublin, prices ranged from ¤19.96 to ¤42.33, a difference of 112%. Mark Beddis, Superintendent Pharmacist of Tesco Ireland said; “Tesco has a very strong, customer orientated pricing strategy across the business and we are pleased to reflect this in our pharmacies. This survey highlights to consumers the benefits that can be found by checking prices and further removing the myth that the prescription belongs to the

Pharmacists are not allowed to advertise the price of medications but the NCA is now suggesting that pharmacies should display their dispensing policies or other factors that may lead to price differentials, so consumers can choose where take their prescriptions. O’Leary of NCA said, “We believe that more needs to be done to help customers compare the costs of prescription medicines and to avail of price differentials. As a pharmacy’s dispensing fee policy may have a large bearing on the final price paid by consumers, a prominent display of the pharmacy’s policy would help to improve price transparency and inform consumers.” A pharmacist in the West of Ireland, who would prefer not to be named said; “I encourage patients to shop around. I am a consumer and I shop around for the best value. Very often there are inconsistencies with the prices. Different pricing structures can lead to the appearance of a saving on one item such as Losec but you may not be saving on others. It’s all smoke and mirrors.”

He continued, “I agree that the price should be highlighted so the consumer can choose. If a patient is unhappy with the price they should tell the pharmacist; name them and shame them.” NCA conducted a similar survey in 2009. However this survey was regarding the cost of personal care goods and over the counter medicines. The 2009 survey found price differences of up to 161.6% between retailers, compared to the 2013 findings on the differences in prescription charges. In the recent survey, differences were found to be, nationally up to 199% and, in local areas up to 122%. O’Leary continued, “We have written today to the pharmacy regulator regarding price transparency, (the Pharmaceutical Society of Ireland) as we want to work with them to improve consumer access to price information in the sector. We are calling for the inclusion of a specific reference to the display of dispensing fee policies by pharmacists at their premises in the PSI Code of Conduct or other relevant guidelines.” The Pharmaceutical Society of Ireland told Irish Pharmacy News that the pricing of medicines is generally not within the remit of the PSI. The PSI can only consider complaints made to the Council of the Pharmaceutical Society of Ireland in relation to the grounds set out in Sections 35 and 36 of the Pharmacy Act 2007, relating to the conduct of named Registered Pharmacists or Registered Retail Pharmacy Businesses. The spokesperson continued, “With respect to the price of prescription medication, it is usually made up of a number of costs and, typically this includes the cost price of the medicine, a percentage mark-up and a dispensing fee. The pharmacist should be able to give full information about any medicine, including the breakdown of the costs. Regarding whether a particular issue constitutes misconduct, as with any complaint, any matter which goes to the Professional Conduct Committee for inquiry would be judged on the merits

“We believe that more needs to be done to help customers compare the costs of prescription medicines and to avail of price differentials. As a pharmacy’s dispensing fee policy may have a large bearing on the final price paid by consumers, a prominent display of the pharmacy’s policy would help to improve price transparency and inform consumers.” of the individual case, so one cannot pre-empt that process.” Collis of Collis’ pharmacy, Dublin said “It would be impossible to display 200 or so prices but the patient should be allowed to shop around and discover the price differences.”

the Irish Pharmacy Union (IPU) commented, “A price variation among pharmacists confirms that the sector is extremely competitive. The IPU outlined that Ireland has the most liberal pharmacy market in all of Europe - while most countries continue to restrict ownership of pharmacy to pharmacists and/or have tight regulations (regarding) governing new openings.” The IPU continued; “It is up to each individual pharmacist to determine what they charge private patients for their medicines. As the survey confirms, prices vary from pharmacy to pharmacy and patients will go to the pharmacy that best suits their needs, not alone in terms of price but also in terms of the nature and quality of the professional service that they receive. A recent survey showed that pharmacists operate on a wafer thin margin of 4% for their business as a whole with one in four pharmacists operating at a loss.” This debate seems as if it will rumble on for some time, particularly because it might be difficult to break down pharmacy costs and/or fees for more than one item. Key findings of the survey include: Nationally, the percentage differences in prices of individual prescription medicines ranged

Mark Beddis

from 37% to 199%. The average percentage difference across all products nationally was 56%.

average difference was 29%. The corresponding figure for Waterford is 27%.

In Dublin, across the 39 products surveyed, the minimum price difference for any individual product was 34%, with the average percentage price difference being 44%.

All prices quoted refer to the price charged to a first time private customer for each of the specific medicines, purchased individually on prescription. The study did not include any prices, which may be charged to individuals who are in receipt of State funding for prescription medicines.

The average price difference across the 39 prescription medicines varied slightly in the local areas surveyed. In Galway, the average difference was 30%, while in Cork and Limerick, the

To read the survey in full go to

He also gave another reason, in his opinion, for the price differences. “The other complicating factor is that every prescription is potentially a claim under the DP scheme. This has a rigid price structure, which is the basis on which we are remunerated. It is important to remember that this situation is transient as all will change when reference pricing comes in. “Thus, the government can bring order and clarity once reference pricing becomes a reality.” When asked if it is fair to the consumer that pharmacists can charge what they like for medication and should the market be regulated, Collis said; “No more regulation, we have enough regulation. Let the patients choose where they want to go. Price transparency is the way to go.” In response to the survey by the National Consumer Association,



Pharmacy graduates Pictured below are The Royal College of Surgeons in Ireland (RCSI) graduates from the Bachelor of Science (Pharmacy) programme at the National University of Ireland (NUI) recent conferring ceremony, with Faculty from the RCSI and Officers from the NUI. Meanwhile, they hosted an event to thank and mark the retirements of several key academics and colleagues:

Ingrid Hook, Des Corrigan, John Clancy, and Owen Corrigan. Each of these individuals has made unique contributions not

only to the School, but also to Irish and international pharmacy and so their presence will be missed.

Pharmaher Healthcare, distributors of L’il Critters Gummy Bear Vitamins, recently announced the winners of their L’il Critters National Pharmacy Colouring Competition. This year the competition was extended to include 8 top of the range bikes. Congratulations to the deserving winners and participating pharmacies: Munster Winners 4-7 year old category Anna Lenihan (Age 5), Passage West, Co Cork Pharmacy - Martin Walsh Pharmacy, Carrigaline, Co Cork 8-12 year old Category Sarah Madden (Age 11), Nenagh, Co Tipperary Pharmacy - Anna Kelly’s Pharmacy, Nenagh, Co Tipperary Leinster Winners 4-7 year old category Corina O’ Keeffe O’ Reilly (Age 7), The Curragh Co Kildare Pharmacy - Monread Pharmacy, Naas, Co Kildare 8-12 year old Category Erin Anderson (Age 11), Arklow, Co Wicklow Pharmacy - Duffy Pharmacy Group, Arklow, Co Wicklow Connaught Winners 4-7 year old category Darren Von Strien (Age 6), Galway Pharmacy - Barna Pharmacy, Barna, Co Galway 8-12 year old Category Emma Urquhart (Age 11), Craughwell, Co Galway Pharmacy - Walsh’s Pharmacy, Orantown Centre, Oranmore, Co Galway Ulster Winners 4-7 year old category Lucy Pattison (Age 6), Enniskillen, Co Fermanagh Pharmacy - Cathcart’s Pharmacy, Derrygonnelly, Co Fermanagh 8-12 year old Category Emily McArdle (Age 9), Middletown, Co Armagh Pharmacy - Tynan Pharmacy, Tynan, Co Armagh


Free cancer screening campaign HP Ireland, Aviva Health Insurance Ireland and the Mater Private Hospital have joined forces on Daffodil Day with Italia ’90 hero Packie Bonner to launch ‘The Power of Prevention,’ a new innovative programme that will offer, for the first time in Ireland, onsite free male cancer (prostate and testicular) screening and risk assessments for all employees (4,500) and their families. This will be undertaken by the staff of the Mater Private Hospital during the month of April. The Power of Prevention is a global health initiative that is supported by Packie Bonner and is now targeting all cancer types. This initiative follows the success of the award winning Power of Pink, a pilot programme that provided onsite breast cancer screening to all HP employees and their families in 2011.

Pictured (left to right)was Lionel Alexander Vice President at HP, Dr. Kiaran O’Malley, Consultant Urologist at the Mater Private Hospital, Martin Murphy, Managing

Director of HP Ireland, Packie Bonner, Italia ’90 hero and Power of Prevention Ambassador, Alison Burns, Managing Director of Aviva Health Insurance Ireland.

News news brief NEW PHARMACY CONCEPT A new and innovative pharmacy concept, under the LloydsPharmacy brand, will open in Blackrock, Co. Dublin. A wholly owned subsidiary of the German based Celesio Group, the new pharmacy model in Blackrock is the first to open in Ireland and is based on best-practise experiences of the Celesio Group across various European markets. The new store will offer innovative service formats, high quality exclusive products and the latest in healthcare technology. Taking a holistic approach to the pharmacy industry, LloydsPharmacy Blackrock will offer expert advice and solutions using state of the art skincare and healthcare technology. Designed to create a positive experience and to help customers understand and manage their healthcare needs better, the pharmacy will include dedicated zones for skin, pain and general healthcare. Bringing pharmacy fit-out and design to a whole new level, a ‘Health Bar’ will take centre stage, where touch screens are provided for detailed product information. Revolutionising skin health, LloydsPharmacy Blackrock will offer customers skin analysis with digital skin scanners, thereby enabling the LloydsPharmacy skin experts to recommend the best course of treatment or product for different skin conditions. Cormac Tobin, as outgoing Managing Director of Unicare said, “We want to open a new chapter in the pharmacy industry in this country, in terms of service, innovation and quality authority around your health wellness and skincare. Trained experts will help customers take control of their healthcare and skincare needs in ways that suit them, either through technology or one-on-one consultations. As well as launching this new industry model, we are also inviting independent pharmacists to talk to us about franchise opportunities which are available now for the Irish market.”


Discounts are essential Pharmacists are charging the HSE official prices on medical card discounted drugs as they are not being fairly reimbursed, according to the Irish Pharmacy Union. It developed that the Irish Pharmacy Union’s members are not applying the discounts they receive on generic drugs for medical card holders because the Health Service Executive (HSE) are not paying pharmacists 100pc of the cost of the drugs.

Pharmacists are passing discounts on, says IPU

This is resulting in pharmacists footing the bill off the balance that is unpaid. A spokesperson for the HSE responded to the discounting claim saying; “The HSE reimburses pharmacists at the prices agreed under the various agreements with industry. Discounts that pharmacists receive from drug companies are not passed on to the HSE.” The Irish Pharmacy Union said the HSE are not completely reimbursing pharmacists, refunding only 91.2% of the discounted bills. This leaves Pharmacists paying 8.2% and leaving them at a loss. An IPU spokesperson said; "The HSE benefits from these discounts and since 2009 has been recouping 8.2pc of the cost of all medicines directly from pharmacist payments.” A concern is fridge items, where pharmacists also feel they are losing money. According to the IPU, occasionally pharmacists receive no discounts on these items.

They added price negotiations were a feature of all businesses and pointed out that the HSE benefited from this practice. The HSE have recouped 8.2 per cent of the cost of all medicines from payments to pharmacists since 2009. The IPU said one in four of its members was operating at a loss, despite reports that they enjoy discounts of up to 90 per cent on the price of generic drugs for which they are reimbursed by the Health Service Executive. While these figures may seem very high according to the IPU generic drugs account for very little of their drugs. 18% of drugs in Ireland are generic compared to 80% in the UK. The union contends that generic medicines cost more in Ireland

because they account for a small part of the market and so sales volumes are lower. However pharmacists are not receiving all their costs back on branded drugs either. According to the IPU every time the Government and manufacturers lowered the price of medicines, these reductions had been passed on by pharmacists to their patients. "Further falls in medicine prices will occur and will also benefit patients," he said. Pharmacists have had their prices cut three times in the past four years. In 2009, some pharmacists opted out of medical card services, however this resumed shortly after.

Retirements and rewards The School of Pharmacy and Pharmaceutical Sciences hosted an event to thank and mark the retirements of pharmacy academics and colleagues: Ingrid Hook, Des Corrigan, John Clancy, and Owen Corrigan. Each of these individuals has made unique contributions not only to the School, but also to Irish and international pharmacy and so their presence will be missed. The evening also included a student awards event, recognising our excellent Pharmacy undergraduates. This prize is awarded to the student who attains the highest overall combined mark in modules PH3009, PH3010, PH3011, PH4009 and PH4010. Winner: Katie Timoney

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Pharmacists Take the Lead In daily life, complexity results from countless factors. Culture, environment, social and economic status and physical ability all contribute, and all complicate managing ill health. Pharmacists bear witness to many of these complexities and increasingly must care for what have come to be known as 'complex patients'. Recognising the valuable impact that pharmacists have in the lives of such individuals, FIP is putting the care of complex patients at the top of the agenda for 2013. WHO ARE YOUR COMPLEX PATIENTS? The issue of 'complex patients' is one that has been addressed by healthcare professionals for some time, yet as the general population ages and chronic disease becomes more prevalent, it is an issue that continues to escalate. It is difficult to define a complex patient, yet it is generally understood that the term applies to those who require an extra amount of care and consideration as a consequence of complicated and extensive medicine regimes compounded by physical and mental limitations. Current statistics suggest that complex patients comprise upwards of 25% of individuals in primary care practices who fulfil one or more of the following criteria:  Multiple, well-defined chronic illness with various complications  Highly treatment involving invasive procedures both for diagnosis and therapy  A peculiar combination of resiliency and fragility  Unexpected responses to common medications and minor illnesses  Longevity (living highly functional lives into the 80’s and 90’s) (http://www. moderncomplexpatient. org/2010/03/30/themodernphenomenon-ofcomplex-patients/) PHARMACISTS LEADING CARE IN COMMUNITIES Several years ago, in a policy shift that truly put pharmacists at the front lines of care, the Board of Pharmaceutical Specialties in the United States recognised Ambulatory Care Pharmacy Practice as a specialty practice in pharmacy. Pharmacists certified within this specialty are considered "experts in optimizing and managing the medications for patients with complex needs and who are also ambulatory".


( feb10/acpp.php). This was a ground-breaking step for pharmacists, as it brought together the two most important aspects of pharmacy practice medicines knowledge and accessibility - and solidified a patient-pharmacist relationship historically reserved for physicians. Such initiatives enable the efficient use of healthcare providers to their maximum capabilities - with pharmacists focussing on patient/medicines management, physicians can concentrate on diagnosis and treatment. Collaborative practice arrangements enable even more synergy among healthcare professionals in the care of complex patients.

health, says that it is known, for example, that pharmacists often feel more comfortable and confident contributing to the management of physical conditions, such as cardiovascular disorders, than mental disorders. He explains that the global disease burden arising from mental illness is immense. Taking the issue of complexity from the perspective of lifethreatening diseases and the medicines that treat them - both current and emerging - Professor Ross McKinnon will be leading a series of lectures that address the complexities of the cancer patient.

A FUTURE VISION FOR COMPLEX PATIENTS With the aims of advocating increasing roles for pharmacists in the management of complex patients, and providing an extensive platform for learning and growth to do just that, FIP has made "Complex Patients" a priority for 2013. Taking place in the beautiful city of Dublin, Ireland, the 2013 FIP World Congress of Pharmacy and Pharmaceutical Sciences has adopted the theme of Complex Patients and will examine the issue from all standpoints: biological (emphasising the current development of systems biology), medical (demographics, genetics, smoking, alcohol, diet and multiple diseases), socioeconomic (availability of resources, literacy) and cultural (beliefs, traditions, religion). Pharmacists have the ability and opportunity to support patients in every aspect of complexity. In delivering the overall message, Programme Chairs Professors Geoff Tucker and Phil Schneider emphasise that patients are likely to become increasingly complex as they grow older and develop multiple diseases requiring

treatment with several medicines. In turn, this creates the need for integrated care across medical specialties and effective collaboration within a team of health professionals. The pharmacist is an important member of this team with an important role to play in understanding and managing the complex patient, especially with respect to responsible medicines use. THE CHALLENGES OF COMPLEXITY - FINDING SOLUTIONS AT THE FIP CONGRESS It is imperative that complexity is also considered from the perspective of the patient, who may or may not consider themselves "complex". For each person, their primary concern is how their illness, and secondary to that, their medicine, will affect their daily lives. With that in mind, the FIP Congress will address complex patients also from illness perspectives. Dr Timothy Chen, associate professor at the University of Sydney specialising in mental

Key factors to consider in such discussions are that cancer does not discriminate, and cancer is also a disease of ageing. This means that for many, cancer is diagnosed in the presence of a range of co-morbidities including chronic conditions such as diabetes, cardiovascular disease and musculoskeletal conditions. Nowhere do pharmacists interact with complex patients more than in the community. Ms Karin Graf supports the goal that pharmacists should be at the core of partnerships when it comes to managing diseases in the community such as asthma, monitoring patients, performing triage, advising about treatment options and preventing additional complexities. More than 300 million individuals worldwide are afflicted with asthma and they often receive care and counselling from pharmacists. Ms Graf's Session in Dublin will focus on how the both the health and economic burdens of asthma can be reduced through these patient-pharmacist relationships. For more information on the FIP Congress in Dublin and its perspective on Complex Patients, visit the website at

News New legislation changes rules on nutrition and health claims Tony Parkin outlines the terms of the new European legislation regarding health claims on food supplements and examines what this will mean in practice. Tony Parkin is the strategic planning and development manager with Seven Seas Limited

Health claims on food labelling and in advertising, for example on the role of calcium in maintaining bone health or vitamin C in boosting the immune system, have become important marketing tools for food and food-supplement manufacturers to persuade consumers to buy their products. The growth of functional foods in recent years has seen an increased usage of product claims that purport to reduce cholesterol or help with heart disease or improve digestive health. Whilst most manufacturers have self-regulated, there has always been a rogue element that has pushed the claims beyond the acceptable limit, either in advertising or packaging, which has tainted the industry as pushing ‘snake oil’. On December 14 last, new European legislation came into force to regulate the claims made by food and food-supplement manufacturers to restrict the use of claims to those that are proven scientifically. Vitamin C products can no longer claim to ‘ward off colds’ but can confidently say they ‘help maintain a healthy immune system’. Will the consumer notice and continue to believe that vitamin C will help with colds? Only time will tell. Most consumers would know little to nothing about this new legislation and most healthcare professionals would be sketchy on the details. This article tries to explain the background, the rationale and the implications. As with all European legislation, there is confusing terminology


– directives, articles, annexes, corigendums and reference numbers that mean nothing to anyone outside of those involved in the process. Food supplements are legislated on an original European Directive from 2002 (2002/46/ EC) and subsequently amended by Directive 2006/37/EC and Regulation 1170/2009/EC. These lay out the framework for food supplements marketed as foodstuffs and were imposed to ensure that consumers were protected through product safety with adequate and appropriate labelling. REGULATION OF SUPPLEMENTS This European legislation was transposed into Irish law by European Communities (Food Supplements) Regulations, 2007. Food and nutritional supplements are regulated by the Food Safety Authority of Ireland (FSAI) and it is the FSAI’s responsibility to enforce any food safety legislation. Directive 2002/46/EC defines a ‘food supplement’ as “foodstuffs to supplement the normal diet, which are concentrated forms of nutrient or other substances with a nutritional or physiological effect, alone or in combination, marketed in dose form...designed to be taken in measured small unit quantities”. In 2006, the Nutrition and Health Claims Regulation (NHCR) was adopted across the European Union; this harmonises the use of specific, agreed claims that can be made on foods. Regulation (EC) No 1924/2006 requires that only nutrition and health claims made on foods that are authorised and included in the European Union register can be used by manufacturers to promote their products. Six years ago, the European Food Standards Agency (EFSA) started to review nutrition and health claims used on foods, including those used on food supplements. European Union member states were asked to submit all the health claims they wanted to include and over 44,000 individual health claims were submitted to the EFSA, along with the data they thought would back up these claims. These 44,000 individual claims were consolidation into

over 4,600 consolidated claims reviewed by the EFSA. APPROVED CLAIMS Of the 4,600 claims, only 222 general health claims were approved. This approved list was based on a review of all available scientific advice among the general population and based on the scientific advisers working for the EFSA. Certain claims were rejected because evidence among the general, healthy population was insufficient, e.g. glucosamine on joint health where the majority of evidence is among sufferers of arthritis, and probiotics where the EFSA argued that each individual strain needed to be properly assessed. The main casualty in this analysis has been probiotics and, despite strong challenges from the yoghurt manufacturers and probiotic lobbyists, the EFSA has remained firm on its denial of any claims – leading to wholesale changes in the way these products are marketed. On May 16 last year, the claims were published in the Official Journal and became European law on June 6. There followed a six-month transition period, after which the supply of non-compliant packaging and other marketing materials was prohibited – which ended on December 14, 2012. The European Union Community Register, which is the list of permitted nutritional and health claims, holds all authorised claims. On the one hand, this new legislation imposes huge restrictions on the food and food supplement industry from a marketing perspective and limits how manufacturers can imply that their products are superior to their competitors. It does, on the other hand, provide a level playing field that all European manufacturers can work to and avoid any wild, outlandish claims that have dogged the industry in years gone by. It will make the marketing and advertising teams work harder but this is no different to the rest of over-the-counter products, where claims are all standardised. WHAT DOES THIS MEAN IN PRACTICE? The legislation on nutrition and health claims only affects communication to the end consumers, through advertising and on-pack; any communication to trade or healthcare professionals is not covered within the

regulations. In practice, this means that manufacturers can still talk to pharmacists about the benefits of their products with nutrients that have not received a positive opinion from the EFSA – so long as it is clearly marked for the use of healthcare professionals. In addition, healthcare professionals can still talk to their customers about the benefits of these products based on the evidence with which they feel comfortable. Although the EFSA has only approved a limited number of nutrients based on the evidence provided, consumers have plenty of their own experience on what has ‘worked’ or not for them. From their point of view, this is far more important than any expert opinion in Brussels. In summary, all claims on foods and food supplements are now standardised – but the debate remains as to the impact this will have on the food and food supplements industry and its ability to communicate and develop new products to meet consumer needs should the regulations be strictly enforced. WHAT IS A CLAIM? A ‘health claim’ is any claim which states, suggests or implies that a relationship exists between a food category, a food or ones if its constituents and health. This would include claims such as ‘calcium helps maintain normal bones’ or ‘vitamin C helps maintain a healthy immune system’. These are discrete from ‘nutritional claims’, which state, suggest or imply that a food has particular nutritional properties, due to the presence, absence, increased or reduced levels of energy or of a particular nutrient or other substance and includes claims such as ‘source of calcium’, ‘low fat’, ‘high fibre’ or ‘reduced salt’. Article 13.1 health claims are classified as ‘general health claims’ that relate to the growth, development and the functions of the body. Examples include: ‘calcium is needed for the maintenance of normal bone’; ‘EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) contribute to the normal function of the heart’; ‘folate contributes to maternal tissue growth during pregnancy – among women planning to become pregnant and pregnant women’.

Irish Pharmacy Awards 2013

Shining a light on Irish pharmacy! DATE FOR YOUR DIARY Baby Sam’s 6th Annual Lunch takes place on Friday 10th May, 2013 at the Four Seasons Hotel in aid of The Jack & Jill Children’s Foundation. Always a fantastic fun afternoon with fabulous food, raffle and auction prizes up for grabs! ¤100 per person (¤1,000 table of 10) book your place or table now by contacting Jack & Jill on 045 894538 or emailing and support Jack & Jill children just like little Sam in your community. See you there. Key to the survival of the pharmacy profession over the last number of year has been innovation, dedication and hard work, displayed not just by pharmacists but also by their staff members and the Irish Pharmacy Awards has the primary objective of rewarding this loyalty whilst emphasising to the public – your customers – the excellence that is ongoing in the face of adversity.

ment ovation in Service Develop ch, winners of the Innn alie Maginnis Nat Garvan and Sheena Lyn MD s tion nica mu IPN Com (Independent) Award with

The Irish Pharmacy Awards deserve to be utilised by ALL pharmacists and their staff to nominate and praise each other’s stealth, raising the pharmacy profession profile through the awards coverage in both national and regional press opportunities. The Awards present a unique platform from which to congratulate those that have endeavoured to continually provide excellence and enhanced care to their local communities. It cannot be overstated enough the positivity this ethos ensues. The standard of applications and nominations already received at the IPN offices highly reflect this philosophy so as the clock keeps ticking towards our April 11th deadline now is the time to put pen to paper! THE PEOPLE’S PHARMACIST The Jack & Jill Children’s Foundation, in conjunction with the Irish Pharmacy Awards 2013, is once again excited to be launching a national campaign to find the 'People's Pharmacist', an Award aimed at giving the public a unique opportunity to nominate and praise their local pharmacist.

The People's Pharmnacist, David and Dervilla Callan with Jonathon Irwin

Now in its second year, the People's Pharmacist award demonstrates those pharmacists that have provided their customers and local community with service going above and beyond their call of duty. One of the best aspects of this award is the stories from individuals about how their pharmacist has been innovative, motivated, dedicated and, to them, special in some way. The People’s Pharmacist Award is a celebration of the various shades of pharmacy, honoring exceptional talent across Ireland. This award is extra special as it is decided by the public, for whom all pharmacists are striving to do their best for. Nominations are now invited and the Award will be presented at the Irish Pharmacy Awards gala dinner. 2012 People's Pharmacist winner Dervilla Callan of Sallins Pharmacy, Naas says: "It was so tremendous to be acknowledged for the work I have done over the past thirteen years. I hope to continue offering a high standard of care to my patients in the future." For full details of the award categories, application/nomination forms and the awards evening itself please visit our website at: or contact Kelly Eastwood at 0044787 6548989 Email:



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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.

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New Canespro Fungal Nail set Canespro is a new clinically proven fungal nail treatment product, launched by Bayer. The major strength of Canespro is the short treatment time of 7 weeks. Treatment is a two step approach. The first step involves treating the infected nail with the 40% urea ointment daily for 2-3 weeks, with daily removal of the softened infected nail. After the infected nail is removed, treatment is completed with an antifungal cream such as Canesten 1%.

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CPD 28: TYPE 2 DIABETES Biography - Ronan Sheridan graduated from the Robert Gordon University, Aberdeen in 2009 with a Masters in Pharmacy with Distinction. He worked for three years as a pre-registration and clinical pharmacist at the Chelsea and Westminster Hospital NHS Foundation Trust, London before joining Market Point and Green Road Pharmacy, Mullingar, Co Westmeath as pharmacist/manager. Sheridan was recently awarded the 2012 Helix Health Young Pharmacist of the Year.

Module 1 June 2012

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

Educational distance

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

Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded 4. EVALUATE - Did article meetprofessionals my learning content forthis healthcare Ireland from

- will this article satisfy those needs - or will more reading be required? learning needs - and how has my practise changed as a result? Have I identified further learning needs?

Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

Chronic Pain5. WHAT – assessment and management in primary care NEXT - At this time you may like

3. PLAN - If I have identified a knowledge gap

to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Type 2 Diabetes 60 Second Summary

Classification and Prevalence - Diabetes mellitus refers to a group of metabolic disorders characterized by hyperglycemia associated with abnormalities in carbohydrate, fat and protein metabolism and resulting in chronic complications including microvascular, 2 Sheehan et alType reported in 1996 that the estimated cost of Introduction macrovascular and neuropathic complications1. diabetes, or pain for 95 patients to the Irish Health Services when added non insulin In 1999, the World Health (WHO) updated the for classification the disease, Pain Organisation is one of the commonest reasons patients to of seek to the amountdependent of Social Welfare payments received and 1 recognising four typesmedical of diabetestype A 1 recent diabetes, typehas 2 diabetes, gestational survey shown that as many diabetes attention. diabetes, is patient amounted to 1.9 million the lost earnings of each and impaired fasting glycaemia. is estimated that worldwide 347 million people have characterised as 8.3 visitsItper year to primary care physicians in Ireland of referral.6 The recent data from PRIME diabetes, with this figure rising to the ageing population, poor survey diet and sedentarypounds at thebytime a relative 2 were duedue to symptoms of pain. A large scale carried deficiency of insulin survey show that the mean cost per chronic pain patient lifestyle. In 2004, an estimated 3.4 million people died from hyperglycaemic events. In out in 15 European countries and Israel in 2006, screening or a resistance to the Ireland approximately 190,000 people are living with diabetes, with this figure due to is almost estimated at €5,665 per year across all grades of pain, effects of insulin. 46,394 respondents reported that the prevalence of chronic which was extrapolated to €5.34 billion or 2.86% of Irish double by 20201. pain of moderate to severe intensity in adult Europeans was Type 2 diabetes accounts for 90-95% of all 7 GDP per year.cases, This compared demonstrates an urgent for cost to 5-10% which need accounts 19%.3 for type Until recently, this typeeffectively. of diabetes effective strategies to1.manage chronic pain was seen only in adults but it is now also Type 2 diabetes, or non More insulinrecent dependent However thestudy, clinical presentation can differ in survey data from another carried out occurring in children. diabetes, is characterised by a relative a variety of ways, as outlined below. Patients in 2,019 people with chronic pain and 1,472 primary Understanding chronic pain deficiency of insulin or a resistance to the will also present with elevated blood glucose An HbA1c of 48 mmol/mol (6.5%) is physicians 15 European countries, have insulin levels, as effects of insulin. It is notcare so much a lackacross of levels, as well as elevated as the cut point for diagnosing Chronic pain recommended is defined as pain that outlasts normal healing insulin that causes the symptoms, but athat failure compensates achieve glucose diabetes demonstrated chronic the painbody affects 12-54% ofto adult 1,2 time (usually three to six months), and is most frequently of target organs to respond normally. It has a homeostasis . its prevalence in Ireland is up to 13%.2 The Type 2 diabetes is commonly associated slow onset of symptomsEuropeans, and for thisand reason associated with musculoskeletal disorders such as low Signs and Symptoms of Type 2 Diabetes with elevated blood pressure, a disturbance (Prevalence, can remain undiagnosedPRIME for several years, Impact and Cost of Chronic Pain) study, back pain and arthritis. However, it can also be associated of blood lipid levels and increased risk of often until secondary complications • Candidiasis on the otherhave hand, determined the prevalence of chronic thrombosis development. Theor cardiovascular with other disorders such as depression metabolic arisen. Type 2 diabetes accounts for 90-95% of pain towhich be as accounts high as 35.5%• inBacterial Ireland.4urinary The PRIME study risk associated with type 2 diabetes means tract infections all cases, compared to 5-10% disorders or neurologic such as multiple the goals ofconditions therapy must: for type 1. Until recently,was this designed type of diabetes to investigate the prevalence of chronic pain • Genital itching sclerosis. was seen only in adults in butIreland; it is now also the psychological and physical health compare • achieve normoglycaemia and HBA1c occurring in children1. • Foot ulceration targets profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive RISK FACTORS FOR DEVELOPMENT 4 • Erectile dysfunction pain-related disability. Responses to survey questions were • Minimise occurrence of hypoglycaemic or neuropathic. Nociceptive pain is caused by an active events 90% of patients who develop typefrom 2 diabetes • Tingling, pain and numbness in obtained 1,204 people. illness, injury and/or inflammatory process associated with are clinically obese (i.e. a BMI of >25). Other peripheral limbs • Minimise risk factors/ long termpain actual or potential tissueother damage i.e. Nociceptive risk factors include decreased physical Despite the magnitude of the problem, chronic pain is complications • Cardiovascular complications exercise, unhealthy diets, hypertension, results from activity in neural pathways secondary to actual under-recognised and undertreated in primary care.2,5 ageing population (> 40 both yrs), dyslipidemia • Encourage self care through education • Persistent or recurrent infections or potential tissue damage. Nociceptive pain is mediated and smoking. A family member withtodiabetes Indeed, up 38% of patients reported being inadequately by pain receptors located in skin, musculoskeletal system, can also predispose one to developing the • Cataracts • Tailor pharmacological therapy to meet the managed in primary care for their pain symptoms.2 In 1 8 disease . needs of the patient bone, and joints. Neuropathic pain, on the other hand, • Development of microalbuminuria addition, people with chronic pain reported waiting up to SIGNS & SYMPTOMS results from direct injury tohave a peripheral or central sensory Pharmacists an important role to play 2.2 years between seeking DIAGNOSIS help and diagnosis, and 1.9 in preventing long termproduce complication with nerve; the affected nerves do not transduction at The characteristic symptoms of type 2 diabetes 2 disease progression. years before their pain was The adequately managed. criteria for a diagnosis of diabetes are, in 8 include polydipsia, polyuria and blurred vision.

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 28: TYPE 2 DIABETES patients with characteristic symptoms along with either • A random venous plasma concentration > 11.1 mmol/l

Module 1


2012 • a fasting plasma glucoseJune concentration > 7.0 mmol/l Or

sionals •intwo Ireland hour plasma glucose concentration >

11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

anagement in primary care In 2011 WHO recommended that the HbA1c

can be used as a diagnostic test for diabetes providing that stringent quality assurance tests are in place. An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests1,2,3. MANAGEMENT Type 2 diabetes is commonly associated with elevated blood pressure, a disturbance of blood lipid levels and increased risk of thrombosis development. The cardiovascular risk associated with type 2 diabetes means the goals of therapy must:

HBA1c cost targets ehan et •al achieve reportednormoglycaemia in 1996 that theand estimated of • Minimise occurrence of hypoglycaemic n for 95 patients to the Irish Health Services when added he amount events of Social Welfare payments received and • Minimise riskamounted factors/ long lost earnings of eachother patient to term 1.9 million complications 6 nds at the time of referral. The recent data from PRIME Encourage selfcost careper through education vey show• that the mean chronic pain patient stimated•atTailor €5,665 per year across all grades of pain, pharmacological therapy to meet the 4 needs of the ch was extrapolated to patient €5.34 billion or 2.86% of Irish 7 National Institute of Clinical Excellence has The P per year. This demonstrates an urgent need for cost developed a framework for the management ctive strategies to manage chronic pain effectively. of type 2 diabetes, which encompasses advice for self care, treatment of the disease and preventing complications2.

derstanding chronic pain


onic painOF is TYPE defined as pain that9 outlasts normal healing 2 DIABETES e (usuallyEach threepatient to six months), and is most frequently will have an individual target ociated with musculoskeletal as low HBA1c, which may bedisorders above thesuch general target of 6.5%. At However, the initial stage diagnoses, k pain and arthritis. it canofalso be associated lifestyle mortification is the initial management. h other disorders such depression or metabolic If this does notas achieve a satisfactory HBA1c sufficient time, drug therapy is initiated. orders orafter neurologic conditions such as multiple rosis. PHARMACOLOGICAL THERAPY

Metformin n (acute or chronic) can be categorised as nociceptive The Nociceptive first line drugpain therapy for glycaemic control europathic. is caused by an active in type 2 diabetes is metformin. The dose can ss, injurybe and/or inflammatory process associated with titrated up over several weeks to minimise ual or potential tissue damage i.e. Nociceptive pain risks of gastrointestinal side effects. Metformin particularly beneficial for overweight ults from isactivity in neural pathways secondary patients, to actual but is also as effective in non-overweight otential patients. tissue damage. Nociceptive pain is mediated pain receptors located in skin, musculoskeletal system, Metformin acts by decreasing intestinal 8 e, and joints. Neuropathic pain, the othermuscle hand, absorption of glucose andon increasing uptake increasingorthe action of ults from glucose direct injury to abyperipheral central sensory insulin at its peripheral receptor. It is excreted ve; the affected nerves do not produce transduction at by the kidneys, and for this reason should iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.

be avoided where there is a degree of renal insufficiency. Administration of metformin to patients with kidney insufficiency can cause a fatal form of lactic acidosis. Sulphonylurea Drugs within class: Gliclazide, Glipizide, Tolbutamide, Glimperidine, Glibenclamide A sulphonylurea is a suitable alternate to metformin if the patient is underweight or cannot tolerate or is contra indicted to metformin. It is also suitable if a rapid therapeutic response is required. They act by stimulating beta-cell insulin secretion and hence lower plasma glucose levels. They are metabolised by the liver and should be avoided in hepatic insufficiency. Once daily dosing can be a treatment option, if adherence is a problem. As sulphonylureas release insulin, they can cause hypoglycaemia, and blood glucose monitoring is advisable. They also have the potential is cause weight gain, thus diet and exercise must be an essential component of the treatment regimen.

is high or they are contraindicated or not tolerated. It can used in addition to a sulphonylurea if metformin is not suitable. Unlike the sulphonylurea, the risk of weight gain is significantly lower. Thiazolidinedione Drugs within class: Rosiglitazone and Pioglitazone This group of drugs improve glucose and lipid metabolism by their agonistic effect at the nuclear PPARγ receptor, increasing transcription of certain insulin sensitive genes. They are useful for patients whose glycaemic control is inadequately controlled by other oral treatments. They can also be used in combination with a sulfonylurea if metformin is not appropriate. They are not suitable for patients with established heart failure, and the use of Rosiglitazone may be associated with an increased risk of ischemia. Liraglutide Drugs within class: Victoza

Drugs within class: Sitagliptin, Saxagliptin and Vildagliptin

Liraglutide 1.2mg daily, only in dual therapy is recommended as a treatment option, in combination with metformin or a sulphonylurea, for type 2 diabetes if

The DDP-4 inhibitors are a suitable alternative to the sulfonylurea if the risk of hypoglycaemia

• The person is intolerant of either metformin or a sulphonylurea, or treatment

DPP-4 Inhibitors

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CPD 28: TYPE 2 DIABETES of diabetic complications, for example, eye and feet examinations or drug therapy management. Diabetic foot care As the majority of type 2 diabetics will seek Module 1 clarification before purchasing any2012 other the June counter foot care products, it is important to ensure the following general advice on foot care:

Educational distance learning content for healthcare professionals•inInspect Irelandfeet daily, including the tops, sides, heels, and between the toes

• When trimming toenails, cut them straight across, and round the edges slightly with an emery board

Chronic Pain – assessment and management in primary care

• To prevent drying and cracking of the skin, use emulsifying ointment on the tops and bottoms of the feet but not between the toes, as this can cause a fungal infection • Wear cotton, synthetic blend, or wool socks that are soft and dry to absorb moisture. • To promote good circulation to the lower limbs when seated, prop your feet up and avoid standing in one position for long periods of time. • Immediately report any sores or skin changes, such as blisters, cuts, or soreness, to your diabetic team not attempt to that remove or calluses Sheehan et •al Do reported in 1996 the corns estimated cost of without seeking the advice of your GP or 8 pain for 95 patients to team the Irish . Health Services when added diabetic Pain is one of the commonest reasons for patients to seek to the amount of Social Welfare payments received and 1 Smoking cessation medical attention. A recent survey has shown that as many the lost earnings of each patient amounted to 1.9 million with metformin or a sulphonylurea is Blood Pressure as 8.3 visits per year to primary care physicians in Ireland Not only is smoking 6 a risk factor for the contraindicated, and time of referral. The recent 2 development of diabetes, it candata also from be a PRIME People 2 diabetes should havepounds at the were due to symptoms of pain. A with largetype scale survey carried showcause that the meancomplications. cost per chronic pain patient of major Smoking their blood pressure taken at least once survey a • The person is intolerant of thiazolidinediones out in 15 European countries and Israelwhose in 2006, screening bloodallvessels, year. Those blood pressure is found and DDP-4 inhibitors, or treatment with a is estimatedaccelerates at €5,665 damage per year to across grades of pain, particularly the smaller blood vessels. This 46,394 respondents reported that the prevalence of chronic to be 140/80mmHg or higher should initially thiazoldidinediones and DDP-4 inhibitors is which was extrapolated to €5.34 billion or 2.86% of Irish can lead to poor circulation, which is a major offeredinadvice on lifestyle changes - such contraindicated. pain of moderate to severe be intensity adult Europeans was 7 risk factor for foot infections and, ultimately, as diet and exercise to help prevent further GDP per year. This demonstrates an urgent need for cost 3 Liraglutide 1.8mg is not 19%. recommended for the amputations. rises in blood pressure. The choice of agents effective strategies to manage chronic pain effectively. 5


treatment of type 2 diabetes .

to reduce blood pressure, including ACE

Smoking doubles the chances of suffering from inhibitors, II receptor antagonists, More recent survey data from anotherangiotensin study, carried out Prolonged Release Exenatide kidney problems and erectile dysfunction. beta blockers, thiazide diuretics and longin 2,019 people with chronic pain and 1,472 primary Understanding chronic pain 6 . acting calcium channel blockers People with diabetes already have an increased Exenatide is licensed for the triple therapy care physicians across 15 European countries, have of heart as disease, which is further elevated regimens in combination with metformin Chronic painrisk is defined pain that outlasts normal healing Aspirin if they smoke. Diabetes acts in several ways and a sulphonylurea, or demonstrated metformin and that a chronic pain affects 12-54% of adult time (usuallytothree to six months), andglucose is mostlevels frequently 2 damage the heart; high affect Studies have shown taking thiazolidinedione, as a treatment option Europeans, andwhen its prevalence in Ireland is up tothat 13%. Thea low-dose with musculoskeletal disorders such more as low the walls of the arteries making them aspirin every day significantly lowers theassociated risk control of blood glucosePRIME remains high (HbA 1c ≥ (Prevalence, Impactofand Cost of Chronic Pain) study, likely to develop fatty deposits which in turn heart attacks. For diabetics there is aback 50% pain and 7.5), and the person has: arthritis. However, it can also be associated on the other hand, determined the prevalence ofdying chronic make it more difficult for the blood to circulate. increase in the risk of from heart disease, other disorders such as depression metabolic • a body mass index (BMI) kg/m2 andas 35.5% People with diabetes are moreorlikely to have therefore all4diabetics overstudy the age of 50with should pain≥to35be as high in Ireland. The PRIME specific psychological or medical problems blood pressure andsuch high as levels of fats disorders orhigh neurologic conditions multiple be offered low dose aspirin. was designed to investigate the prevalence of chronic pain such as triglycerides. They are also more likely associated with high body weight or PHARMACIST INhealth PREVENTINGsclerosis. to have lower levels of the protective HDL in Ireland; compare the psychological and ROLE physical • a BMI < 35 kg/m2, and therapy with COMPLICATIONS cholesterol. profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive insulin would have significant occupational • Support of self blood glucose monitoring 4 Eye Nociceptive checks disability. Responses to survey questions were implications or weightpain-related loss would benefit or neuropathic. pain is caused by an active other significant obesity-related • Monitoring and promoting patient adherence obtained from 1,204 people. mostinflammatory serious complication diabetes with illness, injuryThe and/or process of associated co-morbidities.

with medication and other components of

for the eye is the development of diabetic

actual or potential tissue damage i.e. Nociceptive pain retinopathy. If the blood sugars are well Despite the magnitude of the self-management problem, chronic pain is results from activity in neural secondary to actual controlled, then it pathways is less likely to be a problem. 2,5 Identifying and resolving drug-related issues bothshould under-recognised and•undertreated in primary care. People with type 2 diabetes expect complications lead to loss or potential More tissueserious damage. Nociceptivecan pain is mediated up to 38% reported targeted being inadequately • Providing education of vision, so diabetics should always be to have their blood lipid Indeed, levels checked on of patients by pain receptors located skin, musculoskeletal 2 encouraged to in regularly have their eyes system, tested. diagnosis and then at least once ainyear. managed primary care for• their pain symptoms. In Monitoring blood pressure, weight and bone, and joints.8 Neuropathic pain, on the other hand, Cholesterol levels should also be kept below cholesterol Diet Advice addition, people with chronic pain reported waiting up to 5mmol/litre. For those at increased risk of results from direct injury to a peripheral or central sensory 2.2 years between seeking help and diagnosis, and 1.9 cardiovascular risk, initiation of a statin may be • Reminding patients of the importancenerve; the affected Diets fornerves type 2do diabetes should transduction be built not produce at 2 . appropriate even if levels are within of regular managed. examinations for the presence around the principles of healthy eating with years beforerange their6pain was adequately 8 nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1. Cholesterol

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CPD 28: TYPE 2 DIABETES A healthy diet and weight range is key in Type 2 diabetes management

Module 1 June 2012

sionals in Ireland

anagement in primary care

a focus on foods that do not adversely affect blood glucose levels. Patients should follow a 3 meal a day diet structure, including starchy carbohydrates at each one of the meals- bread, potatoes, rice and pasta. They should avoid or reduce the intake of foods rich in saturated and choose lowthat fat dairy products,cost of ehan et fats, al reported in 1996 the estimated substituting full fat milk or skimmed semin for 95 patients to the Irish Health Services or when added skimmed and low fat cheese and yogurts.

he amount of Social Welfare payments received and HEALTHY DIET OPTIONS FOR DIABETICS lost earnings of each patient amounted to 1.9 million • Eat levels6ofThe fat,recent particularly saturated nds at the timelower of referral. data from PRIME fat. vey show that the mean cost per chronic pain patient meat and fish stimated•atChoose €5,665chicken, per yearturkey, acrosslean all grades of pain, as low fat alternatives to fatty meats. ch was extrapolated to €5.34 billion or 2.86% of Irish • 7Eat five servings of fruit vegetables P per year. This demonstrates an and urgent need for cost every day- choosing from the rainbow of ctive strategies to manage chronic pain effectively. colours available to maximize variety. • Avoid foods high in cholesterol, such as egg

yolks,chronic fatty meat,pain and fatty dairy products. derstanding

• Choose low-fat or completely fat-free dairy

onic pain isproducts, defined as that dairy outlasts normal healing or pain consider alternatives. e (usually three to six months), and is most frequently • Choose cholesterol-lowering fats, such as ociated with musculoskeletal disorders such ascontain low olive oil or canola oil. Many nuts also k pain andhealthy arthritis.fats. However, it can also be associated h other disorders as depression metabolic • Eat oilysuch fish twice a week orormore, and focus on those fish that include levels of orders or neurologic conditions suchhigh as multiple heart-protective fat ( mackerel, trout, salmon rosis. and sardines).

• Cook using methods (baking, n (acute or chronic) canlow-fat be categorised as nociceptive roasting, grilling) and avoid frying. europathic. Nociceptive pain is caused by an active Focusinflammatory on foods thatprocess are high associated in fibre. ss, injury• and/or with • Eat less sodium andi.e. don’t add salt topain your ual or potential tissue damage Nociceptive food- in too muchpathways salt can increase the to risk of ults from activity neural secondary actual high blood pressure. otential tissue damage. Nociceptive pain is mediated • Drink alcohol in moderation - 2 units of pain receptors located in skin, musculoskeletal system, alcohol per day for a woman and 3 units per 8 e, and joints. day Neuropathic for a man. pain, on the other hand, ults from •direct a peripheral or central sensory Limitinjury sugartoand sugary foods e.g. desserts, ve; the affected nerves produce transduction at cakes, sweetdo teanot and sugar-sweetened drinks. iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.

REFERENCES 1. World Health Organisation 2012, Fact Sheet (312). Type 2 diabetes, viewed 4 February 2013, online/basics/en/index1.html 2. Wermeille J, Bennie M, Brown I. Integrating the community pharmacist into the diabetes team: Evaluation of a new care model for patients with type 2 diabetes mellitus. Int J Pharm Pract 2001;9:60 3. National Institute of Clinical Excellence. Guidance on the management of type 2 diabetes, 2009. 4. Venkatesan R et al. Role of community pharmacists in improving knowledge and glycemic control of type 2 diabetes. ISCR 2012; 3: 26-31 5. Novo nordish., Victoza 6mg/ml solution for injection. Summary of Product Characteristics 2012. 6. National Institute of Clinical Excellence. Management of type 2 diabetes - management of blood pressure and blood lipids, 2002. 7. O Donovan et al. The role of pharmacists in control and management of type 2 Diabetes Mellitus; a review of the literature. 2011 http:// PDFFiles/FOURTHISSUE/RA-1-JOD-10-023. pdf 8. National Institute of Clinical Excellence. Diabetes foot problems: Prevention and management of foot problems, 2004. 9. EPG, Professional channel for doctors. Type 2 diabetes, viewed 4 February 2013, http://

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this. Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy. We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and www. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. EPBU/2013/033/1

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Skin cancer – the facts for pharmacists

Ireland may only see the sun for a few precious weeks every year but skin cancer is the most common cancer in this country. The good news is that it is largely preventable – and pharmacists have an important role to play in spreading the message about sun safety. There are two different types of skin cancer: non-melanoma skin cancer and melanoma. Basal cell and squamous cell skin cancer – also known as non-melanoma skin cancer – are the most common types. Pharmacists should suggest that patients see their GP if they present to the pharmacy with: • A new growth or sore that has not healed within a few weeks • A spot or sore that itches, hurts, crusts, scabs or bleeds • A constant skin ulcer that is not explained by other causes Melanoma skin cancers are rarer than non-melanomas but the National Cancer Registry of Ireland reports that growing numbers of people are being diagnosed with this type of cancer each year. It is the most serious form of skin cancer and can spread to other parts of the body. If diagnosed sufficiently early, it is treatable. Patients with moles should be advised to check their skin regularly and to always wear adequate sunscreen. Patients should be advised to watch out for the appearance of a new mole, or any change in the colour, shape or size of existing moles because this may signal that a melanoma is developing. A normal mole is


usually an evenly coloured brown, tan or black spot on the skin. It can be either flat or raised, round or oval and is usually less than the size of the top of a pencil. Of course, prevention is always better than cure and taking steps to protect the skin from an early age can dramatically reduce the risk of skin cancer. The Irish Cancer Society advises that for optimum protection, people should: •

Cover up and wear clothing that covers arms and legs, as well as a broad-brimmed hat that gives shade to the face, the back of the neck and ears

• Seek shade – especially from 11am to 3pm, when UV rays are at their strongest • Wear wraparound sunglasses that give UV protection •

Wear sunscreen with sun protection factor SPF 15 or higher, which should be applied thickly 30 minutes before going into the sun. The sunscreen should protect against both UVA and UVB rays

• Avoid tanning beds or sunbeds.








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AT-RISK GROUPS Pharmacy staff should advise that people at a higher risk of skin cancer should be particularly vigilant. Those in high-risk categories include: • people with fair skin • red or blonde hair • blue, green or grey eyes • if they have freckles or a large number of moles • if they tan poorly or burn easily or had severe sunburn as a child People who have used tanning beds or sunbeds are at higher risk of skin cancer, as are those with a strong family history of skin cancer - up to one in ten melanomas occur in people with inherited dispositions. People with darker skins are up to 20 times less likely to develop melanomas than Caucasians because they have higher levels of the pigment melanin, which provides some form of protection from UV-induced damage. However, people with darker skins can still burn and develop skin cancers, especially on nonpigmented parts of the body, such as the soles of the hands and feet. Pharmacists should be aware that patients who have been exposed to certain chemicals, such as coal tar, soot and petroleum products must be particularly vigilant when it comes to their skin. Radiotherapy and immunosuppressive drugs also increase a patient’s risk of skin cancer. SUNBEDS Far from being a sign of good health, a tan is actually a reaction to DNA damage in the skin. It is a sign that the body is trying to repair damage that has already occurred. Pre-holiday tans or sunbed tans offer little protection against the sun – in fact, studies have shown that tans only offer protection equivalent to using sunscreen with an SPF 3! Studies have also linked sunbed use to both malignant melanoma and non-melanoma skin cancers and it is strongly advised that people should not use sun beds for tanning purposes. People who have used a sunbed – even once – will have exposed themselves to at least a 15% increased risk of developing melanoma. If a person under 30

years of age uses a sun bed, the increased risk of melanoma developing is increased by 75%. If a sun bed is used once a month or more, the risk of skin cancer developing can increase by more than 50%. The amount of UV radiation from a sunbed can be as much as 15 times higher than the mid-day Mediterranean sun. Consequently, people who are prone to burning can burn even more quickly on a sunbed than from being out in the sun. The World Health Organisation actually classifies sunbeds as ‘carcinogenic level 1’, which elevates them to the same level as cigarette smoking. PROTECTING BABY’S SKIN A person’s lifetime risk of developing skin cancer is strongly affected by their exposure to the sun during the first 15 years of their lives. In fact, migration studies have also found that people, who move into areas with higher UV exposures, such as Australia have a higher risk of developing melanoma if they arrived as children (rather than adults). Parents should be advised to protect their children from UV damage on both sunny and cloudy days because up to 90% of UV rays can pass through light cloud. Babies under six months should always be kept in the shade. They should also be kept covered up and should wear materials, which do not allow sunlight through to their delicate skins. They should also wear wide-brimmed hats

during the daytime and even wraparound sunglasses that offer UV protection. If infants are kept in the shade and kept covered up, parents need only use a small amount of sunscreen (with SPF 15 or higher and with UVA protection) on the uncovered areas. There is a plethora of sunscreens, which have been specially developed for children and babies. These are available as sprays, lotions, creams and mists. Sunscreen should be applied liberally to dry skin, 30 minutes before a child goes outside and should be re-applied every two hours. Parents should ‘patch test’ any new sunscreen on baby’s skin first in case there is a reaction to it. If there is, it is best to try a different brand. VITAMIN D Vitamin D is important for bone health, immune function and blood cell formation. It comes from two sources: the diet and UV rays from the sun. Children may not receive as much vitamin D as they should and parents should be reminded that the Health Service Executive recommends that all infants, from birth to12 months and whatever milk they are fed, should be given a daily supplement of vitamin D. Other customers may also be lacking in Vitamin D and are likely to include: • People with darker skin • People who cover up their bodies completely when going outside, such as some religious sects

• Older people • People who are ill and unable to leave their home • Women who are pregnant or breastfeeding. Finally, if customers cannot appreciate the dangers of tanning and feel they must have a tan, the best and safest way to obtain bronzed skin is from a bottle. The majority of fake tans afford only a small amount of protection from damaging UV rays and, at best this will only last for a few hours. As Irish women buy more self-tanning products than anywhere else in the world, it is worthwhile pointing this out to them. SKIN CANCER STATISTICS Skin cancer is one of the most common forms of cancer in this country, with over 8,000 cases diagnosed in Ireland each year. According to the National Cancer Registry of Ireland, the incidence of malignant melanoma (the most serious of skin cancers) increased by 92% in the ten years between 1998 and 2008. Furthermore, the NCRI data shows that the percentage increase in melanoma in women over 60 years of age was 82% and in men, the increase was 152%. Although these figures appear alarming, research has demonstrated that 90% of all skin cancers are preventable.


News Real World Retail news brief announces partnership with HEADACHE TO McLernon Computers BE PHARMACY PRIORITY Pharmacists in Ireland are being urged to reach out to the hundreds of headache sufferers across Ireland. Headaches lead to over 890,000 missed days of work annually and a further one in five (19%) people in Ireland have had limited work ability due to a headache. This research was announced at the launch of Headache Awareness Week in association with Nurofen which took place from 16 to 23 March 2013. The research also revealed that within the workplace, 24% of people said their workload is their biggest headache trigger. Speaking at the launch of Headache Awareness Week in association with Nurofen, Jean McAleenan, Pharmacist, Boots, said, “This research clearly demonstrates the level and severity of headaches experienced by the Irish public with 3.2 million people experiencing a headache in the past year. Headache is one of the main issues that we deal with in pharmacy however it is clear that people don’t fully understand the way to manage and treat headache related pain.” Headache Awareness Week in association with Nurofen has been launched to help educate people on the types and causes of headaches as well as providing advice on how to help relieve them so as to minimise impact on your quality of life. In addition, 90% of school-age children get headaches but pharmacists have also warned that children are suffering unnecessarily with headaches at school and at home. In the run up to Headache Awareness Week the Irish Pharmacy Union (IPU), has called on parents to be vigilant and has issued a number of tips for parents to help their child avoid getting headaches.


Real World Retail (RWR) announces a strategic partnership with McLernon Computers to integrate their retail business intelligence solution with McLernons’ MPS and MPS Retail (EPoS) software. McLernon Computers are the pharmacy software vendor of choice for the profession and have been developing innovative software for over 30 years. Not only does the MPS suite of products offer the most effective tool for the dispensing of prescriptions, re-ordering and submission of claims, as well as managing the front-of-shop, but they also have an additional set of features including prescription scanning, a queuing module for prioritising work flow and a number of interfaces with robotic dispensing solutions.

(From Left)John Hogan, Real World Retail, Robin Hanna, McLernon Computers and Conall Laverty, Real World Retail

Real World Retail – Pharmacy (RWR-P) integrates with McLernon Computers Enterprise (Head Office) system to provide management dashboards along with key reports that offer a view of the whole business. Until now it has been difficult to bring the sales for dispensing and frontof-shop Over The Counter (OTC) and other sales into one place. Now, at the push of a button the pharmacy owner can compare last week’s sales against the same period in the previous year, analyse stockholding by product and by store, generate replenishment reports for bulk ordering, identify best-selling and ‘trending’ products, etc. The benefits for pharmacy include a saving on inventory, better margins and improved sales. The system has been installed in three

of McLernon Computers’ group customers already. One such group says that they have reduced their inventory value by ¤300,000 within five months of the system going live, as well as having improved their service to their customers. Robin Hanna, Sales Director of McLernon Computers, said, “We are very excited about working with Real World Retail and have had very positive feedback when we made joint presentations to several of our customers, with some going on to purchase and implement the programme. We believe no other company can offer this level of business intelligence and in this challenging environment it is imperative you have full visibility of the key aspects in your business. RWR delivers this information!”

"We believe no other company can offer this level of business intelligence" Speaking on behalf of Real World Retail, Conall Lavery, Director, said, “McLernon Computers are the leading vendor of pharmacy dispensing software in the 32 counties and we are delighted and privileged to be working with them. When used with RWR-P their EPoS system is now second to none in terms of reporting, and we are already rolling out a loyalty system for another one of their customers with more in the pipeline.”

total relief ABBREVIATED PRESCRIBING INFORMATION Rinozal 5 mg film-coated tablets Each film-coated tablet contains 5 mg levocetirizine dihydrochloride (equivalent to 4.2 mg of levocetirizine). Presentation: White to off-white, oval, biconvex film-coated tablets, debossed with ‘L9CZ’ on one side and ‘5’ on the other side. Indications: Relief of symptoms of chronic idiopathic urticaria. Dosage: The film-coated tablet must be taken orally, swallowed whole with liquid and may be taken with or without food. Adults and adolescents 12 years and above: 5 mg (one film-coated tablet) once daily. Children aged 6 to 12 years: 5 mg (one film-coated tablet) daily. Children under 6 years: Not recommended. Elderly: No dose reduction is required provided that the renal function is normal. Patients with moderate to severe renal impairment: Moderate (creatinine clearance 30 – 49 ml/min): One tablet every 2 days. Severe: (creatinine clearance ≤30 ml/min): One tablet every 3 days. End stage renal disease – patients undergoing dialysis (creatinine clearance <10 ml/min): contraindicated. In paediatric patients suffering from renal impairment, the dose will have to be adjusted on an individual basis taking into account the renal clearance of the patient, his/her age and body weight. Patients with hepatic impairment: No dose adjustment is needed in patients with solely hepatic impairment. Patients with hepatic impairment and renal impairment: Dose adjustment is recommended (see Patients with moderate to severe renal impairment above). Contraindications: Hypersensitivity to levocetirizine, to any of the excipients, to hydroxyzine or to any piperazine derivatives. Patients with severe renal impairment at less than 10 ml/min creatinine clearance. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose- galactose malabsorption should not take levocetirizine film-coated tablets. Warnings and precautions: Do not exceed the stated dose. The use of levocetirizine dihydrochloride is not recommended in children aged less than 6 years since the currently available film-coated tablets do not yet allow dose adaptation. At therapeutic doses, no clinically significant interactions have been demonstrated with alcohol (for a blood alcohol level of 0.5 g/L). Nevertheless, precaution is recommended if alcohol is taken concomitantly. Caution in epileptic patients and patients at risk of convulsions is recommended. Interactions: Due to the pharmacokinetic, pharmacodynamic and tolerance profile of levocetirizine, no interactions are expected. The extent of absorption of levocetirizine is not reduced with food, although the rate of absorption is decreased. Pregnancy and lactation: Caution should be exercised when prescribing to pregnant or breast feeding women because levocetirizine passes into breast milk. Driving and using machines: Patients intending to drive, engaging in potentially hazardous activities or operating machinery should not exceed the recommended dose and should take their response to the medicinal product into account. In these sensitive patients, concurrent use with alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance. Undesirable effects: Somnolence, dizziness, headache, pharyngitis, rhinitis, abdominal pain, dry mouth, nausea, fatigue, agitation, paraesthesia, diarrhoea, pruritis, rash, asthenia, malaise. Refer to Summary of Product Characteristics for other adverse effects. Pack size: 30 tablets. Marketing authorisation holder: Clonmel Healthcare Ltd, Clonmel, Co. Tipperary. Marketing authorisation number: PA 126/179/1. Full prescribing information is available on request or go to Medicinal product subject to medical prescription. Date last revised: January 2011. 2011/ADV/LEV012


PRESCRIBING INFORMATION (Please consult the Summary of Product Characteristics (SmPC) before prescribing.) Zirtek Allergy & Zirtek Allergy Relief 10 mg film-coated tablets (UK) Zirtek 10 mg film-coated Tablets (ROI) Zirtek Allergy Solution 1 mg/ml & Zirtek Allergy Relief for Children 1 mg/ml oral solution (UK) Zirtek Oral Solution (ROI) cetirizine dihydrochloride Active Ingredient: Tablets 10 mg cetirizine dihydrochloride (also contains lactose). Solution: 1 mg/ml cetirizine dihydrochloride (also contains sorbitol, methylparahydroxybenzoate, propylparahydroxybenzoate). Indication(s): For the relief of nasal and ocular-symptoms of seasonal and perennial rhinitis. For the relief of symptoms of chronic idiopathic urticaria. Dosage and Administration: Tablets: Children aged from 6 to 12 years: 5 mg twice daily (a half tablet twice daily). Adults and adolescents over 12 years of age: 10 mg once daily (1 tablet). Solution: Children aged from 2 to 6 years: 2.5 mg oral solution twice daily, 2.5 mls oral solution twice daily (a half spoon twice daily). Children aged from 6 to 12 years: 5 mg oral solution twice daily, 5mls oral solution twice daily (a full spoon twice daily). Adults and adolescents over 12 years of age: 10 mg oral solution once daily, 10mls oral solution (two full spoons). Patients with renal impairment: Patients with renal impairment: dose adjustment is recommended (consult SPC). Contraindications, Warnings, etc: Contraindications: Hypersensitivity to the active substance, to any of the excipients, to hydroxyzine or to any piperazine derivatives. Patients with severe renal impairment at less than 10 ml/min creatinine clearance. Solution:Patients with rare hereditary problems of fructose intolerance should not take cetirizine 1 mg/ml oral solution Tablets: Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucosegalactose malabsorption should not take cetirizine 10 mg film-coated tablets. Precautions: Caution is recommended if alcohol is taken concomitantly and in epileptic patients or patients at risk of convulsions. Allergy skin tests are inhibited by antihistamines and a wash-out period (of 3 days) is required before performing them. Methylparahydroxybenzoate and propylparahydroxybenzoate may cause allergic reactions (possibly delayed). Interactions: none known. Pregnancy and lactation: Caution should be exercised when prescribing to pregnant or lactating women as cetirizine passes into breast milk. Driving etc: Do not exceed the recommended dose and responses should be taken into account before driving or operating hazardous machinery. Adverse Effects: Common: fatigue, dizziness, headache, abdominal pain, dry mouth, nausea, somnolence, pharingitis. Common adverse effects reported in children: diarrhoea, somnolence, rhinitis, fatigue. Consult SPC for other side-effects. Pharmaceutical Precautions: No special precautions for storage.

Ireland’s best selling antihistamine 3

• Indicated in the treatment of seasonal and perennial allergic rhinitis and chronic idiopathic urticaria1 • Non sedating1 • Once daily tablet dosing1 • Fast onset of action2 • No known drug interactions1

Marketing Authorisation Number(s): UK Tablets 7 pack (GSL) PL 00039/0561 Tablets 21 & 30 pack (P) PL 00039/0542 Solution 70 ml (GSL) PL00039 0541 Solution 150 ml & 200 ml (P) PL 00039/0540 ROI Tablets 7 pack (Pharmacy Only) PA 891/8/2 Tablet 30 pack (POM) PA 891/8/2 Solution 100ml (Pharmacy Only) PA/891/8/3 Further information is available from Marketing Authorisation Holder: UCB Pharma Ltd, 208 Bath Road, Slough, Berkshire, SL1 3WE. Tel: +44 (0)1753 534 655; Fax: +44 (0)1753 536 632 Email: UCB (Pharma) Ireland Ltd ,United Drug House, Magna Drive, Magna Business Park, City West Road, Dublin 24, Ireland. Tel: +353 (0)146 37395; Fax: +353 (0)146 37396 Date of Revision: March 2012 (UK/12ZI0001) Zirtek is a registered trademark References: 1 SmPC 2 J Day Ann Allergy Asthma Imm 1997;79:163-72 3 IMS Data MAT Feb 2012 Date of Preparation April 2012. Full prescribing Information available on request. UK/12ZI0005

Get in touch with your allergy. Fast2


Hayfever - the exquisite allergy

Dr Paul Carson runs the Sinusitis & Allergy facility at Slievemore Clinic, Dublin. He is a member of the British Society for Allergy & Clinical Immunology and the European Academy of Allergy and Clinical Immunology. He is also on the board of the Irish Lung Foundation and scripted the recent Lung Foundation video on United Airways Disease (see Dr Carson’s health books include Sinusitis, steps to healing & Hay Fever, steps to healing (Sheldon Press, London). Full details on

and by the end that month high pollen counts can be detected countrywide. Peak levels of pollen occur on warm, dry and sunny days. Low levels occur on wet, damp and cold days. Rain washes pollen out of the air. Pollen is released in the morning and carried higher into the air by midday. It descends again to ‘nose-level’ in the late afternoon. Cities and dense urban areas stay warmer longer and hold pollen.

Hay fever is an exquisite allergy to grass and tree pollens (and occasionally moulds). However the main culprit (because of the volume of pollen and length of time it’s in the air) is grass pollen. 10,000 grass pollen grains would fit on the tip of a pin so you can imagine just how many pollen grains enter the nose, are then

swept into the sinuses and lungs at the height of the pollen season. Allowing for weather variations, the pollen season starts in the south of Europe. In Ireland grass pollen levels rise first (in early May) along the warmer western coasts

Patients with tree and grass pollen allergy are especially blighted. Their season starts in early spring with mild nasal symptoms. By the time the grass pollen months arrive they are already so compromised even small amounts of grass pollen can trigger quite aggressive nose, eye and sinus symptoms. If the summer is especially warm and sunny with high surges of grass pollen, then those three to four months can be a write-off.

Symptoms:  Sneezing  Blocked and runny nose  Sinus congestion with headaches, especially along the forehead  Itchy, red and watery eyes  Puffy eyes and lower eyelids  Cough and occasional wheeze  Ears popping with occasional hearing impairment  Diminished senses of taste and smell (severe hay-fever sufferers)  Feeling of intense lethargy


Note the red, irritable eyes, puffy lower lids (from constant rubbing)

Some patients with hay-fever notice that the inside of their mouths, lips and tongue itch and swell slightly when they eat certain fruits during the pollen season. This is known as the ‘oral-allergy syndrome’. Here protein in some foods cross react with pollen grains. For example an allergy to birch tree pollen may trigger reactions to celery, curry spices, raw tomato, raw carrot, apples, pears, and kiwi fruit. Grass pollen sufferers occasionally react to oats, rye, wheat, kiwi fruit and raw tomato Grass pollen allergy cannot be cured but recent immunotherapy products (see further on) are significant disease modifiers so there are advances in management for sufferers. FEATURES: In the early stages of hay fever the nose is irritated by intermittent allergy challenge. This triggers sneezing, runny nose, blockage and the use of lots of tissues. The most common feature is a ‘nasal salute’ here the sufferer repeatedly rubs at the nose to relieve the itch and discomfort. However, as the allergic assault progresses the irritative features may abate to a ‘silent but blocked’ stage. Here there is constant nasal obstruction with mouth breathing, dropped chin, throat clearing from a persisting post nasal drip and even sleep difficulties.

The nose and sinuses link directly with the lungs via a number of pathways. Nowadays the upper respiratory tracts (nose and sinuses) and lower respiratory tracts (lungs) are considered to be a single functioning unit. Childhood asthma begins as an untreated nose allergy. Examination Doctors Inspect the nose easily and quickly (takes less than 30 seconds). Using an otoscope (the instrument used to look in ears) with the widest fitting they sweep the light source from the immediate nasal opening to the upper recesses. In severe nasal allergy the obstruction may be immediately obvious. It’s important the examining doctor has a decent light source to see all areas within the nose. Sometimes the most extraordinary things can be found there! TREATMENT: Before offering OTC treatments advise on self-help tips:  Avoid areas of lush grassland  Keep house and car windows closed during peak pollen hours of late morning and late afternoon  Wear wrap-around sunglasses to reduce pollen grains affecting the eyes  If you can, avoid being outdoors late morning and late afternoon  Don’t smoke and keep away from smokers (passive smoking aggravates all allergies)  Get someone else to mow the lawn or wear a face mask if you have to cut the grass.


 Choose seaside breaks for holidays as off shore breezes blow pollen away 

Check TV, radio and newspapers for the next day’s pollen count and plan your schedule accordingly

Put a smear of Vaseline inside each nostril to ease the soreness and to capture pollen entering the nasal passages.

 Never sleep with the bedroom window open.  Don’t drive with the window open. 

Put used tea bags in the fridge. They make great soothing compresses to relieve swollen or puffy eyes.

All patients, be they children or adults, do not seek early attention. When offering help the pharmacist should bear in mind that nasal obstruction is the most important factor. Neglect that and all your best advice is likely to be of little help. While antihistamines do relieve nasal irritability they do not reverse nose blockage. Suggest first a three day course of a nasal decongestant (Otrivine is as good as any but warn about long term use). When your customer feels his/her nose is unblocked then offer an OTC steroid spray such as Flixonase (or your own preferred choice).

Antihistamines may relieve nasal irritability but do not help with nasal obstruction. A combination of a nasal steroid spray and oral antihistamine is the best strategy for the summer. So, when offering advice to that distressed customer with blocked, runny nose and itchy streaming eyes, think of this strategy: 1. Unblock the nose with a nasal decongestant 2. Stabilise the nose with your preferred steroid spray 3. Advise using a daily antihistamine to get best results. 4. Tell him/her to keep this up until the pollen season ends, even when it’s raining heavily 5. If the hay fever is causing severe pain, especially if it’s accompanied by a green nasal discharge there may be infection involved as well. This is where they should see their own GP for assessment.

Adult Dose ONE-A-DAY

EFFECTIVE HAYFEVER RELIEF ABBREVIATED PRESCRIBING INFORMATION Please refer to the Summary of Product Characteristics (SmPC) before prescribing Cetriz 10 mg Film-coated Tablets Indications: Relief of nasal and ocular symptoms of seasonal and perennial allergic rhinitis relief of symptoms of chronic idiopathic urticaria and relief of symptoms of chronic idiopathic urticaria in adults and paediatric patients over 6 years. Dosage: Children 6 to 12 years: 5 mg twice daily (a half tablet twice daily). Adults and adolescents over 12 years of age: 10 mg once daily (1 tablet). Tablets to be swallowed with a glass of liquid. Renal impairment: Mild (CLcr 50-79 ml/min) 10 mg once daily, Moderate (CLcr 30-49 ml/min) 5 mg once daily, Severe (CLcr 30 ml/min) 5 mg every 2 days. Elderly: No dose adjustments. Contraindications: Hypersensitivity to cetirizine, to any of the excipients, to hydroxyzine or to any piperazine derivatives. Severe renal impairment at less than 10 ml/min CLcr. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose- galactose malabsorption should not take Cetriz. Warnings and precautions: Precaution is recommended if alcohol is taken concomitantly, although at therapeutic doses, no clinically significant interactions have been demonstrated. Caution in epileptic patients and patients at risk of convulsions. The use of the film-coated tablet formulation is not recommended in children aged less than 6 years since this formulation does not allow for appropriate dose adaptation. Interactions: No interactions are expected with this antihistamine [neither pharmacodynamic nor significant pharmacokinetic interaction was reported in drug-drug interactions studies performed, notably with pseudoephedrine or theophylline (400 mg/day)]. Absorption of cetirizine is not reduced with food, although the rate of absorption is decreased. Pregnancy and Lactations: Very rare clinical on exposed pregnancies are available (animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/fetal development, parturition or postnatal development). Caution should be exercised when prescribing to pregnant or breast feeding women because cetirizine passes into breast milk. Side Effects: None very common or common. Shelf Life: 2 years. Pack size: 7 & 30 Tablets. Marketing Authorisation Holder (MAH): Actavis Group PTC ehf., Reykjavikurvegi 76-78, 220 Hafnarfjordur, Iceland Marketing Authorisation Number: PA 1380/54/1. Legal Category: Medicinal product not subject to medical prescription. Full prescribing information including the SmPC is available on request from Actavis Ireland Limited, Euro House, Little Island, Co. Cork or email Information about adverse event reporting can be found on the IMB website ( or by contacting Actavis Ireland Limited Date of Generation of API: December 2011. Date of preparation: December 2012. FADGP-013-02.

NASONEX 50 micrograms/actuation Nasal Spray, Suspension mometasone furoate ABBREVIATED PRESCRIBING INFORMATION [Phenylethyl alcohol-free formulation] Refer to Summary of Product Characteristics before prescribing. PRESENTATION: Nasal spray suspension containing mometasone furoate (as monohydrate) 50 micrograms per actuation. USES: Adults and children aged 18 and over: Treatment of nasal polyps. Adults and children over the age of 12 years: For the treatment of the symptoms of seasonal allergic rhinitis or perennial rhinitis. Children 6 to 11 years of age: For the treatment of the symptoms of seasonal allergic rhinitis or perennial allergic rhinitis. In patients who have a history of moderate to severe symptoms of seasonal allergic rhinitis, prophylactic treatment with Nasonex may be initiated up to four weeks prior to the anticipated start of the pollen season. DOSAGE: Nasal Polyposis: Adults and children aged 18 and over: The usual recommended starting dose for polyposis is two actuations (50 micrograms/actuation) in each nostril once daily (total daily dose of 200 micrograms). If after 5 to 6 weeks symptoms are inadequately controlled, the dose may be increased to a daily dose of two sprays in each nostril twice daily (total daily dose of 400 micrograms). The dose should be reduced following control of symptoms. If no improvement in symptoms is seen after 5 to 6 weeks of twice daily administration, alternative therapies should be considered. Efficacy and safety studies of Nasonex Nasal Spray for the treatment of nasal polyposis were four months in duration. Seasonal or Perennial Allergic Rhinitis: Adults and children over the age of 12 years: Two sprays (50 micrograms/spray) in each nostril once daily (total dose 200 micrograms). Once symptoms are controlled, dose reduction to one spray in each nostril (total dose 100 micrograms) may be effective for maintenance. If symptoms are inadequately controlled, the dose may be increased to a maximum daily dose of four sprays in each nostril (total dose 400 micrograms). Dose reduction is recommended following control of symptoms. Children 6 to 11 years of age: One spray (50 micrograms/spray) in each nostril once daily (total dose 100 micrograms). Clinically significant onset of action occurs in some patients within 12 hours after the first dose. Full benefit of treatment may not be achieved in the first 48 hours. Regular use is recommended to achieve full therapeutic benefit. CONTRAINDICATIONS: Hypersensitivity to any of the ingredients. Do not use in the presence of untreated localised infection involving the nasal mucosa. Patients who have experienced recent nasal surgery or trauma should not use a nasal corticosteroid until healing has occurred. PRECAUTIONS AND WARNINGS: Use with caution, if at all, in patients with active or quiescent tuberculous infections of the respiratory tract, or in untreated fungal, bacterial, systemic viral infections or ocular herpes simplex. There was no evidence of atrophy of the nasal mucosa following 12 months of treatment. Patients using Nasonex over several months or longer should be examined periodically for changes in the nasal mucosa. If localised fungal infection of the nose or pharynx develops, discontinuance of Nasonex therapy or appropriate treatment may be required. Persistence of nasopharyngeal irritation may be an indication for discontinuing Nasonex. The concomitant use of additional therapy may provide additional relief particularly of ocular symptoms. There is no evidence of HPA axis suppression following prolonged treatment with Nasonex. Patients who are transferred from long-term administration of systemically active corticosteroids to Nasonex require careful attention. The safety and efficacy of Nasonex has not been studied for use in the treatment of unilateral polyps, polyps associated with cystic fibrosis, or polyps that completely obstruct the nasal cavities. Unilateral polyps that are unusual or irregular in appearance, especially if ulcerating or bleeding, should be further evaluated. Patients who are potentially immunosuppressed should be warned of the risk of exposure to certain infections. Rare cases of nasal septum perforation, increased intraocular pressure and/or cataracts have been reported following the use of intranasal corticosteroids. Nasonex should only be used in pregnant women, nursing mothers or women of child-bearing age if the potential benefit justifies the potential risk to the mother, foetus or infant. Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods. These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations. Potential systemic effects may include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). It is recommended that the height of children receiving prolonged treatment with nasal corticosteroids is regularly monitored. If growth is slowed, therapy should be reviewed with the aim of reducing the dose of nasal corticosteroid, if possible, to the lowest dose at which effective control of symptoms is maintained. In addition, consideration should be given to referring patient to a paediatric specialist. Safety and efficacy of Nasonex Nasal Spray for the treatment of nasal polyposis in children and adolescents under 18 years of age have not been studied. Treatment with higher than recommended doses may result in clinically significant adrenal suppression. If there is evidence for higher than recommended doses being used, then additional systemic corticosteroid cover should be considered during periods of stress or elective surgery. In a placebo-controlled clinical trial in which paediatric patients (n=49/group) were administered Nasonex 100 micrograms daily for one year, no reduction in growth velocity was observed. INTERACTIONS: A clinical interaction study was conducted with loratadine. No interactions were observed. SIDE EFFECTS: Adverse effects commonly reported in clinical trials in adult and adolescent patients include headache, epistaxis, pharyngitis, nasal burning, nasal irritation and nasal ulceration. Other less common and rarely reported side effects are listed in the SPC. PACKAGE QUANTITIES: 18g per bottle, supplied with a metered-dose manual spray pump actuator which delivers 50 micrograms per actuation. Legal Category: Prescription Only Medicine. Marketing Authorisation Number: PA 1286/38/1 Marketing Authorisation Holder: Merck Sharp & Dohme Ireland (Human Health) Limited, Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland. Date of Revision of Text: June 2012 Further information is available on request from: MSD, Red Oak North, South County Business Park, Leopardstown, Dublin 18 or from © Merck Sharp & Dohme Ireland (Human Health) Limited, 2012. All rights reserved. Date of preparation: August 2012.

Reference: 1. Shedden A. Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey. Treat Respir Med. 2005;4(6):438-445.

Red Oak North, South County Business Park, Leopardstown, Dublin 18, Ireland


85 %

of a ex llerg pe ic rie rh nc in e c itis on su ge ffe sti re on 1 rs

Because congestion can impact your patients with allergic rhinitis any time of year...

Again, if your customer is an only-too-regular visitor during the pollen season you might also suggest immunotherapy, the long term strategy to damp down the pollen allergy completely. This can only be provided by their GP. Immunotherapy (also called desensitisation) Allergy management involves avoidance of what a patient is allergic to combined with treating the symptoms. For example, in nasal allergy due to grass pollen sensitivity environmental avoidance measures are combined with suppressant medication. No matter how effective these are they do not alter the allergic status. In other words the patient is still allergic to grass pollen and still gets into trouble in the hay fever season. For almost all allergy sufferers this means many summers of taking anti-hay fever remedies. Now a new therapy (or rather an old therapy updated because immunotherapy has been in use for over 100 years) offers the chance to significantly reduce ‘allergicness’ and maybe even completely stop reactions.

Immunotherapy is where the patient takes exactly what he/she is allergic to but in a modified form. At present the most convenient product, called sublingual immunotherapy, is a dissolvable tablet placed under the tongue and held there for two minutes. In North America, Australia and some European countries, immunotherapy is given by weekly injections. It’s the same principle, just a different mode of delivery. However this is not patient friendly. Immunotherapy blocks the allergic reaction well upstream of the inflammatory response and may even prevent nose and sinus allergy deteriorating to asthma. Moreover its beneficial effect persists long after the end of the course of therapy. It is especially helpful with seasonal pollen hay fever. Allergen immunotherapy:  Reduces symptoms significantly  Reduces the amount of medication needed for comfort and relief

 Reduces nose and chest sensitivity to allergen irritation  Reduces the risk of developing other allergies (especially important in young children with, say a dust mite allergy, where there is concern that pollen allergy may also develop in time) Immunotherapy is licensed for use in children and adults aged 5 years and over. There are two products available: Oralair (a six months preseason product) made by French company Stallergenes and Grazax (a twelve month, all year round product) made by the Danish pharmaceutical Alk-Abello. The commitment to treatment is vital and this is important to understand as the patient will be embarking on a minimum of 3 and possibly 5 years treatment. However immunotherapy is not a guaranteed cure. The regime demands patience, commitment and attention to other trigger factors to ensure best results. Full details on

news brief PHARMACY RESEARCHERS AWARDED FUNDING Two researchers from the School of Pharmacy at Trinity College been successful in being awarded funding from Science Foundation Ireland under its Investigators Programme. Asst. Prof. David Finlay and Prof. Anne Marie Healy were recently awarded funding for the following projects: • Asst. Prof. Finlay: Characterising the role of mammalian target of rapamcyin complex 1 (mTORC1)/Srebp1c signaling in directing the differentiation and function of T cell subsets • Prof. Healy: Co-processing of active pharmaceutical ingredients with functional excipients to prevent unintentional generation of amorphous phase Prof. Anne Marie Healy and Asst. Prof. Lidia Tajber are investigators in the Synthesis and Solid state Pharmaceutical Centre (SSPC), one of seven new, large-scale, world-class research centres which will receive a total of 200 million euro of Science Foundation Ireland (SFI) funding, coupled with over 100 million euro in cash and in-kind contributions from industry partners, over the next six years. The SSPC is a unique collaboration between 17 companies and 8 academic institutions and will position Ireland as a global hub for pharmaceutical process innovation and advanced manufacturing. Building a core capability in the area of process R&D, it will serve to cement the pharmaceutical industry in Ireland. Prof. Healy is also a funded investigator in another of the research centres recently announced by SFI - AMBER: Advanced Materials and BioEngineering Research Centre, led by TCD. AMBER will deliver world-leading research into engineered materials and interfaces for applications in a number of priority sectors in Ireland such as ICT, medical devices, and industrial technology.


Asthma - Eczema

The asthma-eczema connection

There is a strong link between asthma and eczema. If one or both parents have asthma, eczema or seasonal allergies, their child is more likely to develop atopic dermatitis, which is the most common type of eczema. In addition, children with eczema may be more at risk of developing allergies or asthma. Around 35% of adults who had eczema as a child have hay fever or asthma as adults, while up to 70% of children with severe atopic dermatitis go on to develop asthma. By comparison, the rate of asthma incidence among the general population is only about 9% in children and 7% in adults. This progression from eczema to breathing problems is called the ‘atopic march’. Professor Alan Irvine

THE MANAGEMENT OF ECZEMA Eczema is the term for several different skin conditions. However, eczema most often refers to atopic dermatitis, which causes a dry, itchy, red rash. Scratching the skin can cause it to ooze and crust over. Chronic scratching can cause the skin to thicken and darken in colour. About one in every 10 children develops eczema and it most commonly occurs in the infant stage. In most children, symptoms often improve by the age of five or six years. However, many people continue to have eczema as adults, although symptoms tend to be milder. Less often, eczema first develops in adulthood.


There is no known cure for eczema; therefore, treatments aim to control the symptoms by reducing inflammation and relieving itching. Corticosteroids and immunosuppressants are used in more serious cases, but moisturisers and avoidance of allergens can help on a day-to-day basis. The Irish Eczema Society has recently warned those living with the condition against using unlicensed products, especially those bought over the internet. National Eczema Awareness Week 2013 which runs this year from 23rd – 29th September, aims to encourage better understanding of the treatment options available and how it can be optimally managed. With the increasing trend of buying medicine and remedies online, The Irish Eczema Society is urging pharmacists to talk to their patients about their treatment options rather than resorting to purchasing ‘quick fix’ products online, which are not licensed in Ireland. Jeannette Brazel, co-founder of The Irish Eczema Society says: “The Irish Medicines Board has

previously issued a warning against a product which was marketed online as a ‘natural, herbal remedy’ for skin conditions such as eczema. The product was found to contain non-herbal ingredients, which included a steroid, and was banned from being marketed in Ireland.” Commenting on the continuous management and control of the condition, Professor Alan Irvine, Associate Professor at Trinity College Dublin and Consultant Dermatologist says: “Early intervention and proper treatment is crucial for people living with eczema, particularly children. As eczema is associated with several other serious conditions such as food and respiratory allergies, including asthma, educating patients and their families about managing the condition effectively is extremely important. We are continuously researching this condition and finding breakthroughs in our understanding of this difficult, and upsetting, skin condition.

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“Eczema can have a severe impact on the quality of life for both the person living with it and their families. It can cause sleep disturbances and have an emotional impact on patients’ lives, especially if they have severe eczema in visible parts of their body. Treatment can be timeconsuming, but it is important to remember that while there is currently no cure, eczema can be managed effectively." TABLE: The Irish Eczema Society’s Top Tips To Take Control: 1. Emollient therapy is the cornerstone to daily eczema care 2. Advise sufferers only use soap-free products when bathing 3. Cotton clothing and bed linen is less likely to irritate the skin. Specialist eczema clothing is now widely available 4. Try to identify a sufferers triggers – keep note of what causes their eczema to flare-up and avoid these triggers


5. Advise on remembering to avoid using chemical sprays or harsh cleaning products in the home 6. Only use non-bio washing detergents and avoid fabric conditioners 7. Take control of the environment Both asthma and eczema are on the rise in the industrialised world. Researchers in Washington University School of Medicine in St Louis, USA, have studied why so many people with eczema go on to develop asthma. The researchers found that thymic stromal lymphopoietin (TSLP), a signalling molecule secreted by damaged skin cells, elicits a strong immune response from the body to fight off invaders. They hypothesised that eczema-induced TSLP enters the bloodstream and, when it arrives at the lungs, sensitises them so that they react to allergens that would not previously have bothered them. In other words, they become asthmatic.

The study findings suggest that early treatment of skin rash and inhibition of the trigger substance might block asthma development in young patients with eczema. In the longer term, it might be possible to devise drugs that inhibit the production of TSLP or interfere with TSLP-receptor molecules in the lungs. THE MANAGEMENT OF ASTHMA Written by Mary Hughes, Research and Education Consultant, Asthma Society of Ireland. Asthma is an inflammatory disease where there is increased sensitivity of the airways to various stimuli; viral infections are the most common causes of hypersensitivity but symptoms can also be exacerbated by exercise and allergens such as house dust mite and animal dander1,2. Intensive treatment is essential during periods of exacerbation of symptoms which are otherwise managed with use of controllers and avoiding known allergens3. Asthma is the leading chronic illness in children and adolescents


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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.

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There are a number of factors which influence the control children with asthma have over their symptoms, including failure to comply with treatment and greater exposure to triggers16. It is recognised that parents underestimate symptoms and overestimate asthma control based on the GINA criteria4 resulting in many children and adolescents not achieving good control of their asthma. It is also acknowledged that children from ethnic minority groups have a disproportionately higher rate of morbidity associated with chronic illness resulting in adverse outcomes17.

in Western countries4,5. Inadequate management of asthma symptoms is the cause of unnecessary morbidity for children and adolescents and places an unnecessary burden on the health service. It is estimated that the cost to the Irish health system for treatment of asthma in children younger than 15 years was ¤56 million, with an additional ¤116 million for the treatment of wheeze6. Ireland has the fourth highest incidence of asthma in the world7,8, with 18.9% of 13-15 year olds having asthma9. The incidence of asthma in Ireland is increasing according to the Irish data from the International Study of Asthma and Allergies in Children (ISAAC) 5, prevalence in 13-14 year olds has increased by 40% between 1995 and 2003. It is estimated that 20% of Irish children have asthma making it the most common chronic disease in childhood and the most common respiratory illness in Ireland10. Asthma is more common in boys than girls during early childhood, with the prevalence equalising in adolescence1,6. Airway obstruction is caused by bronchoconstriction, hypersecretion of mucous and oedema associated with airway hyperresponsiveness Inflammatory mediators are


released following exposure to inhaled triggers resulting in the activation of endothelial cells, collagen release and airway remodelling1. The airways become narrow, it becomes more difficult to breathe due to airway resistance and sometimes a wheeze is audible. Symptoms typically associated with asthma are coughing, shortness of breath or chest tightness, sleep disturbances due to these symptoms, resulting in children missing school and having reduced engagement in physical activities and in social and family activities11. Asthma severity will dictate treatment so it is essential that a correct diagnosis is made, and other causes for respiratory symptoms are ruled out. Diagnosing asthma and prescribing appropriate medications are essential elements in identifying at-risk children. There is a noticeable variation between the control of symptoms children achieve when under the medical management of specialist and non-specialist asthma care paediatricians12. Recent reports suggest that medication management by patients treated by primary care physicians is poor because general practitioners do not understand inhaler technique resulting in poor instruction and consequently poor control and complaince13. Every child and

adolescent with asthma should also have a personalised asthma plan14. As part of a personal asthma plan it is advisable that control is assessed using Peak Expiratory Fowl flow Rate (PEFR) plus other factors to observe to determine control. When a child is old enough they should also assess lung function by performing daily Peak Expiratory Flow Rate. Children over 6 can usually perform this test, once they are old enough to blow up a balloon, prior to taking inhaled medication. ISSUES WITH CHILDHOOD ASTHMA MANAGEMENT Despite the development and enhancement of asthma medications in the past two decades, there has been an increase in the morbidity associated with asthma4. Asthma is consistently in the top 20 reasons for hospital admission in Ireland, with over 3000 admission to hospital by children less than 14 years for asthma annually15. The average length of stay for a child is 1.9 days, with seasonal increase when children return to school and during the winter months. Irish children lose on average 10 days of school per annum due to their asthma10.

Although national and international asthma management guidelines exist it is accepted that the symptom control of asthma among the child and adolescent population is poor. There are eight long-term goals of asthma management proposed by the Global Initiative for Asthma14 to achieve control of asthma symptoms. The goals are that asthmatic patients should experience minimal chronic symptoms, have minimal exacerbations, have no visits to the emergency department for treatment, have minimal use of rescues β2 agonists, experience no limitations on daily activities, have a near normal Peak Expiratory Flow Rate (PEFR), have a circadian variation of <20% in PEFR, and have minimal adverse effects from medications taken to manage their asthma (e.g. oral candida infections, bruising, bone marrow depression, bone density deficiencies for long term high dose corticosteroid therapy). The focus of the Irish Asthma Guidelines17, is on the disease management issues related to medications for the control of symptoms. Medications are prescribed according to classification of asthma by a general practitioner or paediatrician, and are categorised into long-acting and short-acting control medications14. Long acting or preventer controller medications include corticosteroids, cromylum sodium, leukotriene modifiers, LABAs, methylxanthines and occasionally immunomodulators to achieve and maintain asthma control. Short-acting medications include anticholinergics, SABAs and systemic corticosteroids. Every child with asthma should be prescribed a reliever medication in a mode that is developmentally appropriate for them i.e. an age appropriate inhaler and spacer device. Adherence to asthma treatment guidelines should

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pharmacists can also organise in store Nurse clinics in consultation with the Asthma Society of Ireland where assessments of control can be conducted.

Mary Hughes

make accident and emergency department or overnight hospital admissions avoidable18. THE ROLE OF THE COMMUNITY PHARMACIST The community pharmacist is in an ideal position to contribute to good asthma management due to their expertise on medication and their frequent contact with patients. The community pharmacist may also suggest referral to a medical professional for further assessment if necessary. They play an important role in the four key areas in asthma management in order to maximise control of asthma symptoms: Assessment: Community pharmacists are in an ideal position to assess the health of the patient when they attend the pharmacy with symptoms. The level of control is indicated by the level of medication use and recognition of symptoms in conjunction with PEFRs and checking inhaler technique. In addition the community pharmacist can ask about changes in routine, environment, recent infections, stressors e.g. exams, relationships etc. also as this may affect respiratory function, plus smoking history Parental concern in a young child, or concern in a child themselves will also indicate poor control. Concern about medications and potential sideeffects may also be communicated by parents. Community


Education: Asthma selfmanagement education is the key to asthma control, meaning every child with asthma and their parent should have regular education on inhaler technique, triggers and symptoms, correct use of medications, and review of their personal asthma action plan. Community pharmacists play an important role in providing this education. The provision and revision of fundamental information regarding asthma and recognition of asthma symptoms can be provided, in addition to advising on information seeking techniques and methods with regard to asthma management. Verbal information should be supplemented with written material, especially when dealing with various devices used for the delivery of medications. These are available from the Asthma Society of Ireland and to download from our website. You can also refer patients to the short training videos on inhaler and spacer technique on The Asthma Society of Ireland website. Control of Triggers: The level of activity, allergy avoidance and environmental conditions will indicate the level of medication use. Ask about exercise activity and intensity, environmental factors such as housing conditions and seasonal variations which may also influence symptom control. The community pharmacist can assist patients in the management of exposure to triggers, symptom recognition and reliever use by proving regular education and referring to available educational resources on trigger avoidance. Refer them to the app that has been developed by The Asthma Society of Ireland which includes pollen count indicators. It also

includes the 5 Point Plan for what to do in the event of an asthma attack. This plan is also available on alert cards from the Asthma Society of Ireland which you can make available to all asthma patients. Medications: Poor control will be indicated by use of large amounts of reliever inhaler, and a delay or failure in regular renewal of the preventer controller inhaler regularly. This may prompt the community pharmacist to ask how often are the child is taking their preventer, controller and assessing their inhaler technique. This can then be used in conjunction with the child’s personal asthma plan to indicate control. They may not understand the action of the medication fully and may need re-education on this also. Understanding medications will increase compliance in conjunction with a personal asthma plan. Conclusion: The community pharmacist is in a unique position to support asthmatic children and adolescents and their parents in the control of asthma symptoms. Their relationship with patients will ensure that self-management and control of symptoms can be facilitated on an individual basis by recognising the features of poor control though medication use. Fundamental to this is the need to understand the condition and its treatment and how this applies in an age-appropriate manner to each child and adolescent. You can update your knowledge by accessing the National Asthma Education Programme, which is supported by the Irish centre for Continuing Pharmaceutical Education, and is available on the Asthma Society of Ireland webpage . The Society produces a number of patient information booklets and operates an Asthma Adviceline which is available every Monday to Friday, from 10am – 1pm, on 1850 44 54 64.

REFERENCES: 1. Tolomeo, C. Nursing Care in Pediatric Respiratory Disease. Wiley- Blackwell, 2012;188-220 2. Lenney W. Asthma in children. Medicine. 2008;36(4):196-200. 3. Ziaian T, Sawyer MG, Reynolds KE, Carbone, A. J, Clark, et al. Treatment burden and health-related quality of life of children with diabetes, cystic fibrosis and asthma. Journal of Paediatrics & Child Health. 2006;42(10):596-600. 4. Dozier A, Aligne CA, Schlabach MB. What Is Asthma Control? Discrepancies Between Parents Perceptions and Official (1)Definitions. Journal of School Health. 2006;76(6):215-8. 5. Van Den Akker-van Marle ME, Bruil J, Detmar SB. Evaluation of cost of disease: Assessing the burden to society of asthma in children in the European Union. Allergy. 2005;60(2):140-9 6. El-Gammal A. and O’Connor T. Asthma- Achieving Control. The Irish Journal of Clinical Medicine. 2006, 36(9). 7. Masoli, M, Fabian, D, Holt, S, et al Global Initiative for Asthma (GINA) program: the global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy 2004;59,469-478 8. GINA Global Burden Report 2003 9. Manning PJ, Goodman P, O’Sullivan A, Clancy L. Rising Prevalence of Asthma but Declining Wheeze in Teenagers (1995-2003): ISAAC Protocol. IR Med J. 2007 Nov-Dec; 100(10): 614-5 10. Asthma Society of Ireland. Helping Asthma in Real People (HARP), Preliminary Results July 2008 11. P Manning, P Grealy, E Shanahan. Asthma Control and Management: A Patient’s Perspective. IMJ 2005 Vol 98 No.10 12. Davies G, Paton JY, Beaton SJ, Young D, Lenney W. Children admitted with acute wheeze/asthma during November 1998-2005: a national UK audit. Archives of Disease in Childhood. 2008;93(11):952-8. 13. Improving inhaler technique – who needs teaching? Drug and Therapeutics Bulletin. 2012 October 1, 2012;50(10):109. 14. GINA Guidelines, Global Strategy for Asthma Management and Prevention Updated 2010 15. Hospital In-patient Enquiry. HIPE, 2005 – 2009 16. Schreier HMC, Chen E. Prospective associations between coping and health among youth with asthma. Journal of Consulting and Clinical Psychology. 2008;76(5):790-8. 17. Holohan J, Manning P. Asthma Control in General Practice Irish Asthma Guidelines 2010

Pharmacists are ideally placed to offer asthma management advice

18. Maziak W, von Mutius E, Keil U, Hirsch T, Leupold W, Rzehak P, et al. Predictors of health care utilization of children with asthma in the community. Pediatric Allergy & Immunology. 2004;15(2):166-71.

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Out & About Building for growth conference The URS Conference â&#x20AC;&#x2DC;Building for Growthâ&#x20AC;&#x2122; was recently held at the Heritage Hotel in Portlaoise on the 6th March. URS operates 60+ former IPOS pharmacies and over the past 2 years has re-invigorated a dynamic group of Trusted Caring Irish Community Pharmacies backed up by a central support function. URS ensures that its Local Community Pharamcies can compete with the larger groups on Range and extended services along with that critical Trusted Care that local community pharmacy has been delivering for generations. The Conference was attended by the Pharmacists and Managers from the 60+ plus group of pharmacies operated by the URS throughout nearly every county in Ireland. Tony McEntee, CEO URS, commented that it was fantastic to see such an energetic collection of pharmacists who are committed to the delivery of quality healthcare and advice to their local communities. The ongoing development of the services that URS offers particularly in the development of our pharmacy teams will greatly assist the pharmacies in continuing to be play an increasingly important role in the delivery of community based healthcare. Details can be viewed on the new URS website: Actavis, Flemings Medical and Allphar OTC Services provided sponsorship at the Conference.








1. Cara Wright, Pettits Pharmacy, Catherine Grimes-Horan, CGH, Keith Sheridan, Medicare, Micheal Aherne, Medicare, Maria O'Connell, O'Carrolls Pharmacy. 2. Karl Milne, URS, Gerry O'Connor, Moycullen Pharmacy Galway, Bronagh Brady-Lawlor, Healey's Pharmacy, Mary Greenan and Orla O'Connor, URS. 3. Sophie Timmons, O'Reilly's, Moy, Finnbar Feely, Kinirons, Mike McKenna, Dempsey's Limerick, Cliona Barry, Abbey, Kilmallock, Niamh Tierney, Kellys, Tralee 4. Trudy O'Donovan, Bourkes, Muireann Phelan, We Care, Patrice Barrett, Creedons, Aileen Kelly, Stacks. 5. Damien McCormack, Actavis, Tony McEntee, Uniphar Retail Services and Louise Mooney, Actavis. 6. Dee O'Dywer, Hiltons, David Murphy, Byrnes, Niamh While, Hamilton Long Pharmacy. 7. Guillaume Deporte, McKennas and Keith Sheridan, Medicare.




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Clinical Profiles ONCE A DAY GETS USED, GETS RESULTS We are delighted to announce that Fannin Ltd will be now managing the marketing and distribution of Zindaclin in Ireland from 26th February 2013. Zindaclin is an effective topical therapy for mild to moderate acne. Zindaclin contains Clindamycin and Zinc. It is a once a day gel that has a 2 year shelf life and unlike maybe other acne treatments does not need to be refrigerated, allowing for ease of use. Full prescribing information available upon request from: Fannin Ltd Tel:01 290 7000 Fax:01 290 7111 Email:

Dovobet® (calcipotriol/betamethasone dipropionate) 50 microgram/g + 0.5 mg/g (PA Number: 1025/1/2) Gel 120g (2x60g) launch in March 2013 LEO Pharma wishes to announce that Dovobet® (calcipotriol / betamethasone dipropionate) Gel 120g (2x60g) pack will be launched in Ireland, effective March 2013. 75% of patients have mild to moderate psoriasis1 and up to 80% of patients are reported to have body and/or scalp involvement2. Dovobet® Gel continues to offer healthcare professionals (HCPs) a greater choice in how they manage their patients but also has the advantage of dual indication (“Topical treatment of scalp psoriasis in adults. Topical treatment of mild to moderate “non-scalp” plaque psoriasis vulgaris in adults”). Research has shown that patients and HCPs prefer the gel formulation and find it more cosmetically acceptable.3 The latest IMS data shows that over 42% of the 5,000 prescriptions for Dovobet® Gel4 are for multiple packs of Dovobet® Gel 60g. If you require any further information, please contact our Medical Information department on: Tel: 01 4908924 or email: References: 1. Griffiths CEM, Clark CM, Chalmers RJG, Li Wan Po A,Williams HC et al. A systematic review of treatments for severe psoriasis. Health Technol Assess 2000;4(40) 2. Papp K et al. J Eur Acad Dermatol Venereol 2007;21:1151-1160

Deslor 5mg Film-Coated Tablets and Deslor 0.5mg/ml oral Solution Rowex Ltd is pleased to announce the launch of Deslor 5mg FilmCoated Tablets and Deslor 0.5mg/ml oral Solution (desloratadine). Deslor 5mg Film-Coated Tablets and Deslor 0.5mg/ml oral Solution (desloratadine) is indicated for the relief of symptoms associated with: • Allergic rhinitis • Urticaria The Details are as follows: Deslor 5mg Film-Coated Tablets x 30’s - ¤6.09 Deslor 0.5mg/ml Oral Solution x 100ml - ¤3.52 The presentation is fully reimbursable under the GMS. For further information contact Rowex Ltd., Bantry, Co. Cork. Freephone 1800 304 400, email

Dovobet® (calcipotriol/betamethasone dipropionate) Ointment 50 microgram/g + 0.5 mg/g (PA 1025/1/1) 60g Discontinuation – March 2013 LEO Pharma wishes to announce that Dovobet® Ointment 60g pack size is being discontinued from March 2013. The 120g pack remains available for those patients who are deemed clinically to require and/or prefer an ointment formulation. This discontinuation is not due to any safety or quality issues with Dovobet® Ointment, therefore pharmacists and patients may continue to dispense or use any stock of the 60g pack size they have remaining. If you require any further information, please contact our Medical Information department on Tel: 01 4908924 or email: medical-info.


3. LEO Pharma. Data on file 2009 (Formulation preference study) 4. IMS Medical Index Data (MAT/3/2012)

New infant anti reflux products introduced to ireland Now offering a clinically proven solution for infants suffering from reflux 14 March 2013: Danone Baby Nutrition has just introduced two new anti-reflux products for infants with frequent reflux and regurgitation, Aptamil Anti-Reflux and Cow & Gate anti-reflux. Approximately 1 in 5 infants are thought to suffer from reflux1 and one of the most common causes is that the valve at the top of the stomach has a weak action or does not function at the right time causing food and stomach acid to move back into the oesophagus2. The main signs of reflux include regurgitation or vomiting, excessive or sudden crying, irritability during or after feeds, poor sleep habits with frequent waking, weight loss or poor weight gain and regular coughing. Aptamil Anti-reflux and Cow & Gate anti-reflux are clinically proven to reduce regurgitation episodes by 78%, reduce regurgitation severity score by 67% and reduce reflux episodes by 17%3. They both contain the natural feed thickener carob bean gum which thickens the feed on preparation and, unlike the feed thickener corn starch, it also doubles in viscosity once it reaches the stomach, without degradation by salivary amylase in the mouth4. According to Aileen Regan at Danone Baby Nutrition “In a recent review, carob bean gum was the only thickener which reduced the number of infants with regurgitation5. Both Aptamil Anti-Reflux and Cow & Gate anti-reflux are proven to significantly reduce reflux episodes3,6-7, a problem which affects nearly 1 in 5 babies. We’re delighted that we are able to offer these new clinically proven products to infants in Ireland to help alleviate symptoms of frequent reflux and regurgitation." Both products are Foods for special medical purposes and are available through Pharmacy only, in 900g powder EaZypack. For further press information, please contact Claire Mc Govern at Q4 PR on 01 4751444 or email Important Notice: Aptamil Anti-Reflux and Cow & Gate anti-reflux are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and as part of a balanced diet from 6-12 months. For enteral use only.

NO0912654 Date of Preparation: September 2012



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Product Profiles New improved Aloclair® Plus for mouth ulcers


New fast acting Aloclair® Plus for the treatment of mouth ulcers has NO ALCOHOL so doesn’t sting when it is applied. The improved formula has a higher concentration of active ingredients Sodium Hyaluronate & Polyvinylpyrrolidone(PVP). It gently promotes healing, quickly soothing the pain of mouth ulcers and is suitable for all the family.

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Sea Buckthorn Oil Comes to Ireland Leading sea buckthorn oil product Omega 7 is being launched in Ireland this month. The 100% natural berry extract is becoming famous in the UK and Europe, recently gaining actress and model Linda Lusardi as a passionate advocate. A recent survey has shown that 97% of 2164 users would recommend Omega 7®. Studies have shown that these unique sea buckthorn oil capsules may help lubrication from within, therefore helping to tackle the misery of dry eyes, dry mouth and intimate dryness. Omega 7 fatty acids are important components of the mucous membranes, which line and lubricate the vagina, eyes, mouth and digestive tract. Mucous membranes may become dry as a result of ageing and environmental factors. Omega 7® Sea Buckthorn Oil is also a vegan source of omegas 3,6 and 9, and it's packed full of bio-active compounds. Product distributed by: Blackhall Pharmaceutical Distributors Ltd Information: 01-8405071 or


Randox Laboratories Ltd, a leading clinical diagnostic laboratory based in Northern Ireland, has developed a new sexual health test. Confidante® is the only OTC product which can detect 10 STIs in a single test, including Chlamydia, gonorrhoea and syphilis. Confidante® provides Simple, Accurate & Confidential laboratory STI testing from home. For further information on becoming a Confidante stockist, please call +44 (0) 28 9445 1004 or email

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Please contact Alchemy for Log on details

Market Leading Price Structures Alchemy is a comprehensive service for sourcing exempt medicinal products. We source and supply manufactured specialsextemporaneous products within 72 hours. We have a specialist team in place (pharmacists, technicians and telesales personnel) to guide you through the process in an ethical and professional manner from order to delivery. Full supplier verification ensures complete traceability of all our products. Source and supply short, discontinued, irregular and once off products. No extra delivery charges using customers current delivery arrangements*.

We have a large number of exempt medicines in stock and immediate access to a database of more than 650,000 medicines worldwide.

NEW WEB PORTAL 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. To access our site visit: Contact details Cahill May Roberts, Pharmapark, Chapelizod, Dublin 20.

Provide a first class cold chain service.

Telesales: Hospital Retail

(071) 916 1801 (Option 1) (Option 2)

* Express emergency deliveries may incur a fee

Technical queries: (01) 630 5432 Fax: (071) 9161977

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Appointments Turlough O'Sullivan has been appointed Chairman of Eurosales International. A former Director General of the Irish Business and Employers Confederation (IBEC), Turlough is a director of a number of companies and provides advice, mediation and consultancy services to organisations in the private and public sectors in Ireland and abroad. He has been a member of the National Economic and Social Council and the Board of the Labour Relations Commission. He has also served as a member of the Exective Board of Business Europe and advisor to the Board of the International Organisation of Employers.

Shauna McFadden has been appointed Customer Account Controller, Sysmex, with United Drug. She was appointed to her new position on 15 October last. McFadden lives in Clondalkin, Dublin 22 and she previously worked in Spectrum Print Logistics.

AstraZeneca announced that Marc Dunoyer is to join the company in the newly created role of Executive Vice President, Global Portfolio & Product Strategy. Marc will be responsible for driving business strategy, including business development, mergers and acquisitions, portfolio and product strategies. His most critical priorities will be to bolster the core growth platforms and therapy areas through well executed business development initiatives and leadership of internal efforts.

Cormac Tobin has stepped down from his role as managing director of DocMorris/Unicarepharmacy Ireland to take up the position as managing director of Celesio UK. Tobin joined DocMorris/Unicarepharmacy in 2006 as managing director. He will remain on the Irish board as a non-executive director and will still be involved and contribute towards major decisions for the business in Ireland.

DocMorris/Unicare has recently made a number of new appointments to their branches throughout Ireland. Carmel O'Shea has been appointed Pharmacy Manager at Nutgrove.


Anti-Snoring Ring

Make sure you are stocking the Good Night Ring Specialist Recruiters for Pharmacy TTM Healthcare, Irelandâ&#x20AC;&#x2122;s most trusted recruitment partner, has been delivering exceptional results to clients for over 10 years. We work hard to earn the continued respect and trust of our customers across Ireland. We do this by supplying suitably trained, qualified staff on a consistent basis, providing solutions, always specifically tailored to our clientâ&#x20AC;&#x2122;s needs.

ummer Specials S / g in um bookings Spr or early loc ! f Excellent rates available! Let us help you select your ideal pharmacy staff, make TTM Healthcare your recruiter of choice for 2013.

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Recruiting now for 2013:       

Pharmacy Managers Pharmacy Technicians Supervising Technicians O.T.C.s Support Pharmacists Locum Pharmacists Locum Technicians

in ! Seantded CV upd Interested?

Contact: Colette McInerney T | +353 (0)65 689 6220 M | +353 (0)87 684 5076 E | Distributed in Ireland by






Pharmaher Healthcare Ltd

12E Duleek Business Park, Duleek, Co Meath Tel: 041-988-2255

Christmas 2013 Trade Fair

The Main Hall, RDS, Ballsbridge, Dublin

Sunday 19th MAY 10am - 6pm

Monday 20th MAy 9am - 8pm

Tuesday 21st MAY 9am - 7pm


In this issue: - NEWS: Medicines robot brings pharmacy into 21st century - PROFILE: IACPT President Clare Ward on the growing importance of...


In this issue: - NEWS: Medicines robot brings pharmacy into 21st century - PROFILE: IACPT President Clare Ward on the growing importance of...